Birch Hill Health Services

Inspectors wroteBased on interview and record review, the facility did not ensure the security and privacy of medical information for 1 resident (R) (R7) of 3 sampled residents. R7's care plan was posted in R1's room. Family Member (FM)-C observed the care plan and informed staff.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R3) of 3 sampled residents. R3 was on contact precautions. Multiple staff provided care for R3 without donning the appropriate personal protective equipment (PPE).

Inspectors wroteBased on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R36) of 3 sampled residents. R36 had a Guardian. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R36's nursing home stay exceeded 60 days. R36 also did not receive an annual review to determine appropriate placement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of sexual abuse was reported to the State Agency (SA) for 2 residents (R) (R42 and R8) of 2 sampled residents. Staff witnessed R42 kiss R8 in the hallway on 1/24/26. R42 then followed R8 into R8's room. Licensed Practical Nurse (LPN)-F entered R8's room and observed R42 unzipping R42's pants in front of R8 who was lying on the bed with a book and appeared confused. The allegation of sexual abuse was not reported to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate an allegation of sexual abuse for 2 residents (R) (R42 and R8) of 2 sampled residents. Staff witnessed R42 kiss R8 in the hallway on 1/24/26 then follow R8 into R8's room. Licensed Practical Nurse (LPN)-F entered R8's room and observed R42 unzipping R42's pants in front of R8 who was lying on the bed with a book and appeared confused. The allegation of sexual abuse was not thoroughly investigated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate weight monitoring was provided for 2 residents (R) (R9 and R29) of 4 sampled residents. R9's provider and Power of Attorney for Healthcare (POAHC) were not notified of weight loss or gain greater than 3 pounds (lbs) from 11/4/25 to 1/30/26. In addition, R9 was not re-weighed for weight loss or gain greater than 3 lbs. R9's daily weights were not documented as ordered and were not obtained with a consistent device. R29's provider and Guardian were not notified regarding weight loss or gain greater than 3 lbs from 9/1/25 to 2/1/26. In addition, R29 was not re-weighed for weight loss or gain greater than 3 lbs.

Inspectors wroteBased on observation, staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R41, R32, and R43) of 3 sampled residents. R41 was on enhanced barrier precautions (EBP) for an indwelling catheter. Certified Nursing Assistant (CNA)-D did not wear a gown while emptying R41's catheter. Registered Nurse (RN)-E did not complete proper hand hygiene during medication pass for R32 and R43.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not notify a Guardian of a fall and change in condition for 1 resident (R) (R5) of 5 sampled residents. R5 had a fall with injury on 10/30/25. R5's Guardian was not notified of the fall or change in condition.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 resident (R) (R3) of 1 sampled resident. On 11/7/25, a fracture was discovered in R3's right arm under a cast and above where R3 had a previous fracture repaired on 10/22/25. The facility did not report the injury of unknown origin to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 resident (R) (R3) of 1 sampled resident. On 11/7/25, a fracture was discovered in R3's right arm under a cast and above where R3 had a previous fracture repaired on 10/22/25. The facility did not thoroughly investigate the injury of unknown origin.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure adequate supervision and assistance to prevent accidents was provided for 1 resident (R) (R5) of 3 sampled residents. R5 sustained a fall with injury on 10/30/25 when R5 fell out of bed and onto the floor. Staff did not complete neurological checks in accordance with the facility's policy. In addition, the Interdisciplinary Team (IDT) identified the need for a bolster mattress. The intervention was not added to R5's care plan.

Inspectors wroteBased on staff interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) in a timely manner or the local police department for 1 resident (R) (R1) of 5 sampled residents. Certified Nursing Assistant (CNA)-E reported to Nursing Home Administrator (NHA)-A that CNA-C barricaded R1 in the nurses' station on 4/15/25. The allegation of abuse was not reported to the SA until 4/23/25. The facility also did not report the allegation of abuse to the local police department.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate an allegation of abuse and prevent further potential abuse for 1 resident (R) (R1) of 5 sampled residents. Certified Nursing Assistant (CNA)-E reported to Nursing Home Administrator (NHA)-A that CNA-C barricaded R1 in the nurses' station on 4/15/25. CNA-C was not removed from or supervised during resident care until 4/22/25.

Inspectors wroteBased on record review and staff interview, the facility did not revise care plans in accordance with current care needs for 4 residents (R) (R38, R21, R40, and R35) of 14 sampled residents. The facility did not revise R38, R21, and R40's care plans when R38, R21, and R40 started Hospice care. R35 had a restorative program that indicated R35 should be walked to meals. The facility did not revise R35's care plan to indicate staff did not always ambulate R35 to meals but ambulated R35 at other times during the day.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 of 2 refrigerators in the medication storage room that contained vaccines and insulin maintained an appropriate temperature per the facility's policy and instructions on the facility's temperature log. In addition, the facility did not ensure medications for 7 residents (R) (R40, R33, R21, R22, R1, R194, and R3) of 19 residents in 1 of 1 medication cart were dated appropriately when opened. The medication refrigerator log for September 2024 indicated temperatures had been taken only once per day and 8 of the 22 temperatures were out of range. The refrigerator contained vaccines and insulin which required a temperature between 36-46 degrees F to preserve their integrity. In addition, the facility's policy indicated refrigerator temperatures should be checked twice daily. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R25) of 14 sampled residents was assessed as able to safely and accurately self-administer medication. On 9/23/24, R25 took R25's inhalers to a dialysis appointment to self-administer. R25 did not have a self-administration of medication assessment or a physician order that indicated R25 could safely and accurately self-administer the inhalers.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure bowel movements were monitored in accordance with the facility's protocol for 1 resident (R) (R3) of 14 sampled residents. R3 had a history of bowel obstruction. From 7/16/24 through 7/20/24, R3 went 5 days without a bowel movement (BM). Staff did not monitor R3's BMs and R3 did not have a bowel elimination care plan.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R194) of 2 residents reviewed for pressure injuries received appropriate care and services to promote healing and/or prevent pressure injuries from developing. During R194's dressing change on 9/24/24, Director of Nursing (DON)-B did not apply iodine as ordered by the physician.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R5) of 7 sampled residents was monitored for adverse reactions to antipsychotic medication. R5 was prescribed Seroquel (an antipsychotic medication) for dementia with behaviors. The facility did not complete a baseline Abnormal Involuntary Movement Scale (AIMS) assessment for R5 prior to the start of the medication.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 1 resident (R) (R194) of 5 residents observed during the provision of care. A transmission-based precautions (TBP) sign was not posted outside R194's room to alert staff that R194 was on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). In addition, staff were observed providing care for R194 without gloves or gowns.

Inspectors wroteBased on observation, record review, and staff and resident interview, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 26 residents who resided on the secure unit (A and B wings) and with the potential to affect all 34 residents residing in the facility. Appropriate testing and initiation of precautions were not completed for 2 Residents (R) (R11 and R25) upon symptom onset. Four staff observed did not don (put on), doff (remove), and wear personal protective equipment (PPE) while entering and exiting COVID-19 positive residents' rooms in accordance with Centers for Disease Control and Prevention (CDC) guidelines and the facility's policy. Hand hygiene was not offered to residents prior to the lunch meal on 8/28/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R1 and R19) of 15 sampled residents suspected of having a mental illness and/or intellectual/developmental disability were screened through the Pre-admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required. R1 had pertinent diagnoses and medications that were not included on R1's PASRR Level I Screen. A Level II PASRR was not completed. R19 had pertinent diagnoses and medications that were not included on R19's PASRR Level I Screen. A Level II PASRR was not completed.