Birch Pointe Health and Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food items were stored in accordance with professional standards of practice for food service safety when expired foods were found in kitchen storage areas. Review of the facility's policy titled, Food Receiving and Storage, revised 10/2017, showed foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 1. Observation and interview on 02/10/25, at 9:01 A.M., alongside the Certified Director of Food Service (CDFS), showed a refrigerator in the main kitchen had an opened five-pound container of cottage cheese with a best by date of 02/01/25. The CDFS confirmed this food item was expired. [...]

Inspectors wroteBased on interview, and record review, the facility failed to promote each resident's right to self-determination of care when staff did not provide showers as preferred and care planned for six resident (Resident #6, #7, #10, #30, #39, and #66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received their scheduled showers for six resident nts (Resident (R) R6, R7, R10, R30, R39, and R66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; -Notify the supervisor if the resident refuses the shower/tub bath. [...]

Inspectors wroteBased on record review and interview, the facility failed administer psychotropic drugs only when medically necessary when staff failed to educate the residents and/or residents' representatives of the risks and benefits prior to starting the drugs, failed to monitor and document adequate behaviors indication to use the drugs, failed offer nonpharmacological interventions, and failed to monitor adverse side effects for antipsychotic, antidepressant, and anti-anxiety medication use for four residents (Resident #54, #60, #64, and #80) of five residents reviewed for unnecessary medication use. Review the facility's policy for Antipsychotic Medication Use, revised July 2022, showed the following: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed ensure storage of medication per standards of practice and in a manner that prevented possible of expired medications/supplies when staff failed to remove expired medications/supplies from one of two medication storage rooms and two of four medication carts. Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, showed the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective infection control and prevention program was maintained for six residents (Resident #101, #211, #212, #215, #359, and #54) of 25 residents reviewed for infection control when the facility failed to clean and disinfect patient care equipment in between resident use. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, showed the following: -Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Association (OSHA) Bloodborne Pathogens Standard. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence the facility documented residents' and/or their representatives grievances and provided grievance decisions/resolutions after grievances were voiced for two residents (Resident #60 and #91) of 34 sampled residents. Review of the facility's policy titled, Grievances and Complaints Policy and Procedure, revised 12/2016, showed the following: -The facility had adopted an internal grievance procedure providing for prompt and equitable resolution of complaints/grievances of all types, including but not limited to, those alleging any discriminatory action prohibited by or in violation of patient rights, applicable state and/or federal law, internal policies, rules, enactments, guidelines, codes, regulations, or initiatives issued or enacted by any and all entities holding jurisdiction over this facility; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from unnecessary medications when on one resident (Resident #54), of five residents reviewed for unnecessary medication use, receive opioid pain medication without assessment of the proper pain level, without documention of non-pharmalogical interventions attempted first, and without documented monitoring for side effects. Review of the facility's policy for Medication Therapy, revised April 2007, showed the following: -Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice when facility staff failed to assess, monitor, care plan, and provide treatment for one resident (Resident #1) related to his/her surgical incision to his/her cervical (C) spine (back of neck) resulting in the incision dehiscing (surgical incision edges separated) and greenish-white drainage. The facility census was 111. Review of the facility policy/procedure titled, Wound Care, revised October 2010, showed the following: -The purpose of the procedure was to provide guidelines for the care of wounds to promote healing; -Staff to verify there is a physician's order for the procedure; -Staff to review the resident's care plan to assess for any special needs of the resident; -Staff to document all assessment data obtained when inspecting the wound (wound bed color, size, drainage, etc.); [...]

Inspectors wroteBased on record review and interview, the facility staff failed to take steps to prevent further abuse and protect resident safety when staff failed to implement and care plan consistent and effective interventions for one resident (Resident #1) after resident-to-resident altercations with five residents (Resident #2, #3, #4, #5, and #6) resulting in continued altercations. The facility census was 99. Review of the facility's policy titled, Reporting Abuse, undated, showed the following: -The facility will not condone resident abuse by anyone, including staff members and other residents; -Physical abuse is defined as hitting, slapping, punching, kicking, etc. Review of the facility's policy titled, Preventing Resident Abuse, undated, showed the following: -Preventing resident abuse is a primary concern for the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed maintain an effective infection control program when staff failed to properly dispose of used Personal Protective Equipment (PPE - gloves, gowns and masks) and failed to don the appropriate PPE when entering isolation rooms with residents positive with Coronavirus Disease 2019 (COVID-19); when staff failed to implement source control when the facility had resident positive for COVID-19; and when staff failed to separate and appropriately handle hall trays and cleaning supplies removed from isolation rooms with residents positive with COVID-19. The facility census was 93. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, showed the following: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible abuse involving five residents (Resident #3, Resident #25, Resident #50, Resident #66, and Resident #82) out of 24 sampled residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly and timely investigated when staff failed to document investigations of alleged abuse involving five residents (Resident #3, Resident #25, Resident #40, Resident #66 and Resident #82) out of a sample of 24 residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; [...]

Inspectors wroteBased on record review and interview, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #42) and failed to consistently provide oral care assistance for one resident (Resident #91), with known dental issues, out of a sample of 24 residents. The facility had a census of 93. Review of the facility's policy titled, Activities of Daily Living (ADLs - dressing, grooming, bathing, eating, and toileting), Supporting, revised March 2018, showed the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteBased on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed-hold policy for one resident (Resident #94) who was transferred out to the hospital. A sample of three residents' closed records was selected for review in a facility with a census of 93. Review of the facility's policy titled Bed-Hold Charge, undated, showed the following: -In the absence of the resident from the facility, a daily bed-hold charge will be made until the personal effects of the resident are removed from the facility or a stop bed-hold agreement is signed; [...]

Inspectors wroteBased on interview and record review, facility staff failed to verify a resident's code status and failed to provide basic life support timely, including cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped), for one resident (Resident #95) of a sample of two residents who was found unresponsive. The facility census was 93. Review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised 02/2018, showed the following: -If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/Basic Life Support (BLS) shall initiate CPR unless the resident is a known that a Do Not Resuscitate (DNR - order that specifically prohibits CPR and/or external defibrillation exists for that individual; [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate and collaborate, consistent with professional standards of practice, with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center for one resident (Resident #73), out of a sample of two residents, when staff did not consistently send and receive communication with the dialysis facility regarding each dialysis session. The facility census was 93. Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with, revised October 2010, showed the following: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. [...]

Inspectors wroteBased on observation, interview, and record review staff failed to ensure staff performed hand hygiene when leaving rooms or the hall, failed to sanitize equipment used by multiple residents after possible contamination, and failed to ensure trash cans holding potentially hazardous gloves and gowns were properly covered on the Coronavirus Disease 2019 (COVID-19) (an infectious disease caused by severe acute respiratory syndrome, Coronavirus 2 (SARS-CoV-2)) quarantine hall. Additionally, the facility failed to develop a complete program for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella). The facility's census was 104. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of property when staff discovered missing doses of controlled medications, that were in the possession of the facility, for three residents (Resident #2, #5, and #303). The facility census was 104. Record review of the facility's policy titled, Controlled Substances, revised on December 2012, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Individuals must sign the designated controlled substance record; [...]

Inspectors wrote3. Record review of Resident #95's face sheet showed the following: -readmitted to the facility on [DATE]; -Diagnoses included fracture (broken) and displacement of the resident's left femur (thigh bone). Record review of the resident's Nursing Admission/readmission Assessment, dated 5/4/21, showed the following: -The resident had 2+ edema (swelling with moderate pitting, when pushed, indentation subsides rapidly) to his/her left lower leg; -Cognitively intact; -Substantial/maximal assistance needed for transfers and bed mobility; -Lower extremity range of motion impairment on one side; -Partial loss of voluntary movement in legs and feet. No side specified; -Non-weight bearing. No side specified. Record review of the resident's physician order, dated 5/4/21, showed the following: -No bearing weight on the resident's left leg; -May perform range of motion (ROM) as tolerated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all controlled drugs were reconciled periodically per standards of practice when staff failed to ensure outgoing and incoming nurses counted narcotics during shift change on two of three units in the facility. The facility census was 104. Record review of the facility's policy titled, Controlled Substances, revised on December 2012, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Individuals must sign the designated controlled substance record; [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to treat one resident (Resident #202) in a manner that promoted dignity and respect when staff did not verify the resident's Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome, Coronavirus 2 (SARS-CoV-2)) vaccination status prior to admitting the resident to the COVID-19 quarantine hall when the resident voiced he/she did not wish to be placed on the quarantine hall if avoidable. The facility's census was 104. According to the Center for Disease Control (CDC) regarding COVID-19, people are considered fully vaccinated two weeks after their second dose in a two-dose series, such as the Pfizer or Moderna vaccines, or two weeks after a single-dose vaccine, such as Johnson & Johnson's [NAME] vaccine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to obtain timely treatment orders for new pressure sores, failed to document completing the treatment as ordered once order was received, and failed to complete a timely full assessment of the pressure sores for one resident (Resident #87) who developed two newly identified pressure sores. The facility's census was 104. Record review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, revision dated July 2017, included the following: -Assess the resident on admission and repeat weekly and upon any changes in condition; -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain physician's orders related to the use of as needed use of oxygen, and failed to update a resident's care plan to reflect the use of as needed oxygen, for one resident (Resident #43). The facility census was 104. Record review of the facility's Oxygen Administration Policy, dated October 2010, showed the facility must verify a physician's order for this procedure, review the resident's care plan for any needs of the resident, and assemble the equipment and supplies as needed. 1. Record review of Resident #43's medical record showed the following: -admitted to the facility on [DATE]; -Diagnoses included of chronic rhinitis (sneezing or a congested, drippy nose) and heart failure (when heart muscle doesn't pump blood as well as it should). Record review of the resident's progress note dated 4/15/21, at 1:50 A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made two errors out of 27 opportunities, resulting in an error rate of 7.4 percent affecting one residents (Resident #54). The facility's census was 104. Record review of the facility's Documentation of Medication Administration policy, dated April 2007, showed the facility shall maintain a medication administration record to document all medications administered, as well as reason(s) why a medication was withheld, not administered, or refused (as applicable). 1. Record review of Resident #54's face sheet (a document that gives a resident's information at a quick glance) showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the resident's dental condition and determine if the resident wished to receive dental services for one resident (Resident #85). The facility census was 104. Record review of the facility's Dental Services Policy, revised December 2016, showed the following: -Routine and emergency dental services are available to meet the resident's oral health need as in accordance with the resident's assessment and plan of care; -Routine and 24-hour emergency dental services are provided to residents through a contract agreement with a licensed dentist that comes to the facility as needed, referral to the resident's personal dentist, referral to community dentist, or referral to other health care organizations that provide dental services; [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure approved recipes were followed when preparing pureed foods to ensure residents received the correct consistency and correct amount of calories and nutrients. The facility census was 104. Record review of the facility's Pureed Diet Policy, no date, showed the following: -The purred diet is a modification in consistency of a regular or any therapeutic diet providing foods of smooth semi-liquid or semi-solid consistency requiring no mastication prior to swallowing; -Often individuals on pureed diet texture are nutritionally compromised; -Preparation of the pureed diet should maximize flavor appeal and nutrient density. 1. Observation on 5/58/21, at 10:38 A.M., showed the following: -There were two residents on pureed diets; -Dietary Aide (DA) T made chicken broth. [...]