Birchwood Health Care Center

Inspectors wroteBased on interview and document review, the facility failed to verify and obtain on admission a resident's need for bipap (bilevel positive airway pressure machine which delivers pressurized air through a mask over the nose or mouth to provide improvement in breathing) equipment and failed to notify the provider after prescribed breathing interventions were ineffective for 1 of 1 resident (R90) reviewed for hospitalization. This resulted in an Immediate Jeopardy situation when R90 continued to have respiratory decompensation leading to the need for transfer to the emergency room, intubation, and admission to the intensive care unit. The IJ began on 6/4/26, when R90 was hospitalized , intubated, and admitted to the intensive care unit. Administration was notified of the IJ on 6/11/26, at 3:40 p.m. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents were given an opportunity to wash their hands prior to eating. This had the potential to affect any resident who chose to eat in the main dining room.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a resident's call light was answered timely to prevent a bladder accident for 1 of 1 resident (R53) reviewed for bowel and bladder.

Inspectors wroteBased on interview and document review, the facility failed to meet the requirements for a bed hold notification for 1 of 2 residents (R90) reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff was properly educated on how to monitor a dialysis access site for 1 of 1 resident (R1) reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that assessments and orders were in place for self-administration of medication and bedside storage for 1 of 1 resident (R40) who was reviewed for safe self-administration and storage of medications.

Inspectors wroteBased on interview and document review the facility failed to provide residents the Skilled Nursing Facility Advance Beneficiary notice of Non-coverage (SNF ABN) CMS-10055 when Medicare part A services were being discontinued and the resident stayed in the facility. This affected 4 of 4 (R1, R5, R8, R11) residents reviewed for beneficiary notices.

Inspectors wroteBased on observation, interview and document review the facility failed to thoroughly investigate and failed to comprehensively assess in an effort to identify risks and hazards associated with an elopement for 1 of 3 residents (R1) reviewed after R1 removed his wander alert bracelet and left the facility unsupervised by staff. In addition, the facility failed to ensure a system for all staff to identify who was at risk for elopement.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 2 of 3 (R2, R3) residents who were on enhanced barrier precautions (EBP), required personal cares and ordered treatments and staff did not maintain proper hand hygiene practices or use of gowns while performing cares and treatments.

Inspectors wroteBased on interview, observation, and document review the facility failed to provide adequate supervision resulting in the likelihood of serious harm, injury, impairment, or death for 1 of 3 residents (R1) who was assessed to be at risk for elopement, had exit seeking behavior, and wore a WanderGuard (security device that prevents residents at risk of wandering from a designated area). The facility's failure resulted in an immediate jeopardy when R1 exited the building without staff knowledge and was returned to the facility by a community member (CM)-A.The immediate jeopardy began on [DATE] when R1 exited the facility chapel door at 6:25 p.m. The facility was made aware of R1 missing after CM-A arrived at the facility at 6:44 p.m., with R1 who was found two blocks away. [...]

Inspectors wroteBased on interview and document review, the facility failed to accurately assess elopement risk for 1 of 3 residents (R1) reviewed for elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for 2 of 2 residents (R48, R75) reviewed for call lights.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure feeding assistance and routine personal hygiene cares i.e., nail care, facial hair removal, was provided for 2 of 4 residents (R23, R28) reviewed for activities of daily living (ADLs) and whom were dependent on staff for such cares.

Inspectors wroteBased on interview and record review the facility failed to ensure an antibiotic ointment was still necessary for 1 of 1 residents (R75) reviewed for antibiotic use.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure preferences for drinks and food choices was followed for 2 of 2 residents (R38, R75) reviewed for food choices.

Inspectors wroteBased on interview and record review the facility failed to ensure an antibiotic was monitored, tracked and had an end date for 1 of 1 residents (R75) who was prescribed a topical antibiotic.

Inspectors wroteResident #51 R51's significant change Minimum Data Set (MDS) dated [DATE], indicated R51 had moderate cognitive impairment with medical diagnoses including type 2 diabetes, communication deficit or difficulties, depression, deformities of the musculoskeletal system and muscle weakness. R51's significant change MDS dated [DATE], indicated he required substantial to maximal assistance to move from lying to sitting to standing, partial to moderate assistance to roll left and was always incontinent of bowel movements. R51's significant change MDS dated [DATE], indicated R51 was at risk for developing pressure ulcers, did not have unhealed pressure ulcers, did not have other ulcers, wounds, or skin conditions of his feet, and did not reject care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staffing were available to ensure 1 of 1 resident (R18), reviewed for weight monitoring, had weights completed. Ensured a comprehansive skin assessment, following prescribed wound care orders and implemented intervention to promote healing for 2 of 3 residents (R2, and R51) admitted to the facility without pressure ulcers, ensure that 1 of 1 resident (R18) with continuous oxygen via nasal cannula had current physician orders for oxygen use and failed to assess oxygen saturation levels consistently reviewed for sufficient staffing, ensure adequate supervision was provided to prevent attempted elopement for 1 of 1 (R3) resident reviewed for wandering. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours per day. This deficient practice had the potential to affect all 64 residents who resided in the facility. Review of staff schedule postings for the months of July, August, September and December 2023, on the following dates there was no RN coverage for eight consecutive hours per day: 7/4/23, 7/15/23, 7/16/23, and 12/17/23. The facility was unable to provide verification (such as sign in sheets, documentation completed, email communication, etc.,) of RN in facility on 7/3/23, and 8/12/23. There were no RN's scheduled on the nursing master schedule on 7/3/23, and 8/12/23. During email communication from administrator on 2/8/24 at 12:47 p.m. RN coverage clarification were as follows: [...]

Inspectors wroteBased on interview and document review, the facility failed to complete an annual performance review for 5 of 5 nursing assistants (NA-E, NA-F, NA-G; NA-H, NA-I) whose employee files were reviewed. This had the potential to affect all 64 residents who resided at the facility.

Inspectors wroteBased on interview and document review, the facility failed to maintain a quality assurance process improvement (QAPI) committee that was effective in identifying, implementing actions, and continued monitoring to ensure residents received services to prevent pressure ulcers. This deficient practice had the potential to affect all 64 residents currently residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R48) were appropriately vaccinated against pneumonia upon admission. Furthermore, the facility failed to have a method or system to ensure the facility offered or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. This had the potential to affect all 64 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dignified conversation was maintained for 1 of 1 (R48) residents who was observed during morning cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide routine personal grooming and cleanliness for 1 of 1 residents (R24) reviewed for activities of daily living (ADLs) and who were dependant on staff for their care.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 residents (R18) reviewed for weight monitoring, had weights completed per physician orders. The facility also failed to implement physician orders for 1 of 1 resident (R30) with an order for pulse monitoring. Additionally, the facility failed to ensure special instructions were followed per physician orders for PRN Lasix administration for 2 of 2 residents (R1, R30) reviewed for quality of care. Findings Include: Weight Monitoring R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 was cognitively intact and had no rejection of cares. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent attempted elopement for 1 of 1 (R3) resident reviewed for wandering. Furthermore, the facility failed to evaluate and analyze R3's attempted elopements to develop targeted interventions to reduce the risk for elopement.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure ongoing monitoring of weight for nutrition status was implemented as directed for 1 of 1 residents (R55) reviewed for nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 resident (R18) who used continuous oxygen via nasal cannula had current physician order for oxygen use. The facility also failed to assess oxygen saturation levels consistently for 1 of 1 resident (R18) reviewed for respiratory care. Findings Include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 was cognitively intact and had no rejection of cares. The MDS section titled special treatments/respiratory treatment/oxygen therapy lacked indication R18 used oxygen. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene and personal protective equipment was utilized as recommended by nationally recognized standards during resident cares for 3 of 3 residents (R2, R48 and R51) reviewed for infection control.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the required nurse staffing document contained accurate staffing information. This had the potential to affect all 64 residents residing in the facility and/or visitors who may wish to view the information. Findings Include: Review of the facility master schedule and daily nurse posting for 1/24/24, indicated no changes or updates when staffing levels changed on the master schedule due to call-ins or staff leaving early. On the following dates with staff changes on the master schedule no updates were noted on the daily nurse staffing hours: -1/10/24-one nurse called in on the 2:00 p.m. to10:30 p.m., shift; no staff replacement noted. No update noted to daily nurse staffing for 1/10/24. -1/15/24-one nursing assistant (NA) called in on the 6:30 a.m to 2:30 p.m., shift; no staff replacement noted; [...]

Inspectors wroteBased on interview and record review, the facility failed to reduce the risk of accidents to prevent falls for one of one resident (R1) reviewed for falls with injuries. The facility failed to assess and add interventions following a positive Covid diagnosis with symptoms increasing the potential R1's risk for falls and did not comprehensively analyze and update the care plan with appropriate interventions following a fall that resulted in new fractures.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan that includes instructions and interventions indicating staff assistance with bathing, dressing, grooming, oral cares, mobility, toileting, dining, pain management, fall interventions, and the use of a TSLO (Thoracic-Lumbar-Sacral Orthosis) back brace for one of one resident (R1) within 48 hours of resident's admission.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of one resident (R1) reviewed for care plans. R1's care plan did not include included catheter cares, fall prevention and interventions, the use of a TSLO brace, wound care, bathing, dressing, grooming, oral cares, mobility, toileting, dining, oxygen use, and pain management care.

Inspectors wroteBased on interview and document review, the facility failed to revise the care plan to include a new diagnosis of Diabetes Mellitus for 1 of 1 resident (R2) who returned from the hospital with the new diagnosis and treatment orders for Diabetes Mellitus.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and complete cares for the placement of an indwelling catheter (a catheter tube that is inserted into the bladder through the urethra and remains in situ to drain urine into a bag) upon readmission from the hospital to the facility for one of one resident (R1) who was observed having an indwelling catheter with no documentation in the chart.

Inspectors wroteBased on interview, and document review, the facility failed to ensure licensed nursing staff, unlicensed nursing staff and therapy staff demonstrated competency skills related to placement of a TLSO brace (a specialized brace used to limit the motion in the thoracic, lumbar and sacral regions of the back, used to treat stable fractures or following surgery) for 1 of 1 (R1) resident assessed for quality of care and neglect concern allegations.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure comprehensive assessments for mechanical lift harness/sling size according to manufacturers's recommendations for 2 of 2 residents (R1, R2) and failed to appropriately assess and develop and implement an individualized care plan for safe mechanical lift transfers for R1. Additionally, failed to have a systematic approach for preventative maintenance tracking and repairs for 4 of 4 mechanical lifts.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 1 residents (R1) reviewed for allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of physical abuse were reported timely (within two hours) to the State Agency (SA) for 2 of 4 residents (R4, R5) reviewed for abuse.