Birchwood Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #108) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #108 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 2 of 17 residents (Resident #12 and Resident #17) reviewed for assessments. 1. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #17 admitted to hospice services on 04/12/2025. 2. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #12 admitted to hospice services on 02/26/2025. These failures could place residents at risk of having inaccurate assessment, not having individual needs met and decreased quality of life.

Inspectors wrote2. Record review of Resident #41's face sheet, dated [DATE], reflected Resident #41 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions (a disconnect from reality, where an individual holds strongly to false beliefs that are not based in reality). Record review of Resident #41's annual MDS assessment, dated [DATE], reflected Section A1500 (Preadmission Screening and Resident Review (PASRR)) asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/or intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 5.56%, based on 2 errors out of 36 opportunities, which involved 1 of 6 residents (Resident #43) reviewed for medication administration. The facility failed to ensure MA A administered Resident #43's Artificial Tears and followed the physician's order for Resident #43's Moxifloxacin Ophthalmic Solution (antibiotic eye drops) on 06/17/2025. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #107) reviewed for infection control. The facility did not ensure LVN B performed hand hygiene while providing wound care to Resident #107. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 1 shower rooms on the secured unit and 1 of 2 dining rooms (main building) reviewed for physical environment. 1. The facility did not ensure the dining room did not have cobwebs and crane flies on the ceiling and walls. 2. The facility failed to ensure the shower in the secure unit did not have pink and black grime on the walls. These failures could place the residents at risk for decreased quality of life and infection due to unsanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #13) reviewed for incontinence. The facility failed to ensure Resident #13 was provided proper incontinent care. These failures could place residents at risk for urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 (Resident #29) of 14 residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #29's preference for double protein portions. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #13) reviewed for infection control. The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident #13. The facility failed to ensure CNA B used a clean wipe when cleaning Resident #13's peri area. These failures could place residents and staff at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their own established smoking policy for 1 of 2 smoking area (main building) reviewed for smoking policies. The facility did not ensure cigarette butts were disposed of in a metal container. This failure could place residents at risk of an unsafe smoking environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 residents (Resident # 9 and Resident #15) reviewed for dialysis. The facility failed to have a physician's order for dialysis for Resident #9. The facility failed to ensure nursing staff monitored Resident #15's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access) for signs and symptoms of infection and for the dressing to be intact. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #35) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #35's diagnoses on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (nurse's cart) reviewed for storage of medications. The facility failed to ensure the nurses' cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion.