Birchwood Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, staff interviews and review of the facility policy, the facility failed to promote a dignified dining experience by serving resident meals on an overbed table in a small common area in front of the nurse's station for four residents (Resident (R)5 R23, R72 and R125) out of 21 residents residing in the memory care unit and reviewed for dignity while dining.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to provide a homelike environment in good repair for six of 21 residents (Resident (R) 4, R5, R23, R72, R114 and R125) residing on the Memory Care Unit. Specifically, the facility failed to maintain cabinets, nightstands, windowsills, heating units, cubicle curtains, baseboards, bedroom doors and overbed table stands in good repair and safe operating condition. The failure to maintain an environment in good repair and homelike had the potential to affect the residents' psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff followed physician dietary orders for one of five residents (Resident (R)146 reviewed of 30 sampled residents. This deficient practice has the potential for resident not to receive sufficient calories to prevent further nutritional problems.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)146 reviewed for side rails out of 30 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteComplaint #: NJ178726 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to sanitize and ensure that the frying pan was cleaned to prevent microbial growth. This deficient practice was evidenced by the following: On 11/14/24 at 11:36 a.m. the surveyor, who was accompanied by the Director of Food Services (DFS), observed in the kitchen, Dietary Aide (DA #2) washed a frying pan, rinsed, and then dipped the frying pan in the sanitizer for less than 3 seconds and removed and placed the frying pan on the side of the sink to drain. During an interview with the Director of Food Services (DFS) at 11:09 a.m., he stated that the sanitizing step should not be missed because it was the most important step, and it killed the bacteria and the germs. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to a.) store potentially hazardous foods (PHFs) in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: (PHFs) are foods that must be kept at certain temperatures to minimize the growth of pathogenic microorganisms that may be present in the food or to prevent the formation of toxins in the food. Generally, PHFs are moist, nutrient-rich and have a neutral ph.) On 7/24/24 at 10:05 AM in the presence of the Food Service Director (FSD) and the Administrator in training (AIT) the surveyor observed the following: 1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to assess for complications upon residents' return from the renal dialysis (RD) center for 2 of 5 residents (Resident #55 and Resident #146) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. On 7/22/24 at 11:07, AM the surveyor observed Resident #55 lying in bed with the television on, wearing glasses, call light within reach. The resident stated, I go to dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) M-W-F, but I refused to go today because I don't feel good. I usually get my medication and meal before I leave for dialysis. I have my access on left arm and the nurses checks on this at times. A review of the medical record revealed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), according to the physician's order to meet the needs of the resident. The deficient practice was identified for one (1) of 34 residents, (Resident #55) reviewed for medication management. The deficient practice was evidenced by the following: On 7/22/24 at 11:07 AM, the surveyor observed the Resident #55 in the Unit 3 North Wing in their room, lying in bed with the television on, wearing glasses, and call light within reach. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during medication pass on 1of 2 units (Unit 3 Low side) and b.) follow Center for Disease Control recommendations and guidelines for Hand Hygiene. This deficient practice was evidenced by the following: On 7/24/24 at 7:56 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) prepare medication for administration to an unsampled resident in room [ROOM NUMBER]. The RN opened the drawer of the medication cart, retrieved the blister packs (multi-use medication packs), and removed the medications amlodipine besylate10mg tablet, colace 100mg tablet and doxazosin mesylate 2mg tablet. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan to address the anticoagulant medication prescribed for 1 of 3 residents (Resident # 115) reviewed for anticoagulant medications and evidence by the following: On 7/22/24 at 12:54 PM, the surveyor observed Resident #115 in room and the resident stated takes an anticoagulant medication. The surveyor reviewed the Electronic Medical Records for Resident # 115 that revealed the following: According to the admission Record indicated that Resident # 115 was admitted with diagnoses that included Atrial Fibrillation. According to the Physician's Order Summary Sheet, the resident had the following physician's order for by mouth administration of medications: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that the physician signed and dated monthly medication orders. The deficient practice was identified for 5 of 34 residents reviewed (#2, 84, 115, 32 and 33) and occurred over a 3 month period. The deficient practice was evidenced by the following. 1. A review of the hybrid medical record for Resident # 2 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 2. A review of the hybrid medical record for Resident # 84 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 3. [...]

Inspectors wroteComplaint # NJ00167683 Based on observation and interview, it was determined that the facility failed to maintain the residents' environment and living areas in a sanitary and homelike manner. This deficient practice was identified for 1 of 5 nursing units observed for the facility environment task. This deficient practice was evidenced by the following: On 7/22/24 at 10:30 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/23/24 at 11:30 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/24/24 at 9:49 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/22/24 at 11:29 AM, the surveyor interviewed the porter who stated the floors are done daily. He also stated the rotunda was done already and that he has not done 400 wing yet. [...]

Inspectors wroteNJ 00167683 NJ 00172468 Repeat Deficiency Based on observation, interview, and record review it was determined that the facility failed to ensure the accurate assessment of residents using the Minimum Data Set (MDS) assessment tool. The deficient practice was identified for 3 of 34 residents (#94, 37, 586) reviewed for MDS accuracy and is evidenced by the following. 1. The surveyor observed Resident #94 on 7/23/24 at 11:58 AM, lying in bed with eyes closed. A review of the hybrid medical record revealed the resident was admitted with diagnoses including but not limited to cerebral infarction, gastrostomy, and seizure disorder. Wound Care Consultant reports from 5/6/24 through 7/22/24 documented chronic moisture associated skin damage (MASD) of the sacral area. [...]

Inspectors wroteComplaint # 173271 Based on interview, record review and review of pertinent facility documentation it was determined that the facility failed to a.) thoroughly assess a skin discoloration that was identified on an admission assessment and, b.) implement a care plan for a resident identified as a high risk for skin breakdown. This deficient practice was identified for 1 of 4 residents (Resident #585) reviewed for pressure ulcers and was evidenced by the following: According to the admission Record, Resident #585 was admitted to the facility with the diagnoses which included but was not limited to; spinal stenosis cervical region, muscle wasting and atrophy and type two (2) diabetes mellitus. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous and dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during multiple kitchen tours and was evidenced by the following: On 7/12/2022 at 9:45 AM, the surveyor conducted an initial tour with the Food Service Director (FSD) and observed the following: A large ice machine with a brown and black substance along the entire baffle (device used to restrain the flow of ice or to prevent the spreading of ice in a particular direction) along with dripping condensation into the ice below. The FSD wiped the baffle with a paper towel which removed most of the substance. The FSD acknowledged it was not clean. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a significant change assessment was completed for Residents #66 and #140 for a total of two quarters. This deficient practice was identified for 2 of 2 residents reviewed, and was evidenced by the following: 1. On 7/12/22 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident#66 was cognitively impaired and a wanderer. On that same date at 11:00 AM, the surveyor observed the resident standing in the nursing station with the LPN/UM. The resident was not able to respond appropriately to the surveyor's questions. Later on, the Certified Nursing Aide (CNA) came and accompanied the resident to be toileted by hand-held assistance while walking. The surveyor reviewed the medical records of Resident #66: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow a Physician's Order (PO) for the use of Oxygen (O2) for 2 of 4 residents (Resident#150 and #678), b.) develop a care plan for the use of O2 for 2 of 4 residents (Resident#93 and #678), and c.) date and store the O2 cannula for 1 of 4 residents (Resident #93) reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 7/12/22 at 10:59 AM, the surveyor observed resident #150 in their bed with an oxygen nasal cannula (N/C; O2 tubing that is placed in the resident's nose) in place. The oxygen concentrator (a medical device that gives you extra oxygen) reflected the oxygen was set at 5 liters (L). The surveyor reviewed the medical records of Resident #150. The resident's admission Record (face sheet; [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to assure that a.) a medications were available for administration during the medication administration observation for one (1) of four (4) residents (Resident #98) observed, b.) medications that were ordered by the physician were available for administration during the months of May, June and [DATE] for two (2) of five (5) residents, (Resident #12 and #93) who attended the resident council meeting and c.) a medication was removed from active inventory after being discontinued in [DATE] until surveyor inquiry for one (1) of five (5) medication carts inspected. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to: a.) appropriately perform hand hygiene during the medication pass observation for 1 of 5 nurses, and during incontinence care for 1 of 3 residents (Resident #158), b.) appropriately don (put on) Personal Protective Equipment (PPE) prior to entering and while providing care to residents on Transmission Based Precautions (TBP), c.) appropriate clean multi-use resident equipment, d.) follow appropriate sequential infection control practices when providing care to residents on TBP, and e.) follow the Center for Disease Control (CDC) guidelines and facility policies and procedures to prevent the spread of infection to residents. [...]

Inspectors wroteBased on the interview, and review of medical and facility policy, it was determined that the facility failed to provide information in a manner easily understood by the resident or resident representative about the right to formulate an Advanced Directive (AD). This deficient practice was identified in 1 of 3 residents reviewed for AD (Resident #150) and evidenced by the following: During an interview of the surveyor on 7/15/22 at 11:11 AM, Resident #150 stated that he/she does not recall if staff offered them AD information. The surveyor reviewed the electronic Medical Record (eMR) for Resident #150. The resident's admission Record (face sheet; an admission summary) indicated that the resident was admitted to the facility and had diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 3 of 35 residents reviewed (Resident #66, #149, and #167) as evidenced by the following: 1. On 7/12/22 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident#66 was cognitively impaired and a wanderer. On that same date at 11:00 AM, the surveyor observed the resident standing in the nursing station with the LPN/UM. The resident was not able to respond appropriately to the surveyor's questions. During the observation the surveyor could not observe a wander guard on the resident. The surveyor reviewed the medical records of Resident #66: [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to clarify a physician order for 1 of 3 residents (Resident #63) reviewed for code status according to professional standards of clinical practice. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a physician's order (PO) for a right-hand grip splint. This deficient practice was identified for 1 of 3 residents (Resident #73) reviewed for limited range of motion (ROM). This deficient practice was evidenced by the following: On 7/12/22 at 11:30 AM, the surveyor observed the resident awake, dressed, and seated in a wheelchair in the rotunda area. The resident's right hand was observed contracted with no device in use. The resident was alert, and able to answer questions appropriately. Later that same day at 01:00 PM, the surveyor observed the resident out of bed seated in a wheelchair in their room with no device in use. On 7/13/22 at 11:50 PM, the surveyor observed the resident awake, out of bed and seated in a wheelchair. The resident was self-propelling back to their room. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly label an opened Blood Glucose test strip, b.) identify, and dispose of an expired biological in 1 of 5 medication carts and 1 of 2 medication rooms inspected. This deficient practice was evidenced by the following: On [DATE] at 9:41 AM, the surveyor inspected wing three (3) medication (med) room in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed one box of Sterile 0.9% NaCl (Sodium Chloride) solution for inhalation dated [DATE]. The surveyor interviewed LPN #1 who stated that the med room is inspected by the Unit Manager (UM) who is away on vacation. LPN #1 also acknowledged the expired Sterile Sodium Chloride for inhalation should not have been in the med room. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to safety store Oxygen (O2) equipment in a resident's private room. This deficient practice was identified for one of six resident's reviewed, (Resident #678) for respiratory care and was evidenced by the following: On 7/12/22 at 11:25 AM, the surveyor observed Resident #678 laying in bed in their room. At that time, the surveyor attempted to interview the resident and the resident responded with yes or no answers. The surveyor observed a free standing, portable O2 cylinder in the upright position in the resident's room to the left of the resident's nightstand while facing the head of the resident's bed. The portable O2 cylinder was not observed to be stored in a container. [...]