Birchwood Rehabilitation & Healthcare Center

Inspectors wroteBased on review of select facility policies and procedures and clinical records, observations, and staff interviews, it was determined the facility failed to ensure a resident who needs respiratory care is provided such care, consistent with the professional standard of practice and the comprehensive person-centered care plan for one out of 27 residents reviewed (Resident 38) and failed to ensure tracheostomy care was provided consistently with professional standards of practice for one out of four residents reviewed with the presence of a tracheostomy (Resident 81).

Inspectors wroteBased on clinical record review, select facility policy review, and staff interview, it was determined the facility failed to ensure effective pain management by administering pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions prior to administering an opioid pain medication ordered on an as needed basis for one of four residents reviewed for pain management (Resident 81).

Inspectors wroteBased on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure accurate reconciliation and documentation of controlled substance medications for 3 out of 27 residents reviewed (Residents 6, 94, and 115).

Inspectors wroteBased on a review of clinical records, facility policy, documentation provided by the facility, and staff interviews, it was determined the facility displayed past non-compliance by failing to protect one of 27 residents reviewed (Resident 34) from sexual abuse perpetrated by another resident (Resident 33).

Inspectors wroteBased on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement a discharge plan that accurately reflects a resident's discharge goals or preferences for one out of 27 residents reviewed (Resident 26).

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined the facility failed to complete an accurate Minimum Data Set (MDS) for one of 27 residents reviewed (Residents114).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to address the presence, care, monitoring, and maintenance of a vascular access device for 1 of 17 residents reviewed (Resident 114).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered residents' medications for two of 27 residents reviewed (Residents 94 and 121).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure timely identification, confirmation, and physician notification of a significant unplanned weight loss for 1 of 27 residents reviewed (Resident 118).

Inspectors wroteBased on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to timely notify the physician of abnormal lab results for one resident out of 27 residents reviewed (Resident 15).

Inspectors wroteBased on observation, review of select facility policy, and staff interview, it was determined the facility failed to ensure an environment free from potential spread of infection and failed to properly store resident personal care equipment on 2 of 2 nursing units (First Floor and Second Floor).

Inspectors wroteBased on review of clinical records, facility investigative reports, and staff interviews, it was determined the facility failed to adequately investigate resident falls and timely develop and implement effective safety interventions to prevent falls for residents with a known history of falls and unsafe behaviors. This deficient practice resulted in repeated falls for one resident (Resident 3) and a serious injury (fracture of knee) requiring hospitalization for another resident (Resident 1), affecting two of the seven sampled residents.

Inspectors wroteBased on review of the facility's abuse prohibition policy and procedures, report of alleged abuse, clinical record review, and staff interviews, it was determined the facility failed to fully implement its abuse prohibition procedures to identify potential sexual abuse, ensure timely notification of administration and the State Survey Agency, notify the resident's representative and physician, and promptly investigate an allegation of sexual abuse for one of seven sampled residents (Resident 2).

Inspectors wroteBased on review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to implement individualized, person-centered interventions identified in the care plan to address dementia-related behaviors for one of seven sampled residents (Resident 4).

Inspectors wroteBased on clinical record review, facility policy review, staff interviews, and observations, it was determined the facility failed to ensure the safety and supervision of two residents identified at risk for wandering and elopement. The facility allowed one resident lacking decision-making capacity and under court-appointed guardianship to leave the premises unsafely (Resident 2) and failed to prevent another resident with known wandering behaviors from exiting through malfunctioning or unsecured doors (Resident 3), resulting in serious injury for two of five residents. These failures placed five residents (Residents 1,2, 3, 4 and 5) at the facility in immediate Jeopardy in which the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death.

Inspectors wroteBased on a review of clinical records, select investigative reports, and employee job descriptions and staff interview it was determined the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to monitor one resident's whereabouts and prevent an elopement for one (Resident 3) out of 5 sampled residents and failed to ensure the safety and supervision of a resident who lacked decision-making capacity and required protective oversight, allowing the resident to exit the building, placing the resident at risk for serious harm (Resident2) which created an Immediate Jeopardy situation.

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an effective, individualized, person-centered care plan to address a resident's dementia-related behavioral symptoms for one of 5 residents reviewed (Resident 1).

Inspectors wroteBased on review of clinical records, select facility policy, and staff interview it was determined the facility failed to evaluate nutrition and hydration requirements to ensure acceptable parameters of nutritional status and hydration status to the extent possible for one resident out of 12 sampled (Resident A1).

Inspectors wroteBased on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to obtain physician orders for oxygen therapy and failed to maintain oxygen equipment in a functional and sanitary manner for four residents out of 23 sampled (Residents 6, 56, 60 and 68).

Inspectors wroteBased on a review of the Resident Assessment Instrument (RAI) Manual, clinical record review, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within the required 14-day timeframe for 2 of 23 residents reviewed (Residents 41 and 45).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one out of 23 residents sampled (Resident 49).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to address the resident's immediate care and safety needs upon admission for one of 23 residents reviewed (Resident 318).

Inspectors wroteBased on select facility policy, a review of clinical records and resident and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered a resident's medications for one resident of 23 reviewed (Resident 56).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined the facility failed to ensure a timely and thorough assessment of pressure ulcers/injuries upon admission for one of 23 sampled residents (Resident 39).

Inspectors wroteBased on observations, select policy review, a review of clinical records, and staff interview it was determined the facility failed to provide care and services designed to prevent potential complications associated with tube feedings for one resident receiving an enteral feeding out of 23 residents sampled (Resident 58).

Inspectors wroteBased on clinical record and select facility policy review and staff interview, it was determined that the facility failed to provide effective pain management and administer pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident out of four residents sampled for pain (Resident 114).

Inspectors wroteBased on observations, a review of clinical records, resident and staff interviews, it was determined the facility failed to provide sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by one resident out of 21 sampled (Resident 97).

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that a PRN (as-needed) psychotropic medication was limited to 14 days without a documented physician rationale for extension and failed to document the use of non-pharmacological interventions prior to administering a PRN antianxiety medication, for Resident #39.

Inspectors wroteBased on review of the facility's Medication Storage and Labeling policy, observations, manufacturer's instructions, and staff interviews, it was determined that the facility failed to ensure medications and biologicals were stored and labeled in accordance with professional standards and manufacturer recommendations. Specifically, the facility failed to ensure that opened multi-dose medication vials were labeled with an open date and failed to ensure that expired intravenous (IV) supplies were not available for resident use on two of two nursing areas (First Floor Nursing Unit and First Floor Medication Room).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined the facility failed to ensure that a dependent resident was provided with the necessary services to maintain personal hygiene by failing to provide showers as scheduled for one of six residents sampled (Resident CR1).

Inspectors wroteBased on review of select facility policy and clinical records, and staff interview it was determined the facility failed to timely monitor the nutritional parameters of a resident with an identified significant weight loss for one of six residents sampled (Resident CR1).

Inspectors wroteBased on a review of clinical records, select facility policy, observations and staff interview it was determined the facility failed to ensure the resident environment was free from potential accident hazards for two out of two nursing units observed (100 and 200 halls).

Inspectors wroteBased on clinical record review, review of a facility investigation, and staff interview, it was determined the facility failed to implement planned interventions to prevent a fall with injury, resulting in a facial fracture for one resident (Resident 1) out of 5 reviewed.

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in one of the two nursing halls (First floor nursing unit).

Inspectors wroteBased on a review of clinical records, observations and staff and resident interviews it was determined that the facility failed to provide planned care and services, consistent with professional standards of practice to treat pressure sores and prevent worsening for one resident out of 19 sampled (Resident 32).

Inspectors wroteBased on clinical record and select policy review, and staff interview it was determined that the facility failed to provide care and services designed to prevent potential complications with enteral tube feedings for one resident receiving an enteral feeding out of 19 residents sampled (Resident 56).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 19 residents sampled (Resident 46).

Inspectors wroteBased on observation, a review of temperature logs and staff interview it was determined that the facility failed to store drugs and pharmacy supplies under proper temperatures (2nd Floor Medication Room) and adhere to expiration/use by dates in one medication storage rooms out of two medication storage rooms.

Inspectors wroteBased on review of clinical records and facility-initiated transfer notices and a staff interview, it was determined that the facility failed to provide written notices of facility-initiated hospital transfers of residents, prepared in a language and manner that could be easily understood to three out of 19 residents reviewed (Resident 32, 56, and 87).

Inspectors wroteBased on a review of facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview it was determined that the facility failed to assure that one resident (Resident B2) out of four sampled was free from physical abuse perpetrated by another resident (Resident B1).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to develop a person-centered comprehensive plan of care to meet the specific supervision needs of one resident out of 12 sampled (Resident B1).

Inspectors wroteBased on review of select facility policy, clinical records and documentation and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of 12 sampled (Resident A1).

Inspectors wroteBased on a review of select facility policy, the minutes from Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined that the facility failed to demonstrate sufficient efforts to respond and resolve resident and/or family complaints that includes concerns expressed during Resident council, including those voiced by eight residents. (Resident 1, 8, 13, 14, 15, 16, CR2 and CR6)

Inspectors wroteBased on a review of clinical records and facility documentation, and staff, resident and family interview, it was determined the facility failed to develop operational policies and procedures, and follow CMS (Center for Medicare and Medicaid Services) guidance to protect the resident from unacceptable practices of disenrolling residents from the Medicare Advantage Plans by ensuring all risks of disenrolling are explained and the residents are competent in making the informed decision for nine of 20 reviewed (Resident 9, 10, 11, 12, CR3, CR4, CR5, CR6, and CR7).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on one of two resident care units. (first floor)

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene, by failing to provide showers as scheduled for two of 20 residents sampled (Residents 3 and 12).

Inspectors wroteBased on review of clinical records, information submitted by the facility, and select facility reports and staff interviews, it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of one resident at risk for elopement (Resident 2) and failed to implement appropriate interventions based on individual needs of a resident at increased risk for falls to promote resident safety and prevent falls for one resident (Resident 3) out of 20 sampled.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain infection control practices to prevent spread of infection for one of 20 sampled residents. (Resident 5)