Birchwood Terrace Rehab & Healthcare

Inspectors wroteBased on observations, interviews, and policy reviews, the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide dignity and respect to residents who require feeding assistance for 8 of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to protect one out of two sampled residents' [Resident #2] right to be free from physical abuse from a resident to resident altercation.

Inspectors wroteBased on observations, interviews and record review the facility failed to implement an infection prevention and control program that follows the accepted national standards regarding preventing, identifying and controlling communicable diseases. Specifically, the facility failed to follow the CDC (Centers of Disease Control) and state health department recommendations for outbreak management, related to testing and other mitigation strategies including containment and personal protective equipment (PPE) use. The deficient practices associated with the lack of infection control measures led to the determination that the residents in the facility were in immediate jeopardy of serious harm and/or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to providing safe water temperatures of less than 120 degrees Fahrenheit (F).

Inspectors wroteBased on observation, resident interview, staff interview, and record review, the facility failed to provide a respectful and dignified dining experience that enhances residents' quality of life as evidenced by failure to serve meals to residents at a table at approximately the same time, and the facility failed to ensure care was provided to residents to maintain their respect and dignity as evidenced by the failure to assist with care related to Activities of daily living (ADLs) for 8 of 47 sampled residents (#72, #69, #90, #100, #72, #81, #12, and #47).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that resident care plans described the resident specific care and services that will be furnished so that the resident can attain or maintain his/her highest practicable physical, mental and psychosocial well-being for 10 of 40 sampled residents (Residents #65, #67, #50, #282, #41, #87, #34, #93, and #109, and #76) related to activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) without assistance receives the proper level of assistance for 11 of 40 sampled residents (Residents #65, #67, #50, #282, #41, #87, #34, #93, #109, #76, and #9)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide engaging activities both in and out of resident rooms for 1 of 40 sampled residents (Resident #78); failed to provide an ongoing activities program to support residents in their choice of group, individual, and independent activities to meet the interests of and support the well-being of each resident as evidenced by a lack of opportunities for residents to go outside of 1 of 3 units (Unit B); and failed to provide weekend activities for all interested residents.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that residents who are trauma survivors receive trauma-informed care that mitigates triggers that may re-traumatize residents for two of 5 residents sampled for trauma (Residents # 91, #18).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and services to attain the highest practicable well-being for each resident and in accordance with each resident's plan of care, potentially impacting all residents of the facility. Per review of the Facility assessment dated [DATE], the percentage of residents that require a one or two person assist for activities of daily living (ADL) is 49% for transferring, 11% for eating, and 45% for toileting and residents that are completely dependent on staff assistance for ADLs is 25% for transferring, 15% for eating, and 25% for toileting. The facility determined the staffing needs to meet the care requirements of the resident population is based on meeting or exceeding the minimum PPD requirements. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication error rates were not 5% or greater. The total error rate for all observations was calculated at 72% for 4 of 10 sampled residents (Residents #50, #20, #13, and #45).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident was assessed for injuries and complications in accordance with professional standards and per facility policy after sustaining a fall for 1 of 40 residents in the sample (Resident #22).

Inspectors wrotePer observation and staff interview the facility failed to ensure that medications and biologicals were removed from use when expired.

Inspectors wroteBased on interviews and record review, the facility failed to notify the resident in writing of a transfer/discharge for one applicable resident (Resident #1).

Inspectors wrotePer interview and record review the facility failed to ensure that annual performance reviews were completed for 4 of 4 staff members in the applicable sample. On 6/14/23 this surveyor requested the 2022 annual performance reviews of 5 sampled staff members. On 6/14/23 at 3:15 PM the Administrator was unable to produce the reviews and confirmed that they had not been completed since 2021.

Inspectors wroteBased upon interview and record review, the facility failed to ensure that comprehensive care plans were revised with person-centered, effective interventions to prevent falls for 1 resident [Res. #78] of 27 sampled residents.

Inspectors wroteBased upon interview and record review, the facility failed to ensure residents received adequate supervision to prevent falls and/or injury from falls for 1 resident [Res. #78] of 27 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize and competently and thoroughly address the physical, mental, and psychosocial needs of 1 of 8 sampled residents who reside on the special care unit (Resident #9). The facility also failed to implement individualized approaches to care that are directed toward understanding, preventing, relieving, and/or accommodating Resident #9's expressions of distress with the provision of personal care.

Inspectors wroteBased on interviews and record review, the facility failed to accommodate a resident's request to leave the facility for 1 of 27 sampled residents (Resident #477) who wanted to attend a family gathering and failed to have a system to inform residents and/or their representative on the need to request and the process to request to leave the facility.

Inspectors wrotePer observation and staff interview the facility failed to ensure that the resident shower and tub rooms in the special care unit were kept orderly and sanitary.