Birchwood Care Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident call light cord was within reach from the shower floor for 1 of 1 multi-resident (R39, R14, R25, R32) bathroom reviewed for call light accessibility. Findings include: R39's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, had hallucinations and delusions and no refusals of care. R39 was independent with activities of daily living (ADLs) but needed substantial and/or maximal assistance with showers/bathing. R39 had diagnoses which included schizophrenia and cataracts. R39's care plan printed 5/3/24, identified R39 was a low fall risk and directed staff to educate and remind R39 to use the call light and call for staff when weak. R14's quarterly MDS dated [DATE], identified R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had hallucinations, delusions, inattention, disorganized thinking, and no rejections of care. R14 was independent with all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure a multi-resident bathroom ceiling vent fan was cleaned for 4 of 4 residents (R39, R14, R25, R32) reviewed for cleanliness of environment. Findings include: During observation on 4/29/24 at 12:24 p.m., grayish white colored dust thickly covered 50 to 75% of a bathroom ceiling vent. The ceiling vent fan ran but no air flow felt. During interview on 5/1/24 at 9:16 a.m., the administrator (admin) expected maintenance and housekeeping to keep vents and fans clean as often as necessary. Admin stated usually maintenance cleaned high vents and fans, and housekeeping cleaned lower vents and fans. The facility recently changed housekeeping from in-house to a contracted company, so a cleaning schedule was being developed. During interview on 5/1/24 at 9:22 a.m., the assistant director of maintenance (M)-B stated they cleaned vents and fans when dust was observed or when residents came and told them. M-B stated they tried to check rooms twice a month but sometimes didn't happen. M-B stated they had a log for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the medical provider of on-going medication refusals for 1 of 1 resident (R14) reviewed for notification of change. Findings include: R14's quarterly Minimum Data Set, dated [DATE], identified R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had hallucinations, delusions, inattention, disorganized thinking, and no rejections of care. R14 was independent with all ADLs. R14 had diagnoses of diabetes mellitus and schizophrenia. R14's Care Area Assessment (CAA) dated 11/3/23, dlirium triggered for inattention and disorganized thinking. The CAA identified the symptoms were not new and had abnormal blood sugar levels due to R14's refusal to take insulin. The CAA cognitive loss triggered due to refusal of cognitive assessment and staff indicating short and long-term memory loss, poor decision making, inattention, and disorganized thinking. The CAA indicated R14 received frequent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to ensure 2 of 2 residents (R47 and R 53)'s grievances were documented, responded to and resolved in a timely manner. Findings include: R47's 2/23/24 quarterly Minimum Data Set (MDS) assessment identified his cognition was intact, and he had behaviors which included hallucinations, delusions, and verbal behavior directed toward others. He had diagnoses which included Schizophrenia, major depressive disorder, dependent personality disorder, and obsessive compulsive disorder (OCD). R47 was independent with activities of daily living (ADLs), but needed redirection and cueing to correct daily routines. R47's current undated care plan identified target behaviors of hallucinations, thought blocking delusions, paranoia and disorganized thinking. Interventions included validation when he expressed delusional content, Associated Clinic of psychology (ACP) services weekly and as needed (PRN), 1:1 visits to allow R47 to vent his feelings. Medications as ordered, with monitoring for side effects and effectiveness. Observation/interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure allegations of potential abuse were reported to the administrator and State Agency (SA) immediately, but not later than 2 hours after the allegation is made, for 1 of 1 residents (R45) reviewed for resident-to-resident verbal altercation. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate impairment with tasks of daily life, fluctuating inattention behaviors, continuous disorganized thinking, and no altered level consciousness. R28's MDS indicated he was usually able to make himself understood and was able to understand others. MDS indicated R28 experienced hallucinations and delusions and displayed verbal behaviors directed towards others in addition to other behavioral symptoms not directed towards others. MDS indicated R28 did not have physical behavioral symptoms director towards others. R28's diagnoses included schizophrenia and anxiety. R28's Care Area Assessment (CAA) for communication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure allegations of resident-to-resident verbal abuse were thoroughly investigated, and protection provided for 1 of 1 residents (R45) who were involved in a resident-to-resident verbal altercation by R28. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate impairment with tasks of daily life, fluctuating inattention behaviors, continuous disorganized thinking, and no altered level consciousness. R28's MDS indicated he was usually able to make himself understood and was able to understand others. MDS indicated R28 experienced hallucinations and delusions and displayed verbal behaviors directed towards others in addition to other behavioral symptoms not directed towards others. MDS indicated R28 did not have physical behavioral symptoms director towards others. R28's diagnoses included schizophrenia and anxiety. R28's Care Area Assessment (CAA) for communication dated 7/7/23, indicated R28 had loose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect a resident's diagnosis of post traumatic stress disorder (PTSD) (a mental health condition triggered by a traumatic event) for 2 of 2 residents (R57, R14) reviewed for MDS accuracy. Findings include: The resident assessment instrument (RAI) manual version 3.0 indicated under section I, Active Diagnoses, the items in this section were intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Section I in the RAI manual further indicated definitions of active diagnoses were physician documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a comprehensive care plan for psychotropic medications for 1 of 5 residents (R56) reviewed for psychotropic medications. Findings include: R56's admission Minimum Data Set (MDS) dated [DATE], indicated R56 had intact cognition and experienced hallucinations. MDS indicated R56 had diagnoses of diabetes, depression, and a psychotic disorder other than schizophrenia. MDS indicated R56 received an antipsychotic on a routine basis and an antidepressant medication. R56's Care Area Assessment (CAA) dated 2/14/24, for psychotropic drug use indicated R56 had mental illness diagnoses and was being treated with long-term psychotropic medications. The CAA further indicated staff would follow the plan of care to maintain R56's current level of functioning for improvement with symptom relief. R56's physician orders included the following: - Olanzapine (Zyprexa) oral tablet 7.5 milligrams (mg), Give 1 tablet orally at bedtime to treat psychotic depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure appropriate interventions, as a result of multiple falls and comorbidities contributing to the risk of additional falls, were identified and implemented for 1 of 2 residents (R2) reviewed for accidents, hazards and supervision. Findings include: R2's Face Sheet form indicated the following diagnoses: paranoid schizophrenia, end stage renal disease, hypokalemia (low potassium), bilateral myopia (difficulty in focusing on objects that are far away), presbyopia (the loss of your eyes ability to focus on nearby objects), hypertension, and osteoarthritis. R2's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, had hallucinations and delusions, did not reject care, had a cane or crutch and a walker, did not have impairment in range of motion, was independent with activities of daily living (ADLs), was occasionally incontinent of bladder, had two or more falls without injury since the previous assessment, took…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess for and identify potential triggers to avoid re-traumatization for 2 of 2 residents (R57, R14) who had a history of trauma. Findings include: R57's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, had moderate depression symptoms, sometimes socially isolated, had verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed at others such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds 1 to 3 days of the previous 7 days. The MDS indicated R57 had delusions and further, rejected care, was independent with most activities of daily living (ADLs) had bipolar disorder, and manic depression. R57's Medical Diagnosis form dated 1/5/24, indicated R57 had post traumatic stress disorder (PTSD) (a mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was adequate monitoring and provider notification for insulin parameters for 1 of 3 resident (R56) reviewed for unnecessary medications. Findings include: R56's admission Minimum Data Set (MDS) dated [DATE], indicated R56 had intact cognition, experienced hallucinations, had no delusions, exhibited no physical or verbal behaviors, and had no rejection of cares. The MDS also indicated R56 had diagnoses of type 2 diabetes, depression, and schizoaffective disorder (a disorder characterized by a combination of symptoms of schizophrenia, like hallucinations and delusions, and a mood disorder, like depression). R56's Care Area Assessment (CAA) for self-care and mobility dated 2/14/24, indicated he was able to perform activities of daily living (ADLs) independently but required some cues and reminders as he could loose focus related to having active false fixed perceptions that required staff supervision to ensure follow through. R56's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for 3 of 5 residents (R260, R46, R10) observed to receive medication. A total of (3) errors out of 25 opportunities were identified resulting in a 12% (percent) facility error rate. Findings include: R260's physician orders dated [DATE], included the following order: • mucus relief oral tablet extended release 12 hour 600 milligram (MG) (guaifenesin) give 600 mg by mouth two times a day for RSV, respiratory distress related to acute respiratory distress syndrome. There was no stop date on the order. During interview and observation on [DATE] from 7:20 a.m., to 7:32 a.m., registered nurse (RN)-A stated she would be helping to administer medications until the trained medication aide (TMA) arrived. At 7:20 a.m., RN-A prepared R260's medications, except for the mucus relief and stated she did not see the medication for mucus relief. At 7:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to accommodate dietary preferences for 1 of 1 resident (R57) reviewed for food. Findings include: The facility form, Alternate Meal Choices, available seven days a week, indicated if a resident did not like a meal on the menu, a request for an alternate meal: peanut butter and jelly sandwich, grilled cheese sandwich, meat and cheese sandwich, and chef salad could be submitted. The facility Week 4 at a Glance menu dated 4/28/24, through 5/4/24 indicated the following food items: • 4/28/24: the breakfast items indicated choice of cereal, egg bake, sweet roll, milk; the noon meal indicated fried chicken mashed potatoes, chicken gravy, cascade veggies, pie, and milk. The alternate food item was country fried steak and gravy. The evening meal indicated corn dogs, macaroni and cheese, baked beans, seasonal fresh fruit and milk and the alternate was taco salad. • 4/29/24: the breakfast items indicated choice of cereal, fried eggs, toast,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility's current administration failed to ensure proper oversight for the facility's financial operations. This practice resulted in resident personal funds accounts being unaccounted for. This had the potential to affect all 58 residents who resided in the facility at the time of the survey. Findings include: The facility computerized Trust Transaction History dated 3/21/24, indicated a balance of $74,000.06 in the residents' trust fund bank account. The First Bank and Trust Savings Account statement dated 3/21/24, indicated a balance of $56,359.21. The First Bank and Trust Checking Account statement dated 3/21/24, indicated a balance of $900.72. According to all calculations, the computerized Trust Transaction History indicated a $74,000.06 balance in the resident's personal funds accounts. The First bank and Trusts savings and checking accounts totaled $57,259.93. The current amount of cash within the safe and cash box at the facility was $3,266.35., indicating a discrepancy of $13,473.78 which was unaccounted for. On 3/21/24 at 12:52…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 53 of 58 residents with personal funds accounts (including R5, R6, R8, R11 and R12) deposited with the facility, had access to the personal funds after hours and on weekends. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. On 3/21/24 at 8:41 a.m., R5 stated he could only get money out of his account twice a month. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact. On 3/21/24 at 8:44 a.m., R6 stated he could only pull money out of his account Monday through Friday from 8:00 a.m. until 10:00 a.m. R6 stated if the banking office was closed, he couldn't get his money. R8's admission MDS dated [DATE], indicated R8 was cognitively intact. On 3/21/24 at 8:54 a.m., R8 stated he would be able to take money from his account during banking hours from 8:00 a.m. until 10:00 a.m. but not after that time frame. R11's quarterly MDS dated [DATE], indicated R11 was cognitively intact.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to reconcile resident personal fund accounts for 53 of 58 residents (including R5, R6, R8, R11, and R12). In addition, the facility failed to provide quarterly statements for resident personal fund accounts for 53 of 58 residents reviewed for personal fund accounts. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. On 3/21/24 at 8:41 a.m., R5 stated he had not received a quarterly statement for his personal fund account. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact. On 3/21/24 at 8:44 a.m., R6 stated he had not received a quarterly statement for his personal fund account. R8's admission MDS dated [DATE], indicated R8 was cognitively intact. On 3/21/24 at 8:54 a.m., R8 stated he had not received a quarterly statement for his personal fund account. R11's quarterly MDS dated [DATE], indicated R11 was cognitively intact. On 3/21/24 at 9:04 a.m., R11 stated he he had not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to implement interventions to prevent elopement, failed to follow safety plan for leaving the premises, and failed to timely report missing person in accordance with care plan and facility policy for 1 of 1 resident (R1) who had a history of multiple elopements related to audible hallucinations. Findings include: During interview on 3/13/24 at 2:20 p.m., R1 stated he enjoyed being able to leave the facility to take walks, use public transportation, go to restaurants, and visiting with his mother. He managed his own money and had a bus card. R1 recalled running away from the facility this week and was not planning on coming back. R1 explained there was two ways he would leave the facility and indicated it was dependent on the voices he heard in his head. The first way was taking his phone, going to the nurses station to sign out, and get his GPS tracker. The other way was when the voices gave him the desire to escape or the need to runaway.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure appropriate services and treatment that included medication management and monitoring and failed to ensure coordination of care between mental health care providers to ensure the highest level of mental and psychosocial well being for 1 of 3 residents (R1) who had a diagnosis of schizophrenia with audible hallucinations and a court order for medication management to control symptoms of psychosis. Findings include: R1's court document dated 5/5/22 identified R1 does not have the ability to understand and use information about his mental illness, its symptoms, and treatment. Neuroleptic medications are currently prescribed for respondent (R1) by his treatment provider. They are prescribed to relieve his psychotic symptoms, including command hallucinations and paranoia. The documents included a [NAME] order (court order that gives the court the power to order administration of medication for committed person who is unwilling to take prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.