Birch Healthcare Center

Based on interview and record review, it was determined that the facility failed to document that the resident and/or the resident's representative was fully informed of the risk and benefits of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents. (Resident identifier is #10.) Findings include:Review on 9/18/25 of Resident #10's diagnosis list revealed that he/she had diagnoses of Dementia, Depression and Cognitive communication deficit.Review on 9/18/25 of Resident #10's physician orders revealed Resident #10 was prescribed the following psychotropic medications:Trazodone HCL (hydrochloride) Oral tablet 100 MG (milligrams) Give 1 tablet by mouth at bedtime for insomnia, order date was 6/24/25Risperidone Oral tablet 0.5 MG Give 1 tablet by mouth two times a day for Depression, order date was 6/25/25Sertraline HCL Oral tablet 50 MG Give 1 tablet by mouth one time a day for Depression, order date was 6/25/25. Review on 9/18/25 of Resident #10's medical record revealed that there was no evidence Resident #10 was informed…

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 record review, it was determined that the facility failed to report an alleged violation of abuse no later than 24 hours to the State Survey Agency (SSA) for 1 of 2 residents reviewed for abuse in a final sample of 18 residents (Resident identifier is #67).Findings include:Interview on 9/16/25 at approximately 9:22 a.m. with Resident #67 revealed that he/she had an alleged verbal and physical altercation with Resident #68 on 9/14/25 after Bingo. Resident #68 grabbed Resident #67's upper arm. Resident #68 swore at Resident #67 and told them to die. Resident #67 said they reported the incident on 9/15/2025 to Staff F (Rehabilitation Director). Interview on 9/18/25 at 9:25 a.m. with Staff F revealed that Resident #67 informed them about the verbal and physical altercation. Staff F revealed that he/she notified Staff E (Social Service Director) and Staff G (Administrator). Interview on 9/18/25 at 9:35 a.m. with Staff G confirmed that they became aware of the resident to resident incident on 9/15/25. Staff G revealed that the allegation of abuse was not reported to…

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 record review, it was determined that the facility failed to ensure that residents received scheduled medications on days that they attended dialysis for 1 of 1 resident reviewed for dialysis in a final sample of 28 residents (Resident Identifier is #6).Findings include: Interview on 9/16/25 at approximately 1:41 p.m. with Resident #6 revealed that he/she attended dialysis on Mondays, Wednesdays, and Fridays for a diagnosis of Stage 5 Kidney Disease. Interview on 9/17/25 at approximately 2:00 p.m. with Staff B (Medication Nursing Assistant) revealed that Doxazosin medication was not given on days of dialysis. Review on 9/18/25 of Resident #6's medication administration record (MAR) revealed an order for Doxazosin Mesylate tablet 1 MG, give 1 tablet by mouth in the afternoon for HTN [Hypertension], dated of 6/5/25. Resident #6's MAR revealed that his/her Doxazosin was not given on the following dates: 8/6/25, 8/8/25, 8/10/25, 8/13/25, 8/15/25, 8/18/25, 8/22/25, 8/25/25, 8/27/25, 9/1/25, 9/3/25, and 9/17/25. Interview on 9/18/25 at approximately 11:16 a.m. with…

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 observations, interviews, and record review, it was determined that the facility failed to ensure open injectable medications were labeled in accordance with the manufacturer's instructions in 1 out of 2 medication carts observed. Findings include: Observation on 8/27/24 at approximately 8:30 a.m. of the orange medication cart on the B wing revealed an open multiple-dose vial of Lantus (Insulin Glargine) Solution without an open date and/or an open expiration/discard date that was in use for Resident #50. Interview on 8/27/24 at 8:40 a.m. with Staff A (Licensed Practical Nurse) confirmed the above finding. Review on 8/27/24 of the Lantus (Insulin Glargine) manufacturer's instructions revealed: The Lantus vials you are using should be thrown away after 28 days, even if it has insulin left in it.

Based on record review, observation, interview, and policy review, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) for 1 of 6 residents reviewed for infection control (Resident Identifier #55) and the facility failed to perform hand hygiene during medication administration for 3 of 5 residents observed (Resident Identifiers are #21, #44 and #49). Findings Include: Resident #55: Review on 8/27/24 of Resident #55's medical record revealed they had an order for EBP for medication received through a peripheral line and an infected wound. Observation on 8/27/24 at approximately 10:00 a.m. of Resident #55 revealed an EBP sign and PPE inside the resident's room. Staff B (Licensed Nurse Aide) was observed assisting Resident #55 with transfers and positioning without wearing a gown or gloves. Interview on 8/27/24 at approximately 11:35 a.m. with Staff B confirmed the above finding and revealed that they were aware that Resident #55 was on EBP. Review on…

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 reviews, it was determined the facility failed to follow physician orders related to notifying the provider when blood sugar level was above 400 milligram/deciliter (mg/dl) for 1 of 5 residents reviewed for unnecessary medications (Resident Identifier is #38). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th edition St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients . Review on 7/25/23 of Resident #38's active physician orders revealed the following orders: 1. Insulin Lispro 100 units/milliliters (ml) inject 10 units subcutaneously before meals for a diagnosis of diabetes mellitus type 2, notify the physician or nurse practitioner for blood sugar levels less than 60 or greater than 400 mg/dl with a start date of 6/6/23, scheduled for 7:30 a.m., 11:00 a.m., and 4:00 p.m. 2. Insulin…

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 record review, it was determined that the facility failed to store refrigerated medications within required temperatures per manufacturer's specification for 1 of 1 medication room observed (Birch Unit, A-Wing, medication room). Findings include: Observation on 7/24/23 at 8:45 a.m. of the medication room refrigerator revealed 2 unopened vials of Novolog insulin, 2 unopened vials of Humalog insulin, an unopened Levemir insulin pen, an unopened Lantus insulin pen, and an unopened Trulicity insulin pen stored up against an ice-frosted wall in the refrigerator. Review on 7/24/23 of manufacturer specifications for Novolog, Humalog, Levemir, Lantus, and Trulicity for insulin vials and pens indicates to store unopened items refrigerated between 36 degrees Fahrenheit (°F) to 46 °F. Review on 7/24/23 of the medication room Refrigeration Temperature Log revealed no temperature recordings on July 22 and 23, 2023, and temperatures were out of required range on 6/2/23 (34 degrees °F), 6/23/23 (34° F), 5/12/23 (32° F), and 5/14/23 (34° F), with no follow-up…

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 policy review, it was determined that the facility failed to ensure food was prepared and served in a sanitary environment in 1 of 1 main kitchens observed. Findings include: Observation on 7/24/23 at 8:44 a.m. in the main kitchen with Staff A (Food Service Director) revealed that the range hood was last inspected on 11/20/22 with a next service date of 180 days (approximately 5/20/23). Further inspection revealed dust particles encapsulating the light fixtures under the hood. In addition, all fire suppression discharge nozzles under the hood had dust particles on them. Interview on 7/24/23 at 8:48 a.m. with Staff A confirmed the above findings. Review on 7/27/23 of the facility's policy titled, Sanitation Inspection, last revised 3/20/23 revealed: All food service areas shall be kept clean, sanitary, free from litter, and rubbish, and protected from rodents, roaches, flies, and other insects. Review on 7/27/23 of the FDA [Food and Drug Administration] Food Code, dated 2022, retrieved from: https://www.fda.gov/media/164194/download, revealed .…

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 policy review, it was determined that the facility failed to ensure a safe and sanitary environment in 7 of 41 resident rooms observed on the Birch Unit. Findings include: Birch Unit Observation on 7/24/23 at approximately 11:30 a.m. revealed the following: Resident room [ROOM NUMBER] the bathroom door had large black scrapes along the bottom of the entire door that went up approximately 2 feet high. The bathroom door frame also had dark black marks from the bottom of the frame to approximately 12 inches high. Resident room [ROOM NUMBER] had approximately 10 white drywall patches on the wall behind the television. Each patch was approximately 2 inches by (x) 5 inches. Further inspection revealed a 12 inch x 2 inch large hole behind bed A. Resident room [ROOM NUMBER] the bathroom had black writing approximately 4 feet high on the wall opposite the toilet. This area was approximately 3 inches x 2 inches. The bathroom door had large black scrapes along the bottom of the entire…

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.