Inspection Reports for Birch Healthcare Center
62 Rochester Hill Rd, Rochester, NH 03867, United States, NH, 03867
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 18, 2025
Visit Reason
The inspection was conducted to investigate complaints related to medication documentation, abuse reporting, and dialysis medication administration at Birch Healthcare Center.
Findings
The facility failed to document that a resident was fully informed about psychotropic medication risks and benefits, failed to timely report an alleged abuse incident to the State Survey Agency, and failed to ensure scheduled medications were given on dialysis days for a resident.
Complaint Details
The complaint investigation included review of medication documentation for psychotropic drugs, reporting of an alleged resident-to-resident abuse incident, and medication administration on dialysis days. The abuse allegation was not reported to the State Survey Agency as required.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to document that the resident and/or representative was fully informed of the risks and benefits of psychotropic medications for 1 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report an alleged abuse violation to the State Survey Agency within required timeframe for 1 of 2 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure scheduled medications were given on dialysis days for 1 of 1 resident reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for unnecessary medications: 5
Total residents in final sample: 18
Residents reviewed for abuse: 2
Residents reviewed for dialysis: 1
Dates Doxazosin medication was not given: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Resource Nurse | Confirmed failure to document resident informed consent for psychotropic medications | |
| Rehabilitation Director | Notified about resident-to-resident abuse incident | |
| Social Service Director | Notified about resident-to-resident abuse incident | |
| Administrator | Confirmed awareness of resident-to-resident abuse incident but did not report to SSA | |
| Director of Nursing | Confirmed abuse incident was not reported to SSA and had not spoken to involved residents | |
| Medication Nursing Assistant | Revealed Doxazosin medication was not given on dialysis days | |
| Unit Manager | Confirmed missed medications and lack of provider notification | |
| Nurse Practitioner | Was not aware that Doxazosin was not given on dialysis days and was not notified |
Inspection Report
Routine
Deficiencies: 3
Aug 29, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication labeling and infection prevention and control protocols, including adherence to CDC guidance on Personal Protective Equipment (PPE) and hand hygiene during medication administration.
Findings
The facility failed to ensure open injectable medications were properly labeled according to manufacturer instructions and failed to follow CDC guidance for PPE use for Enhanced Barrier Precautions for one resident. Additionally, hand hygiene was not performed during medication administration for three residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Open multiple-dose vial of Lantus (Insulin Glargine) Solution was not labeled with an open or expiration/discard date as required. | Level of Harm - Minimal harm or potential for actual harm |
| Staff failed to wear gown or gloves when assisting a resident on Enhanced Barrier Precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Staff did not perform hand hygiene between medication administration for three residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Confirmed finding of unlabeled injectable medication |
| Staff B | Licensed Nurse Aide | Observed not wearing gown or gloves while assisting resident on Enhanced Barrier Precautions |
| Staff C | Medication Nurse Assistant | Observed not performing hand hygiene between medication administration for three residents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 16, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding a fall incident involving Resident #1, where improper use of equipment during transfers was suspected to have caused injury.
Findings
The facility failed to ensure proper use of Hoyer lift equipment during transfers, resulting in Resident #1 falling and sustaining an acute L1 compression fracture and a fracture to the right talar neck. Staff were unaware of resident-specific sling sizing, and Resident #1 was found to be in the wrong sling at the time of the incident.
Complaint Details
The investigation was complaint-related, focusing on a fall incident involving Resident #1. The complaint was substantiated as the fall was linked to improper use of the Hoyer lift sling.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff use equipment properly during transfers, resulting in a fall with fracture for Resident #1. | Level of Harm - Actual harm |
Report Facts
Resident weight: 153
Date of incident: Mar 25, 2024
Date of device/transfer evaluation: Mar 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Heard noise and found Resident #1 on the floor after fall |
| Staff B | Licensed Nursing Assistant | Involved in transfer during which Resident #1 fell; unaware of resident-specific sling sizing |
| Staff C | Licensed Nursing Assistant | Assisted in transfer during which Resident #1 fell |
| Staff D | Licensed Nursing Assistant | Unaware of specific Hoyer pads for residents |
| Staff E | Licensed Nursing Assistant | Used sling size based on visual judgment, unaware of assessments |
| Staff F | Unit Manager | Reported that assessments are done to determine sling size based on resident weight |
| Staff G | Director of Nursing | Confirmed Resident #1 was in the wrong Hoyer sling on the day of the incident |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jul 26, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to follow physician orders related to notifying the provider when blood sugar levels were above 400 mg/dl, improper storage of refrigerated medications, unsanitary food preparation environment, and unsafe and unsanitary resident rooms.
Findings
The facility failed to notify the physician or nurse practitioner of blood sugar levels above 400 mg/dl for Resident #38 as ordered, failed to maintain medication refrigerator temperatures within required ranges, failed to maintain a sanitary kitchen environment, and failed to ensure a safe and sanitary environment in several resident rooms on the Birch Unit.
Complaint Details
The complaint investigation found that Resident #38's blood sugar levels above 400 mg/dl were not reported to the physician or nurse practitioner as ordered. Interviews with nursing staff and the medical director confirmed lack of notification and documentation. Additional findings included medication storage and environmental sanitation issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to follow physician orders related to notifying the provider when blood sugar level was above 400 mg/dl for Resident #38. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store refrigerated medications within required temperatures per manufacturer's specifications in the medication room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was prepared and served in a sanitary environment in the main kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a safe and sanitary environment in 7 of 41 resident rooms observed on the Birch Unit. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Blood sugar readings above 400 mg/dl: 12
Temperature log out of range: 4
Resident rooms with environmental deficiencies: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse | Interviewed regarding notification procedures for blood sugar levels above 400 mg/dl |
| Staff E | Regional Registered Nurse | Interviewed and confirmed lack of documentation for notifications of blood sugar levels above 400 mg/dl |
| Staff F | Medical Director | Interviewed and confirmed not being notified of Resident #38's blood sugar levels above 400 mg/dl |
| Staff B | Unit Manager | Interviewed and confirmed medication storage temperature and refrigerator log deficiencies |
| Staff A | Food Service Director | Interviewed and confirmed unsanitary conditions in the main kitchen |
| Staff C | Regional Director of Operations | Interviewed and confirmed environmental deficiencies in resident rooms on Birch Unit |
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