Inspection Reports for Birchwood Rehabilitation And Healthcare Center
205 Birchwood Ave, NJ, 07016
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Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform covered components and the public about the privacy practices related to medical information, including how information may be used, disclosed, and the rights of individuals under these practices.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, legal duties of the department, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 188
Deficiencies: 0
Jan 2, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 1
Nov 14, 2024
Visit Reason
The inspection was conducted due to a complaint (Complaint #: NJ178726) regarding food procurement, storage, preparation, and sanitary practices at Birchwood Rehabilitation and Healthcare Center.
Findings
The facility was found not in substantial compliance with food safety requirements, specifically failing to properly sanitize a frying pan used in food preparation, which could lead to microbial growth and potential harm to residents. Dietary staff did not follow manufacturer guidelines for sanitizing, and policies were undated.
Complaint Details
Complaint #: NJ178726 was substantiated based on observation, interviews, and documentation review. The deficiency involved improper sanitization of frying pans by dietary staff, risking resident safety.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to procure, store, prepare, and serve food in accordance with professional food safety standards, specifically improper sanitization of frying pans leading to microbial growth. | Level D |
Report Facts
Census: 171
Deficiency completion date: Dec 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide | DA #2 | Observed washing and sanitizing frying pan improperly |
| Dietary Supervisor | DS #1 | Interviewed regarding proper sanitizing procedures and staff practices |
Inspection Report
Routine
Census: 171
Capacity: 128
Deficiencies: 10
Aug 6, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements but had deficiencies related to maintaining a safe, clean, and homelike environment, accuracy of assessments, comprehensive care plans, treatment and services to prevent pressure ulcers, dialysis care, physician visits, pharmacy services, food safety, infection control, and life safety code violations.
Severity Breakdown
SS=D: 6
SS=E: 3
SS=F: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to maintain residents' environment and living areas in a sanitary and homelike manner. | SS=D |
| Facility failed to ensure the accurate assessment of residents using the Minimum Data Set (MDS). | SS=D |
| Facility failed to develop a comprehensive care plan to address medication needs for some residents. | SS=D |
| Facility failed to provide treatment and services to prevent pressure ulcers and promote healing. | SS=D |
| Facility failed to ensure residents receiving dialysis had proper assessments and care plans. | SS=E |
| Facility failed to ensure physician visits and orders were properly documented and signed. | SS=D |
| Facility failed to provide pharmaceutical services ensuring accurate medication administration. | SS=E |
| Facility failed to maintain food safety requirements including proper storage and sanitation. | SS=F |
| Facility failed to establish and maintain an infection prevention and control program. | SS=E |
| Facility failed to comply with life safety code requirements including fire sprinkler system maintenance and corridor door integrity. | SS=F |
Report Facts
Complaint numbers: 9
Sample size: 37
Residents reviewed for MDS accuracy: 34
Residents reviewed for medication management: 34
Residents reviewed for dialysis care: 5
Residents reviewed for physician orders: 34
Residents reviewed for medication administration: 34
Residents reviewed for food safety: 128
Residents affected by life safety deficiencies: 128
Inspection Report
Routine
Census: 181
Deficiencies: 0
Aug 25, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Annual Inspection
Census: 187
Deficiencies: 9
Aug 4, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to residents' rights to formulate advance directives, comprehensive assessments after significant changes, accuracy of assessments, services provided meeting professional standards, infection prevention and control, pharmacy services, food safety, life safety code violations including emergency lighting and sprinkler system installation, electrical system maintenance, and oxygen equipment safety.
Deficiencies (9)
| Description |
|---|
| Facility failed to provide information in a manner easily understood by residents about the right to formulate an Advance Directive. |
| Facility failed to ensure that a significant change assessment was completed for residents with changes in physical or mental condition. |
| Facility failed to accurately assess residents' status in the Minimum Data Set (MDS). |
| Facility failed to clarify a physician order for code status for one resident. |
| Facility failed to maintain proper infection prevention and control practices including hand hygiene and use of PPE. |
| Facility failed to provide pharmaceutical services in accordance with professional standards including medication administration errors and documentation. |
| Facility failed to maintain proper food safety and sanitation practices including cleaning schedules and food storage. |
| Facility failed to maintain proper life safety code compliance including emergency lighting, exit signage, sprinkler system installation, and electrical system maintenance. |
| Facility failed to ensure safe storage and handling of oxygen equipment. |
Report Facts
Census: 187
Sample: 35
Deficiencies identified: 9
Inspection Report
Life Safety
Deficiencies: 6
Aug 3, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 08/03/2022 and 08/04/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Cranford Rehabilitation and Healthcare Center.
Findings
The facility was found noncompliant with several Life Safety Code requirements including emergency lighting, exit signage, sprinkler system installation, HVAC ventilation maintenance, electrical receptacle safety, and emergency generator controls. Deficiencies were identified but no residents were found to be immediately affected. Corrective actions and education plans were implemented.
Severity Breakdown
SS=E: 4
SS=D: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide a fully functioning battery backup emergency light above 1 of 1 emergency generator's transfer switch. | SS=E |
| Failed to ensure illuminated exit signs in two locations to clearly identify exit access path for an enclosed center courtyard. | SS=E |
| Failed to provide proper fire sprinkler coverage in an alcove area next to resident room #301. | SS=D |
| Failed to ensure proper maintenance of 2 of 12 resident bathroom exhaust systems. | SS=E |
| Failed to ensure 1 of 6 electrical outlets next to a water source had proper working GFCI protection. | SS=D |
| Failed to install a remote manual stop station for the emergency generator as required. | SS=E |
Report Facts
Deficiencies cited: 6
Resident bathrooms inspected: 12
Resident bathrooms with deficient exhaust: 2
Electrical outlets tested: 6
Electrical outlets deficient: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified multiple deficiencies and educated maintenance staff on corrective actions | |
| Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 6
Aug 14, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ145079, NJ144758, NJ143533, NJ143556 to determine compliance with 42 CFR Part 483 B for Long Term Care Facilities.
Findings
The facility was found non-compliant in multiple areas including failure to ensure call light systems were within residents' reach, inadequate preparation and education for residents prior to discharge, failure to provide timely activities of daily living (ADL) care, insufficient nursing staff competency in providing care, unlocked treatment carts, and inadequate infection prevention and control practices including improper use of PPE and unsafe food handling.
Complaint Details
The complaint investigation was based on complaint numbers NJ145079, NJ144758, NJ143533, NJ143556. The facility was found not in compliance with multiple regulatory requirements related to resident rights, discharge preparation, ADL care, nursing staff competency, medication storage, and infection control.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure the call light system was within a resident's reach. | SS=D |
| Failure to provide resident and/or resident representative education before discharge. | SS=D |
| Failure to ensure activities of daily living were completed in a timely manner for dependent residents. | SS=E |
| Failure to ensure nursing staff demonstrated competency in skills necessary to care for residents. | SS=D |
| Failure to ensure treatment carts were kept locked when unattended. | SS=D |
| Failure to maintain an effective infection prevention and control program, including improper use of PPE and unsafe food handling. | SS=E |
Report Facts
Census: 185
Sample Size: 12
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #13 | Certified Nursing Assistant | Named in deficiency related to call light system and ADL care. |
| CNA #12 | Certified Nursing Assistant | Named in deficiency related to ADL care. |
| LPN #6 | Licensed Practical Nurse | Named in deficiency related to discharge education and teaching. |
| LPN #9 | Licensed Practical Nurse | Named in deficiency related to infection control and PPE use. |
| LPN #10 | Licensed Practical Nurse | Named in deficiency related to infection control and PPE use. |
| LPN #14 | Licensed Practical Nurse | Named in deficiency related to treatment cart locking and infection control. |
| CNA #1 | Certified Nursing Assistant | Named in deficiency related to infection control, PPE use, and food handling. |
| Director of Nursing | Director of Nursing | Provided statements regarding call light policy, discharge education, PPE use, and infection control expectations. |
| Maintenance Director | Maintenance Director | Named in deficiency related to PPE use. |
| Consultant #1 | Consultant | Provided expert opinion on proper perineal care. |
Inspection Report
Routine
Census: 163
Deficiencies: 0
Apr 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 0
Dec 29, 2020
Visit Reason
The inspection visit was conducted based on a complaint investigation to determine compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint visit.
Complaint Details
The visit was complaint-related and the facility was found to be in compliance with the requirements.
Report Facts
Sample Size: 3
Inspection Report
Abbreviated Survey
Census: 154
Deficiencies: 0
Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 4
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