Inspection Reports for
Birchwood Rehabilitation And Healthcare Center

The facility failed to maintain the Memory Care Unit environment in good repair, affecting six residents, with issues such as broken furniture, missing air conditioner/heating unit covers, and damaged baseboards. Additionally, nursing staff failed to follow physician dietary orders for one resident, resulting in missed nutritional supplementation.

The facility failed to promote a dignified dining experience for residents in the memory care unit by serving meals on overbed tables in a small common area without a dedicated dining room. Additionally, the facility failed to ensure proper assessment, documentation, and informed consent prior to bed rail use for one resident, lacking exploration of alternatives and signed consent.

Complaint #: NJ178726. The complaint was substantiated based on observation, interviews, and documentation review showing improper sanitization of kitchen equipment.

The facility failed to sanitize a frying pan properly, as staff dipped it in sanitizer for less than the required 20 seconds, risking microbial contamination. Multiple staff interviews confirmed the sanitizing process was not followed correctly, potentially exposing residents to infection.

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.

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 NJ00167683 involved unsanitary conditions in the facility environment, including dirty floors and shower rooms. Complaint #173271 involved failure to provide appropriate pressure ulcer care and accurate resident assessments. Both complaints were substantiated with findings of minimal harm or potential for actual harm.

The facility was found to have unsanitary conditions including dark dirty areas on the 400 hallway floors and doorways, and unclean shower rooms. Additionally, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents and did not implement appropriate care plans for residents at high risk for skin breakdown, including failure to document skin discolorations and preventive interventions.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for anticoagulant medication, inconsistent post-dialysis site assessments, failure to ensure physician signatures on monthly orders, inaccurate administration of Midodrine medication, poor food storage and sanitation practices in kitchen refrigeration and freezer units, and failure to follow proper hand hygiene protocols during medication administration.

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.

The facility was found deficient in multiple areas including failure to provide information on advance directives, incomplete significant change assessments, inaccurate resident assessments, failure to clarify code status orders, failure to follow physician orders for splint use, oxygen therapy management issues, medication availability and administration problems, improper medication labeling and storage, poor kitchen sanitation, infection control breaches including hand hygiene and PPE use, and unsafe storage of oxygen equipment.

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.

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.

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.

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.