Inspection Results » Birch Manor Healthcare Center

Health Inspection on August 3, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-10-08)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-10-08)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-10-08)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-10-08)
   • Keep all essential equipment working safely. (Corrected 2018-10-08)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-10-08)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-10-08)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-10-08)
   • Have the Quality Assessment and Assurance group have the required members and meet at least quarterly (Corrected 2018-10-08)
   • Implement a program that monitors antibiotic use. (Corrected 2018-10-08)
   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2018-10-08)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-10-08)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-10-08)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-10-08)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-10-08)
   • Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Corrected 2018-10-08)
   • Provide activities to meet all resident's needs. (Corrected 2018-10-08)
   • Prepare residents for a safe transfer or discharge from the nursing home. (Corrected 2018-10-08)
   • Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. (Corrected 2018-10-08)
   • Ensure a qualified health professional conducts resident assessments. (Corrected 2018-10-08)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-10-08)
   • Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (Corrected 2018-10-08)
   • Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. (Corrected 2018-10-08)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-10-08)
   • Encode each residentÂ’s assessment data and transmit these data to the State within 7 days of assessment. (Corrected 2018-10-08)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2018-10-08)
   • Allow resident to participate in the development and implementation of his or her person-centered plan of care. (Corrected 2018-10-08)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-10-08)
   • Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (Corrected 2018-10-08)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2018-10-08)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-10-08)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-10-08)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-10-08)
   • Make sure that a working call system is available in each resident's bathroom and bathing area. (Corrected 2018-10-08)
   • Respond appropriately to all alleged violations. (Corrected 2018-10-08)

4. Widespread: No actual harm with potential for minimal harm

   • Post nurse staffing information every day. (Corrected 2018-10-08)
   • Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (Corrected 2018-10-08)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-10-08)