Birchwood Care Home

Inspection findings

1. May 19, 2026 Fire Safety · 3 findings
   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jul 12, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jul 19, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0921 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that testing and maintenance of electrical equipment is performed.

     Corrected Jul 19, 2026 · CMS fire safety

2. Jul 29, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 15, 2025 · CMS health inspection

3. Mar 20, 2025 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0032 Emergency Preparedness Deficiencies

     Provide primary/alternate means for communication.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected May 2, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 2, 2025 · CMS fire safety

4. Jul 3, 2024 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 1, 2024 · CMS health inspection

5. Jun 18, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 10, 2024 · CMS health inspection

6. May 3, 2024 Fire Safety · 42 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0009 Emergency Preparedness Deficiencies

     Include a process for Emergency Preparedness collaboration.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0018 Emergency Preparedness Deficiencies

     Establish procedures for tracking staff and patients during an emergency.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0023 Emergency Preparedness Deficiencies

     Establish policies and procedures for medical documentation.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0025 Emergency Preparedness Deficiencies

     Create arrangements with other facilities to receive patients.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0026 Emergency Preparedness Deficiencies

     Establish roles under a Waiver declared by secretary.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0029 Emergency Preparedness Deficiencies

     Develop a communication plan.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0030 Emergency Preparedness Deficiencies

     List the names and contact information of those in the facility.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0031 Emergency Preparedness Deficiencies

     Provide emergency officials' contact information.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0032 Emergency Preparedness Deficiencies

     Provide primary/alternate means for communication.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0036 Emergency Preparedness Deficiencies

     Establish emergency prep training and testing.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity C

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0865 Administration Deficiencies

     Have a plan that describes the process for conducting QAPI and QAA activities.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Jun 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected May 1, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jul 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Jul 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Jul 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0901 Electrical Deficiencies

     Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jul 12, 2024 · CMS fire safety

7. Mar 22, 2024 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0567 Resident Rights Deficiencies

     Honor the resident's right to manage his or her financial affairs.

     Corrected Apr 17, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0568 Resident Rights Deficiencies

     Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

     Corrected May 17, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0835 Administration Deficiencies

     Administer the facility in a manner that enables it to use its resources effectively and efficiently.

     Corrected Apr 19, 2024 · CMS health inspection

8. Mar 15, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0742 Quality of Life and Care Deficiencies

     Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

     Corrected Apr 20, 2024 · CMS health inspection