Birchwood Park Rehabilitation

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Rule F0550. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Rule F0607. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Rule F0677. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Rule F0698. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

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

Rule F0689. G: actual harm. Correction date, as CMS recorded it: Feb 15, 2025.

Provide safe, appropriate pain management for a resident who requires such services.

Rule F0697. G: actual harm. Correction date, as CMS recorded it: Feb 15, 2025.

Allow residents to self-administer drugs if determined clinically appropriate.

Rule F0554. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 14, 2025.

Protect a residents’ right to refuse some types of non-requested transfers within the nursing home.

Rule F0560. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.

Rule F0586. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Rule F0636. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Assess the resident when there is a significant change in condition

Rule F0637. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

PASARR screening for Mental disorders or Intellectual Disabilities

Rule F0645. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Provide activities to meet all resident’s needs.

Rule F0679. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Ensure the activities program is directed by a qualified professional.

Rule F0680. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Rule F0756. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

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.

Rule F0761. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

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

Rule F0835. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Employ staff that are licensed, certified, or registered in accordance with state laws.

Rule F0839. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Rule F0849. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Hire a qualified full-time social worker in a facility with more than 120 beds.

Rule F0850. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

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

Rule F0883. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status.

Rule F0887. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Rule F0940. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Rule F0941. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Rule F0942. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Rule F0944. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Provide training in compliance and ethics.

Rule F0946. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Rule F0947. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Rule F0949. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 15, 2025.

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Rule F0603. G: actual harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Rule F0686. G: actual harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Honor the resident’s right to organize and participate in resident/family groups in the facility.

Rule F0565. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

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

Rule F0568. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

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

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Keep residents’ personal and medical records private and confidential.

Rule F0583. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

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.

Rule F0584. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Rule F0623. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

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

Rule F0656. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Rule F0677. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Provide enough food/fluids to maintain a resident’s health.

Rule F0692. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Rule F0698. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Ensure that residents are free from significant medication errors.

Rule F0760. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Rule F0840. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

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

Rule F0921. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

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

Rule F0684. G: actual harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Rule F0550. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Rule F0607. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 14, 2025.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Rule F0661. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Feb 15, 2025.

Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted

Rule F0655. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 30, 2024.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Rule F0805. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 2, 2024.