Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 495150

Birchwood Park Rehabilitation

114 federal citations on record , including 2 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $131,178.

Abuse Icon 2 Immediate Jeopardy

Record summary

Federal record · Q1 2026
114
Total citations
62
Last 3 years
7
Actual harm+
1
Federal penalties
$131,178
Total fines
1
Overall ★ rating

Most common violation categories here

Resident Rights26 Care Planning18 Quality of Care16 Administration14 Abuse & Neglect10

Most common F-tags at this facility

F6073 F6093 F6103 F8833 F5843

Citation history

114 on record
SurveyF-TagViolationSeveritySource
Apr 4, 2025F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DComplaint
Apr 4, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Apr 4, 2025F610Respond appropriately to all alleged violations.DComplaint
Apr 4, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Apr 4, 2025F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DComplaint
Apr 4, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DComplaint
Dec 19, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.GComplaint
Dec 19, 2024F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.DComplaint
Dec 19, 2024F641Ensure each resident receives an accurate assessment.EComplaint
Dec 19, 2024F610Respond appropriately to all alleged violations.DComplaint
Dec 19, 2024F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DComplaint
Dec 19, 2024F558Reasonably accommodate the needs and preferences of each resident.DComplaint
Dec 19, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DComplaint
Dec 19, 2024F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.DComplaint
Dec 19, 2024F880Provide and implement an infection prevention and control program.FComplaint
Dec 19, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Dec 19, 2024F840Employ 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.DComplaint
Dec 19, 2024F760Ensure that residents are free from significant medication errors.DComplaint
Dec 19, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint
Dec 19, 2024F698Provide safe, appropriate dialysis care/services for a resident who requires such services.EComplaint
Dec 19, 2024F692Provide enough food/fluids to maintain a resident's health.DComplaint
Dec 19, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Dec 19, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.EComplaint
Dec 19, 2024F658Ensure services provided by the nursing facility meet professional standards of quality.DComplaint
Dec 19, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EComplaint
Dec 19, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EComplaint
Dec 19, 2024F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DComplaint
Dec 19, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Dec 19, 2024F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).GComplaint
Dec 19, 2024F584Honor 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.FComplaint
Dec 19, 2024F583Keep residents' personal and medical records private and confidential.DComplaint
Dec 19, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Dec 19, 2024F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.DComplaint
Dec 19, 2024F565Honor the resident's right to organize and participate in resident/family groups in the facility.EComplaint
Dec 19, 2024F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.EStandard
Dec 19, 2024F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.EStandard
Dec 19, 2024F946Provide training in compliance and ethics.EStandard
Dec 19, 2024F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.EStandard
Dec 19, 2024F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.EStandard
Dec 19, 2024F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.EStandard
Dec 19, 2024F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.EStandard
Dec 19, 2024F887Educate 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.DStandard
Dec 19, 2024F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
Dec 19, 2024F850Hire a qualified full-time social worker in a facility with more than 120 beds.FStandard
Dec 19, 2024F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Dec 19, 2024F839Employ staff that are licensed, certified, or registered in accordance with state laws.FStandard
Dec 19, 2024F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.EStandard
Dec 19, 2024F761Ensure 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.EStandard
Dec 19, 2024F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Dec 19, 2024F697Provide safe, appropriate pain management for a resident who requires such services.GStandard
Dec 19, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GStandard
Dec 19, 2024F680Ensure the activities program is directed by a qualified professional.FStandard
Dec 19, 2024F679Provide activities to meet all resident's needs.FStandard
Dec 19, 2024F645PASARR screening for Mental disorders or Intellectual DisabilitiesEStandard
Dec 19, 2024F637Assess the resident when there is a significant change in conditionDStandard
Dec 19, 2024F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.DStandard
Dec 19, 2024F586Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.DStandard
Dec 19, 2024F560Protect a residents' right to refuse some types of non-requested transfers within the nursing home.DStandard
Dec 19, 2024F554Allow residents to self-administer drugs if determined clinically appropriate.DStandard
Apr 15, 2024F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.DComplaint
Apr 15, 2024F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedDComplaint
Nov 3, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.EComplaint
Sep 30, 2021F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FStandard
Sep 30, 2021F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EStandard
Sep 30, 2021F886Perform COVID19 testing on residents and staff.LStandard
Sep 30, 2021F885Report COVID19 data to residents and families.EStandard
Sep 30, 2021F883Develop and implement policies and procedures for flu and pneumonia vaccinations.EStandard
Sep 30, 2021F881Implement a program that monitors antibiotic use.EStandard
Sep 30, 2021F880Provide and implement an infection prevention and control program.LStandard
Sep 30, 2021F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.FStandard
Sep 30, 2021F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Sep 30, 2021F840Employ 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.FStandard
Sep 30, 2021F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.FStandard
Sep 30, 2021F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.FStandard
Sep 30, 2021F730Observe each nurse aide's job performance and give regular training.DStandard
Sep 30, 2021F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.EStandard
Sep 30, 2021F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.DStandard
Sep 30, 2021F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.EStandard
Sep 30, 2021F685Assist a resident in gaining access to vision and hearing services.DStandard
Sep 30, 2021F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Sep 30, 2021F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EStandard
Sep 30, 2021F645PASARR screening for Mental disorders or Intellectual DisabilitiesDStandard
Sep 30, 2021F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.DStandard
Sep 30, 2021F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.EStandard
Sep 30, 2021F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DStandard
Sep 30, 2021F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.EStandard
Sep 30, 2021F584Honor 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.DStandard
Sep 30, 2021F583Keep residents' personal and medical records private and confidential.DStandard
Sep 30, 2021F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.DStandard
Sep 30, 2021F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DStandard
Mar 5, 2020F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EStandard
Mar 5, 2020F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
Mar 5, 2020F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Mar 5, 2020F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Mar 5, 2020F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.DStandard
Mar 5, 2020F761Ensure 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.EStandard
Mar 5, 2020F758Implement 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 necessary and PRN use is limited.DStandard
Mar 5, 2020F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Mar 5, 2020F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Mar 5, 2020F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EStandard

Federal enforcement history

Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $131,178 .

DateTypeFinePayment denial
Dec 19, 2024Fine$131,178—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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