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Complaint Investigation

Birchwood Rehabilitation & Healthcare Center

August 20, 2025 · Nanticoke, PA · 395 Middle Road
Citations 3
CMS Rating 1/5
Beds 121
Provider ID 395651
Healthcare Facility
Birchwood Rehabilitation & Healthcare Center
Nanticoke, PA  ·  View full profile →
Inspection Summary

BIRCHWOOD REHABILITATION & HEALTHCARE CENTER in NANTICOKE, PA — inspection on August 20, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

During the onsite visit to the facility on [DATE], verification of the implementation of the facility's removal plan was completed and the Immediate Jeopardy was lifted on [DATE], at 9:30 AM. 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices. 28 Pa Code 201.18(b)(1) (e)(1) Management. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Birchwood Rehabilitation & Healthcare Center

395 Middle Road Nanticoke, PA 18634

SUMMARY STATEMENT OF DEFICIENCIES

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an effective, individualized, person-centered care plan to address a resident's dementia-related behavioral symptoms for one of 5 residents reviewed (Resident 1).Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) and anxiety disorder (a mental health condition characterized by persistent worry or fear that interferes with daily functioning). A quarterly Minimum Data Set (MDS an assessment completed periodically to plan resident care) dated June 23, 2025, indicated that Resident 1 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). A review of nursing documentation from April 20, 2025, through August 14, 2025, revealed repeated instances of dementia related behavioral symptoms.

These included verbal and physical aggression toward staff (e.g., hitting, kicking, yelling), intrusion into other residents' rooms, refusals of care, accusatory statements directed at staff, and physical aggression toward a visiting family member of another resident.

Documentation also noted the resident was often difficult to redirect.

The resident's current care plan for cognitive impairment related to dementia failed to identify these specific behaviors and lacked individualized, person centered interventions to address and manage each behavioral symptom.

There was no documented evidence the care plan incorporated information based on a thorough assessment of the resident's preferences, social history, customary routines, or personal interests, as required to support effective behavioral management strategies. An interview with the Director of Nursing on August 14, 2025, at 4:40 PM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related behaviors.28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Birchwood Rehabilitation & Healthcare Center

395 Middle Road Nanticoke, PA 18634

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited BIRCHWOOD REHABILITATION & HEALTHCARE CENTER in NANTICOKE, PA for a deficiency under regulatory tag F-F0835 during a complaint investigation conducted on 2025-08-20.

Category: Administration Deficiencies

The facility was found deficient in the following area: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of BIRCHWOOD REHABILITATION & HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-17.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NANTICOKE, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BIRCHWOOD REHABILITATION & HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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