Birchwood Rehabilitation & Healthcare Center

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

There was no documentation the facility NHA, DON, attending physician, or the resident's responsible party were made aware of the alleged sexual abuse at the time of the incident. Review of the facility's internal investigation revealed the facility did not initiate an investigation until August 28, 2025, two days after the alleged incident. Review of reports submitted to the State Survey Agency revealed the facility failed to notify

the agency within the required two-hour timeframe following the allegation of sexual abuse. During an

interview with the Assistant Director of Nursing on September 17, 2025, at 10:15 AM, it was confirmed that Employee 3 did not report the allegation of abuse in accordance with facility policy, resulting in delayed identification, notification, and investigation. The facility failed to implement its abuse prohibition procedures by not promptly identifying the alleged sexual abuse of Resident 2, not ensuring timely notification of administration, physician, responsible party, and State Survey Agency, and by delaying the initiation of an investigation into the allegation. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 201.14(a)(c) Responsibility of Licensee. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services. 28 Pa. Code: 211.10 (c)(d) Resident care policies.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Birchwood Rehabilitation & Healthcare Center

395 Middle Road Nanticoke, PA 18634

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documentation revealed Resident 1 had an unwitnessed fall from bed. He was observed lying on his back

on the fall mat. The call bell was not activated. The head of the bed was noted to be at a 90-degree angle.

Nursing assessed the resident. No injury was noted. There were no witness statements available at the time of the survey regarding the August 28, 2025, fall incident. There was no root cause analysis for this fall to determine the possible cause of the fall and to determine interventions to prevent future falls. A review of

the care plan for at risk for falls revealed a new intervention dated August 29, 2025, to encourage Resident 1 to keep the head of the bed at 45 degrees or below at hour of sleep.On September 2, 2025, at 7:25 AM, facility investigative documentation and nursing documentation revealed the resident had another unwitnessed fall from bed. He was found naked on the right-side floormat. Nursing assessed him and noted

he winced with pain upon minimal movement, though no signs of leg shortening or external rotation (potential signs and symptoms of possible hip fracture) were present. The physician was notified and ordered an X-ray of the left hip and pelvis. Documentation did not indicate if the resident was incontinent or

the last time care had been provided. At 8:44 AM the resident complained of pain and staff administered Acetaminophen 650 mg. On September 3, 2025, at 1:32 PM, documentation noted an X-ray was to be obtained due to continued pain. At the time of this fall, interventions in place included a bed bolster overlay,

a fall mat to the right side of the bed and keeping the head of the bed lower than 90 degrees when not eating. A new intervention was added to provide a stuffed animal for comfort.A review of a witness statement dated September 2, 2025, revealed Employee 12 (housekeeping) saw the resident on the floor while walking by the room and alerted the nurse. No additional witness statements were available. A review of the X-ray obtained September 2, 2025, indicated no fracture of the left hip. Documentation revealed the resident did not get out of bed again until September 6, 2025, at 8:39 PM. On September 5, 2025, at 5:15 PM, nursing documentation revealed the resident complained of leg pain during repositioning. The physician was contacted and ordered an X-ray of the left leg. Acetaminophen 650 mg was administered. On September 6, 2025, at 8:39 PM, documentation revealed the resident continued to complain of increasing pain. An X-ray of the left knee revealed an acute comminuted distal femoral fracture (a fracture in which the bone is broken into multiple pieces at the end of the femur near the knee). The physician was notified, and

the resident was transferred to the hospital. Hospital documentation revealed the resident was evaluated with CT scans and X-rays that confirmed a left periprosthetic femur fracture. He was transferred to the trauma unit, admitted , and treated with pain management and therapy. The fracture was determined to be non-operative. The resident was discharged and readmitted to the facility on [DATE REDACTED], at 4:31 PM. There was no evidence that Resident 1's falls were adequately investigated or that individualized fall prevention interventions, including ADL care needs, were developed and implemented to prevent falls. One of these falls resulted in a serious injury requiring hospitalization. During an interview on September 17, 2025, at 3:00 PM, the corporate nurse consultant, was unable to provide evidence that Resident 1's falls had been adequately investigated or that individualized fall interventions were implemented to prevent a fall with serious injury. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Birchwood Rehabilitation & Healthcare Center

395 Middle Road Nanticoke, PA 18634

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744

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

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to implement individualized, person-centered interventions identified in the care plan to address dementia-related behaviors for one of seven sampled residents (Resident 4). Findings include: A review of

a facility policy for Dementia-Clinical Protocols, reviewed August 2025 revealed, for residents with a confirmed dementia diagnosis, the interdisciplinary team will develop and implement a resident-centered care plan designed to maximize remaining function and quality of life. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE REDACTED], with diagnosis to include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 3, 2025, revealed Resident 4 to be severely, cognitively impaired with a BIMS score of 3 (brief interview for mental status, is a cognitive screening tool that helps nursing staff measure how well residents can remember, process and recall information. A score of 0 to 7 indicates severe cognitive impairment) and required assistance of staff for activities of daily living.A care plan addressing behaviors, including yelling out and resistance with care, initiated July 24, 2024, directed staff to approach the resident in a calm manner to avoid frustration and escalation of behaviors. The care plan further instructed that if the resident became agitated and showed signs of escalation, staff were to stop the activity and re-approach the resident later to complete care when she was calmer. Review of facility investigative documentation and nursing notes dated August 30, 2025, at 7:30 PM, revealed Employee 5 (nurse aide) reported to Employee 6 (RN Supervisor) that she heard a noise from Resident 4's room that sounded like a muffled human voice. Employee 5 stated she suspected staff inside the room were holding their hand over Resident 4's mouth to prevent her from yelling. Employees 7 and 8 (nurse aides) were providing care to Resident 4 at the time. Both staff members were suspended and sent home pending the outcome of a facility investigation. A review of a witness statement dated August 30, 2025, revealed Employee 8 (nurse aide) stated, I did not cover Resident 4's mouth at any point. I understand the seriousness of this allegation, but it is not true. At the time of me changing Resident 4, she was very combative, screaming, and she was angry. A review of a witness statement dated August 30, 2025, from Employee 7 (nurse aide) indicated, I walked into Resident 4's room to assist Employee 8 (nurse aide) to put Resident 4 in her chair. At no time did either of us cover Resident 4's mouth. The resident was combative and screaming. At no point did anyone stop her from screaming. Although the facility's investigation did not substantiate abuse, there was no evidence that staff implemented the care-planned dementia interventions when Resident 4 became agitated. Specifically, there was no documentation or evidence that staff stopped

the care and re-approached the resident at a later time as directed by the care plan. During an interview conducted on September 17, 2025, at 3:00 PM, the Assistant Director of Nursing and the Corporate Nurse Consultant confirmed that the individualized dementia care plan interventions were not implemented for Resident 4. 28 Pa Code 211.12 (d)(5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet