Inspection visit

Health inspectionMay 8, 2024

BIRCHWOOD NURSING AND REHABILITATIONCMS #6758385 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 05/07/2024 at around 10:38 AM, the shower on the secured unit had pink grime on the grout on one of the side walls towards the bottom and black grime on the grout starting about mid area of the wall down to the corner. During an interview on 05/07/2024 at 10:40 AM, the Housekeeping Supervisor said she was new to the position that it was her second day as supervisor. The Housekeeping Supervisor said the showers should be cleaned every other day unless they had a shower scheduled that day. The Housekeeping Supervisor said the last time the shower in the secure unit should have been cleaned was the day before yesterday (05/05/24). The Housekeeping Supervisor said Housekeeper C should have cleaned it. The Housekeeping Supervisor said she had not had time to clean the showers because they were very short staffed. The Housekeeping Supervisor said it was important to clean the showers to keep bacteria down, prevent infections, and for sanitation and because it was a public shower. During an observation of the shower in the secure unit and an interview on 05/07/2024 at 10:49 AM, Housekeeper C said she was not sure if the pink and black grime on the walls would come off, but she would try to clean it. Housekeeper C said the Housekeeping Supervisor and herself were responsible for cleaning the showers. Housekeeper C said she cleaned it a couple days ago and it should have been cleaned Sunday (05/05/24) by the Housekeeping Supervisor. Housekeeper C said it was important for the showers to be cleaned to keep them sanitary and not have bacteria growing. During an interview on 05/08/24 at 12:00 PM, the Administrator said the showers should be cleaned daily. The Administrator said he provided oversight to housekeeping. The Administrator said he rounded daily around the facility and had not noticed the pink and black grime. The Administrator said it was important for the showers to be clean so infections would not occur. Record review of the facility's undated policy titled, Resident Rights, indicated, .Safe environment- The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide .2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 1 shower rooms on the secured unit and 1 of 2 dining rooms (main building) reviewed for physical environment. 1. The facility did not ensure the dining room did not have cobwebs and crane flies on the ceiling (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 10 Event ID: 675838 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0584 and walls. Level of Harm - Minimal harm or potential for actual harm 2. The facility failed to ensure the shower in the secure unit did not have pink and black grime on the walls. Residents Affected - Some These failures could place the residents at risk for decreased quality of life and infection due to unsanitary conditions. The findings included: 1. Record review of the face sheet, dated 05/08/2024, revealed Resident #50 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbances (group of symptoms that affects memory, thinking and interferes with daily life) and diabetes mellitus (high blood sugar). Record review of the admission MDS assessment, dated 04/19/2024, revealed Resident #50 had clear speech and was understood by the staff. The MDS revealed Resident #50 was able to understand others. The MDS revealed Resident #50 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #50 thought it was very important to do things with groups of people. The MDS revealed Resident #50 was independent with eating. Record review of the comprehensive assessment, initiated on 04/10/2024, revealed Resident #50 had an ADL self-care deficit and was at risk for malnutrition. The interventions included: monitor and document meal intake and provide supervision assistance with eating as needed. During an interview on 05/06/2024 beginning at 11:17 AM, Resident #50 stated her only concern at the facility was the cafeteria. Resident #50 stated there were dead flies on the ceiling and walls in the dining room above the candy bar sign. Resident #50 stated the flies had been there since she admitted to the facility. Resident #50 stated she had reported it to multiple staff members and asked them to clean it, but it had not been cleaned. During an observation on 05/06/2024 at 11:44 AM, two crane flies were hanging from cobwebs above the sign in the main building dining room. There were numerous cobwebs on the walls and ceiling. During an interview on 05/06/2024 beginning at 12:07 PM, Resident #50 was in her room sitting up in a wheelchair with her meal tray in front of her. Resident #50 stated she used to eat in the dining room, but she told staff about the cobwebs and flies, and nothing got fixed so she removed herself. During an observation on 05/07/2024 at 12:21 PM, two crane flies were hanging from cobwebs above the sign in the main building dining room. There were numerous cobwebs on the walls and ceiling. During an interview on 05/08/2024 beginning at 2:08 PM, the Housekeeping Supervisor stated she had only been in the supervising position for 2 days. The Housekeeping Supervisor stated she was unsure who was responsible for ensuring the dining room had no cobwebs or bugs on the ceiling and walls. The Housekeeping Supervisor stated she was unaware there were cobwebs and bugs on the walls and ceiling. The Housekeeping Supervisor stated it should not have been liked that. The Housekeeping Supervisor stated it was important to ensure the walls and ceiling were cleaned especially in the dining room, so the cobwebs or bugs did not fall into the food. The Housekeeping Supervisor stated she would not have wanted it like that in her own home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 2 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 05/08/2024 beginning at 3:05 PM, the Administrator stated the housekeeping staff were responsible for cleaning from the ceiling to the floor every day. The Administrator stated the housekeeping staff had a deep cleaning schedule that had not been followed well since they were in between supervisors. The Administrator stated the person over housekeeping was coming to the facility to provide training to the current staff. The Administrator stated he was currently responsible for ensuring the dining room was cleaned but after training the Housekeeping Supervisor would have been responsible. The Administrator stated it was important to ensure the dining room walls and ceiling had no cobwebs or bugs for cleanliness and to maintain a homelike environment. Event ID: Facility ID: 675838 If continuation sheet Page 3 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #13) reviewed for incontinence. The facility failed to ensure Resident #13 was provided proper incontinent care. These failures could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: Record review of a face sheet dated 05/07/24 indicated Resident #13 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #13 had a BIMS score of 00, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #13 was always incontinent of urine and was frequently incontinent of bowel. The MDS assessment indicated Resident #13 required partial/moderate assistance with toileting and substantial/maximal assistance with personal hygiene. Record review of Resident #13's care plan last reviewed 04/25/2024 indicated she required the assistance of 1 staff for toilet use. Resident #13's care plan indicated she had potential for pressure ulcer development to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #13's Order Summary Report dated 05/08/2024 indicated Amoxicillin-Potassium Clavulanate tablet 875-125 mg give 1 tablet by mouth every day and evening shift for bacterial infection related to urinary tract infection for 10 days with a start date of 05/08/2024. During an observation on 05/07/2024 at 10:37 AM, CNA B provided incontinent care with LVN A. CNA B put on gloves and removed Resident #13's brief. Resident #13 had a bowel movement. CNA B wiped Resident #13 and with the same wipe that had stool on it wiped her again from front to back. CNA B grabbed another wipe and did the same thing. CNA B did not use a clean wipe or clean area on the wipe when wiping Resident #13's peri area. After wiping Resident #13's peri area, CNA B removed one glove and grabbed a clean brief and applied it with her ungloved hand. CNA B did not change gloves and perform hand hygiene prior to applying the clean brief. CNA B finished removed her other glove and washed her hands. During an interview on 05/07/2024 at 10:44 AM, CNA B said when she provided incontinent care to Resident #13, she should have changed both of her gloves before applying the clean brief and should have only wiped once instead of multiple times with the same wipe. CNA B said she was in a hurry, and she was nervous so that's why she had not done that. CNA B said she was trying to flip sides on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 4 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wipe but was unable to. CNA B said she should have changed gloves and only wiped once because it could cause urinary tract infections. During an interview on 05/08/2024 at 10:43 AM, LVN A said the charge nurses were responsible for ensuring the CNAs provided proper incontinent care. LVN A said she noticed CNA B did not change gloves at the appropriate times and wiped more than once with the same wipe. LVN A said she tried to prompt CNA B, but she did not hear her. LVN A said the same wipe should not be used multiple times to prevent the stool from causing a urinary tract infection. LVN A said gloves should be changed to get rid of the dirty. During an interview on 05/08/2024 at 12:06 PM, the Administrator said the expectations were for the CNAs to follow the policy for incontinent care and do it as they were supposed to do it. The Administrator said the DON was responsible for providing oversight for the CNAs. The Administrator said it was important for proper incontinent care to be performed to help eliminate urinary tract infections. During an interview on 05/08/2024 at 12:29 PM, the DON said when providing incontinent care, the CNAs should wipe once and throw the wipe away and get a new one. The DON said gloves should be changed between the dirty and clean, and the CNAs should wash their hands in between glove changes. The DON said the ADON, herself, or designees visually watched the CNAs provide incontinent care at least once a quarter if not more to ensure they performed incontinent care properly. The DON said it was important to provide proper incontinent care because the residents could get an infection. Record review of the facility's policy titled, Perineal Care, effective date 05/11/2022, indicated, . This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . 11) [NAME] gloves and all other PPE per standard precautions i. Choose your PPE by considering the type of exposure, the durability and appropriateness for the task 12) Soak towels in a washbasin filled with warm water (make sure it is at a comfortable temperature) and facility approved cleansing agent or remove an adequate number of pre-moistened cleansing wipes . Female resident: Working from front to back, wipe . Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke .21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area . 24) Doff gloves and PPE 25) Perform hand hygiene . Important Points . Do not wipe more than once with the same surface . Always perform hand hygiene before and after glove use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 5 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 (Resident #29) of 14 residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #29's preference for double protein portions. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of a face sheet, dated 05/08/2024, indicated Resident #29 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect your mood), and abnormal weight loss. Record review of an order summary report dated 05/08/2024 indicated Resident #29 had an order for regular diet, regular texture, double protein portions with meals with an order start date of 01/10/2024. Record review of Resident #29's quarterly MDS assessment, dated 03/11/2024, indicated Resident #29 understood others and made himself understood. Resident #29 had a BIMS score of 15, which indicated his cognition was intact. Resident #29 was independent for eating. Record review of the care plan last revised on 09/27/2023 indicated Resident #29 was at risk for malnutrition and was on a regular diet with thin liquids, and double protein portions with meals. The care plan interventions included, encourage 3 or less snacks/day as tolerated, serve diet as ordered and food serve supervision to monitor and discuss food preferences. Record review of the lunch meal ticket dated 05/06/2024 for Resident #29 indicated Resident #29 was on a regular diet and should have received double protein portions. During an observation on 05/06/2024 at 12:00 p.m., Resident #29 was sitting at the table in the dining room. The DON served Resident #29's meal tray with only one slice of meat loaf. The surveyor showed the DON that Resident #29 did not receive double protein portion. During an interview on 05/06/2024 at 1:00 p.m., Resident #29 stated he did not eat a lot of vegetables and he preferred double meat. During an interview on 05/08/2024 at 12:48 p.m., [NAME] D stated she was responsible for ensuring residents received the correct portions. [NAME] D stated she thought the piece that was given to Resident #29 was big enough for double portions, but she should have given two slices to equal double portions. [NAME] D stated he received double protein (meat) portions because he did not like vegetables. [NAME] D stated it was important to ensure Resident #29 received the correct portion to prevent weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 6 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/08/2024 at 12:59 p.m., the Dietary Manager stated [NAME] D was responsible for ensuring Resident #29 received the correct portions. The Dietary Manager stated Resident #29 only eats the protein (meat) and did not like vegetables or starches. The Dietary Manager stated two slices of meat loaf should have been served. The Dietary Manager stated she was responsible for overseeing by monitoring lunch meals. The Dietary Manager stated she had not noticed this issue in the past, but staff had been verbally in-serviced. The Dietary Manager stated it was important for their food preferences and meal tickets to be followed to prevent weight loss. During an interview on 05/08/2024 at 2:45 p.m., The DON stated she was responsible for checking the trays to ensure the proper diet has been served. The DON stated Resident #29 should have had double protein portions on his tray. The DON stated she thought the piece was bigger than a regular portion until surveyor pointed it out that it was the same portion as the resident next to him. The DON stated it was important for Resident #29's food preference to be followed to make sure he was getting the nutrition and calories that he needs since he preferred meat instead of vegetables and starches. The DON stated this failure put Resident #29 at risk for weight loss. During an interview on 05/08/2024 at 2:56 p.m., the Administrator stated he expected for the meal tickets and for food preferences to be followed. The Administrator stated the nurse should be checking the meal tickets for accuracy. The Administrator stated the Dietary Manager was responsible for ensuring the residents were served according to their meal tickets and preferences. The Administrator stated it was important for their food preferences and meal tickets to be followed because it was their right, and wellbeing. Record review of the facility's undated policy, titled Resident Meal Service and HS Snack, indicated, 9. If a resident request larger amount of food for all meals, a large portions diet can be ordered and served. For occasional request a double portion of any meal component may be offered FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 7 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #13) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident #13. The facility failed to ensure CNA B used a clean wipe when cleaning Resident #13's peri area. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: Record review of a face sheet dated 05/07/24 indicated Resident #13 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with behaviors). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #13 had a BIMS score of 00, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #13 was always incontinent of urine and was frequently incontinent of bowel. The MDS assessment indicated Resident #13 required partial/moderate assistance with toileting and substantial/maximal assistance with personal hygiene. Record review of Resident #13's care plan last reviewed 04/25/2024 indicated she required the assistance of 1 staff for toilet use. Resident #13's care plan indicated she had potential for pressure ulcer development to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #13's Order Summary Report dated 05/08/2024 indicated Amoxicillin-Potassium Clavulanate tablet 875-125 mg give 1 tablet by mouth every day and evening shift for bacterial infection related to urinary tract infection for 10 days with a start date of 05/08/2024. During an observation on 05/07/2024 at 10:37 AM, CNA B provided incontinent care with LVN A. CNA B put on gloves and removed Resident #13's brief. Resident #13 had a bowel movement. CNA B wiped Resident #13 and with the same wipe that had stool on it wiped her again from front to back. CNA B grabbed another wipe and did the same thing. CNA B did not use a clean wipe or clean area on the wipe when wiping Resident #13's peri area. After wiping Resident #13's peri area, CNA B removed one glove and grabbed a clean brief and applied it with her ungloved hand. CNA B did not change gloves and perform hand hygiene prior to getting the clean brief and applying it. CNA B finished removed her other glove and washed her hands. During an interview on 05/07/2024 at 10:44 AM, CNA B said when she provided incontinent care to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 8 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #13, she should have changed both of her gloves before applying the clean brief and should have only wiped once instead of multiple times with the same wipe. CNA B said she was in a hurry, and she was nervous so that's why she had not done that. CNA B said she was trying to flip sides on the wipe but was unable to. CNA B said she should have changed gloves and only wiped once because it could cause urinary tract infections. CNA B said changing gloves and performing hand hygiene was important to prevent the spread of infection. During an interview on 05/08/2024 at 10:43 AM, LVN A said the charge nurses were responsible for ensuring the CNAs provided proper incontinent care. LVN A said she noticed CNA B did not change gloves at the appropriate times and wiped more than once with the same wipe. LVN A said she tried to prompt CNA B, but she did not hear her. LVN A said the same wipe should not be used multiple times to prevent the stool from causing a urinary tract infection. LVN A said gloves should be changed to get rid of the dirty. During an interview on 05/08/2024 at 12:06 PM, the Administrator said the expectations were for the CNAs to follow the policy for incontinent care/hand hygiene and do it as they were supposed to do it. The Administrator said the DON was responsible for providing oversight for the CNAs. The Administrator said it was important for the CNAs to change gloves, perform hand hygiene, and wipe properly during incontinent care to eliminate urinary tract infections and infection. During an interview on 05/08/2024 at 12:29 PM, the DON said when providing incontinent care, the CNAs should wipe once and throw the wipe away. The DON said the CNAs should get a new one, and gloves should be changed between the dirty and clean. The DON said the CNAs should wash their hands in between glove changes. The DON said the ADON, herself, or designees visually watched the CNAs provide incontinent care at least once a quarter if not more to ensure they performed incontinent care properly. The DON said it was important to change gloves, use clean wipes, and perform hand hygiene when providing incontinent care because the residents could get an infection. Record review of the facility's undated policy titled, Hand Hygiene, indicated, You may use alcohol-based hand cleaner or soap/water for the following .after removing gloves . Record review of the facility's policy titled, Perineal Care, effective date 05/11/2022, indicated, . This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . 11) [NAME] gloves and all other PPE per standard precautions i. Choose your PPE by considering the type of exposure, the durability and appropriateness for the task 12) Soak towels in a washbasin filled with warm water (make sure it is at a comfortable temperature) and facility approved cleansing agent or remove an adequate number of pre-moistened cleansing wipes . Female resident: Working from front to back, wipe . Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke .21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area . 24) Doff gloves and PPE 25) Perform hand hygiene . Important Points . Do not wipe more than once with the same surface . Always perform hand hygiene before and after glove use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 9 of 10 Printed: 05/15/2026 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 675838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Nursing and Rehabilitation 110 W Hwy 64 Cooper, TX 75432 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow their own established smoking policy for 1 of 2 smoking area (main building) reviewed for smoking policies. Residents Affected - Few The facility did not ensure cigarette butts were disposed of in a metal container. This failure could place residents at risk of an unsafe smoking environment. The findings included: Record review of the smoking policy, revised 11/01/2017, revealed Ashtrays will be a metal container with a self-closing cover device into which ash trays may be emptied . During an observation and interview on 05/06/2024 between 11:30 AM and 11:39 AM the main building smoking area had a plastic-lined trashcan. There were approximately 30 red-tipped cigarette butts at the bottom of the plastic-lined trashcan. The Housekeeping Supervisor was in the smoking area. The Housekeeping Supervisor stated she was responsible for emptying the ashtrays and the red metal trashcan. The Housekeeping Supervisor stated she emptied the cigarette butts in the metal ashtrays into the red metal trashcan and then emptied the red metal trash can into the plastic-lined trashcan. During an interview on 05/08/2024 beginning at 2:08 PM, the Housekeeping Supervisor stated she had only been in the supervising position for 2 days. The Housekeeping Supervisor stated she was unsure who was responsible for emptying the cigarette butts in the red metal trashcan. The Housekeeping Supervisor stated no one asked her to do it, she just started emptying the red metal trashcans. The Housekeeping Supervisor stated she was unsure if the cigarette butts should have been emptied into the plastic-lined trashcan but that was where she had been emptying the cigarette butts. During an interview on 05/08/2024 beginning at 3:05 PM, the Administrator stated the cigarette butts in the red metal trashcan should not have been emptied into the plastic-lined trashcan. The Administrator stated the Maintenance Supervisor was responsible for emptying the cigarette butts and was unsure why the Housekeeping Supervisor was doing it. The Administrator stated it was important to ensure the cigarette butts were disposed of properly to prevent a fire. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675838 If continuation sheet Page 10 of 10

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0584GeneralS&S Epotential for harm
F584 - Safe Environment
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.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0926GeneralS&S Dpotential for harm
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.

FAQ · About this visit

Common questions about this visit

What happened during the May 8, 2024 survey of BIRCHWOOD NURSING AND REHABILITATION?

This was a inspection survey of BIRCHWOOD NURSING AND REHABILITATION on May 8, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BIRCHWOOD NURSING AND REHABILITATION on May 8, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 8, 2024