Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Dignity during dining was not maintained for four residents in the memory care unit when meals were served on overbed tables in a small common area in front of the nurse's station. Residents ate in a room used as a dining, activity, and TV area with a loud movie playing, and one resident had to lean forward in a Geri chair with food spills noted on the shirt. Staff said meals were always served there because there was no dining room, and the ADM was unaware it was a concern.
Surveyors identified multiple deficiencies in the Memory Care Unit, including missing or broken furniture components, damaged surfaces, and unaddressed maintenance issues in both resident rooms and common areas. Staff interviews confirmed these problems and described a logbook system for reporting repairs, but the environment was not maintained in good repair as required by facility policy.
A resident with dementia and diabetes, who was at risk for nutritional problems, did not receive a physician-ordered Ensure Plus supplement at the scheduled time because it was not available on the medication cart. Staff interviews confirmed the supplement was not administered as ordered due to stocking issues, and the DON stated staff are expected to follow physician orders.
Bed rail use was not properly supported for a resident with dementia and severe cognitive impairment. Staff did not document that alternatives were tried before side rails were used, and the UM and RNS were unsure about signed informed consent and prior alternative measures. The DON stated staff were expected to document risk versus benefits and obtain consent, and the facility policy required attempts at alternatives, interdisciplinary evaluation, resident assessment, and informed consent before bed rail use.
The facility was found to have deficiencies in food storage and kitchen equipment maintenance, potentially leading to foodborne illnesses. Observations included ice accumulation in the walk-in freezer, inconsistent temperature readings in refrigerators, and unclean kitchen equipment. Interviews with staff confirmed these issues, acknowledging the risk of foodborne illnesses and degraded food quality.
The facility failed to consistently document post-dialysis access site assessments for two residents with end-stage renal disease, despite orders to monitor for complications every shift. Observations and interviews revealed inconsistent documentation practices, with missing records over several months. The Director of Nursing acknowledged the documentation issues, and the facility was unable to provide additional evidence of assessments.
A resident with hypotension was prescribed Midodrine with instructions to hold the medication if SBP exceeded 130. Despite this, the medication was administered multiple times without adhering to the SBP parameter. The LPN responsible admitted to errors in the EHR system and was unaware of the need to document held medications. The consultant pharmacist's recommendations to reevaluate the medication were not followed, leading to continued administration outside prescribed parameters.
A surveyor observed infection control deficiencies during medication administration in an LTC facility. An RN failed to perform hand hygiene before and after administering medications, despite Enhanced Barrier Precautions signage. Additionally, a House Keeper did not follow proper handwashing procedures. The facility's policies align with CDC guidelines, but staff did not adhere to them.
The facility failed to maintain a sanitary and homelike environment, with surveyors observing dirty areas in hallways and an unsanitary shower room on the 400 wing. The porter and Director of Housekeeping acknowledged issues with floor maintenance, citing years of wax buildup. The shower room was found with used items left behind, and staff interviews revealed uncertainty about cleaning responsibilities and frequency. Despite some maintenance efforts, issues persisted.
The facility failed to ensure accurate MDS assessments for three residents. A resident with chronic MASD was inaccurately documented as having no skin conditions. Another resident with rectal cancer was not coded for cancer in the MDS, despite medical records indicating its presence. Additionally, a resident who suffered a fall resulting in a fracture was incorrectly reported as having no falls in the discharge MDS. These errors highlight a pattern of oversight in documenting residents' conditions.
A facility failed to create a comprehensive care plan for a resident prescribed an anticoagulant medication. The resident, diagnosed with Atrial Fibrillation, had a physician's order for Apixaban. However, no care plan was in place to address the medication needs. An LPN indicated that the Unit Manager should have completed the care plan, but it was unclear why it was not done. The issue was discussed with the Administrator and DON, but no further information was provided.
A resident admitted with conditions like spinal stenosis and diabetes was identified as high risk for skin breakdown, but the facility failed to document detailed skin assessments and implement a care plan. Despite noted discolorations, preventive interventions were not initiated, and required documentation was incomplete, as confirmed by facility staff interviews.
The facility failed to ensure that physicians signed and dated monthly medication orders for five residents over a three-month period. Medical records showed that physicians did not sign the monthly orders for April, May, or June 2024. The Wing 2 Unit Manager and the DON confirmed that physicians should sign orders electronically, but this was not done.
Dignity During Dining Not Maintained in Memory Care Unit
Penalty
Summary
The facility failed to promote a dignified dining experience for four residents in the memory care unit by serving their evening meals on overbed tables in a small common area in front of the nurse's station. During observation of the evening meal, residents were seated in the same room used as the dining room, activity room, and TV room, which did not have a dedicated dining table or chairs. A Christmas movie was playing loudly on the television while the residents ate. One resident was seated in a Geri chair with the back not upright, forcing the resident to lean up to reach the food, and food spills were noted on the resident's shirt. Two other residents were seated in chairs in front of the window with their meals on overbed tables and ate without interaction from staff or other residents. Another resident was seated in a wheelchair with the meal tray on an overbed table across the arms of the chair, positioned in front of the nurse's station and facing the television, while slowly feeding himself/herself and not engaging with staff or other residents. Staff stated the residents always had meals in the same area because there was no dining room, and the Administrator stated there was not a dining room in the memory unit and was not aware it was a concern. The facility policy stated mealtime should be pleasant and that residents should be encouraged to eat in the dining room when possible, in a comfortable environment free of loud noises.
Failure to Maintain Homelike Environment and Good Repair in Memory Care Unit
Penalty
Summary
The facility failed to provide a homelike environment in good repair for six residents residing on the Memory Care Unit. Observations revealed multiple deficiencies in resident rooms and common areas, including missing covers on air conditioner/heating units, broken drawers in closets and nightstands, missing or chipped laminate on windowsills and cabinets, partially detached privacy curtains, chipped and missing paint on overbed table stands, and missing baseboards. Additionally, common area issues included missing heating unit covers, torn vinyl on chair cushions, and dried substances on walls. These deficiencies were directly observed by surveyors during their inspection of the unit. Interviews with facility staff, including the Maintenance Director, LPN, CNA, and DON, confirmed the presence of these issues and described the process for reporting and addressing maintenance concerns through a logbook system. The facility's policy requires the maintenance department to keep the building and equipment in safe and operable condition at all times, and to maintain the building in good repair and free from hazards. The observed failures to maintain the environment in good repair had the potential to affect the psychosocial needs of the residents.
Failure to Administer Physician-Ordered Nutritional Supplement
Penalty
Summary
Nursing staff failed to follow physician dietary orders for a resident with dementia and type II diabetes who was identified as having a potential for nutritional problems. The resident's care plan included an intervention to provide an Ensure supplement as ordered, and physician orders specified Ensure Plus twice daily at 9:00 AM and 5:00 PM for protein calorie malnutrition. On the evening of 12/09/25, observation revealed that the resident was not provided the 5:00 PM Ensure Plus supplement with dinner. Interviews with staff indicated that the Ensure Plus supplement was not available on the medication cart at the time it was due. The unit manager obtained the supplement and gave it to the LPN, but the LPN confirmed that the supplement had not been administered because it was not on the cart. The LPN stated it was the nurse's responsibility to ensure the cart was stocked. The Director of Nursing stated that staff are expected to follow physician orders and administer supplements in a timely manner.
Bed Rail Use Without Alternatives, Risk-Benefit Documentation, or Informed Consent
Penalty
Summary
The facility failed to ensure that alternative measures were tried before side rails were used, and it also failed to document discussion of the risks and benefits and obtain signed informed consent prior to bed rail use for one of four residents reviewed, R146. R146 was admitted with a diagnosis of dementia, and the quarterly MDS assessment with an ARD of 11/12/25 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The care plan revised 12/04/25 stated that R146 used enablers for increased independence and mobility, and a physician order dated 04/05/24 directed 1/2 rails while up in bed as a mobility enabler. The Side Rail/Enabler/Entrapment Evaluation dated 05/22/25 and 10/31/25 did not document that alternatives were explored before bed rail use. On 12/09/25 at 8:00 PM, R146 was observed lying in bed with side rails in the up position. During interviews, the UM stated residents used side rails for bed mobility and was unsure whether signed informed consent was present or whether alternatives had been explored; the RNS stated staff did not look at alternatives prior to bed rail use and was unsure about entrapment risk assessment; and the DON stated staff were expected to explore alternatives, document risk versus benefits in the EMR, and obtain signed consent. The facility policy titled Bed Safety and Bed Rails dated August 2022 stated that bed rails are prohibited unless criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
Deficiencies in Food Storage and Kitchen Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies related to food storage and kitchen equipment maintenance, which could potentially lead to foodborne illnesses. During the survey, it was observed that the walk-in freezer had sheets of ice on the floor and icicles hanging from the ceiling, condenser fans, and food boxes. Additionally, several boxes of opened food items, such as croissants, turkey burgers, and breaded eggplant, were not labeled with open or expiration dates and were unsealed, covered with snow, frost, and ice crystals. The walk-in refrigerator #1 had inconsistent temperature readings from different thermometers, and a box of bacon was found opened, unsealed, and unlabeled. Walk-in refrigerator #2 was out of service, and there was no plan for its repair, despite communication from the repair service. Further observations revealed that the temperatures of potentially hazardous foods in walk-in refrigerator #1 were above the safe range, with heavy cream and cottage cheese measuring 46.7 degrees F and 50.4 degrees F, respectively. The facility's kitchen equipment was also not maintained in a clean and sanitary manner. The microwave's interior ceiling was covered with multi-color splatter debris, the meat slicer was found with caked-on brown debris despite being covered with a plastic bag indicating it was clean, and the shelf under the griddle had sediment and debris. Interviews with the Food Service Director, kitchen supervisor, clinical dietary manager, and licensed nursing home administrator confirmed the issues with the freezer and refrigerator, acknowledging that these conditions could lead to foodborne illnesses and degrade food quality. The facility's policies on food safety, physical environment, and monitoring of cooler/freezer temperatures were reviewed, highlighting the need for proper labeling, dating, and maintenance of equipment to prevent contamination and ensure food safety.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to properly assess and document the condition of dialysis access sites for two residents, leading to a deficiency in providing safe and appropriate dialysis care. Resident #55, who has end-stage renal disease and severe cognitive impairment, was observed refusing dialysis due to feeling unwell. Despite having orders to monitor the dialysis access site on the left arm for signs of complications every shift, the facility's records showed inconsistent documentation of these assessments over a two-month period. Similarly, Resident #146, also diagnosed with end-stage renal disease and severe cognitive impairment, had orders to monitor the dialysis access site for complications every shift. However, the nursing progress notes revealed missing documentation for post-dialysis access site assessments over a three-month period. The facility's policy required nurses to monitor and document the status of the resident's access site upon return from dialysis, but this was not consistently done. Interviews with the facility's staff, including the Director of Nursing and registered nurses, confirmed the lack of documentation for post-dialysis assessments. The Director of Nursing acknowledged the poor documentation practices, and the registered nurse admitted to the absence of required documentation in the electronic health records. Despite requests for additional documentation, the facility was unable to provide evidence of consistent post-dialysis assessments, leading to the deficiency finding.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services by not ensuring the accurate administration of Midodrine, a medication used to increase blood pressure, according to the physician's order for a resident with hypotension. The resident, who had severe impaired cognition, was prescribed Midodrine to be administered at bedtime with the condition to hold the medication if the systolic blood pressure (SBP) was greater than 130. However, the medication was administered multiple times over several months without adhering to the SBP parameter, despite the resident's blood pressure readings exceeding the prescribed limit on several occasions. The deficiency was identified through a review of the electronic medication administration records (eMARS) and interviews with facility staff. The LPN responsible for administering the medication admitted to making errors in the electronic health record (EHR) system, stating that they were unaware of the need to document when the medication was held and to notify the appropriate personnel. The LPN had been working with the EHR system for three years but was not familiar with the process of canceling a medication in the system when it was held. The facility's consultant pharmacist had noted the issue in the Medication Review Reports (MRR) for two consecutive months, recommending reevaluation of the resident's need for Midodrine. However, the recommendations were not followed up by the unit manager, leading to continued administration of the medication outside the prescribed parameters. The facility's policy on medication administration required obtaining and recording vital signs and holding medications for vital signs outside the physician's prescribed parameters, which was not adhered to in this case.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to minimize the potential spread of infection during medication administration, as observed by a surveyor. A Registered Nurse (RN) was seen preparing and administering medications to residents without performing hand hygiene before or after the process. This occurred despite the presence of Enhanced Barrier Precautions (EBP) signage, which required hand hygiene before entering and exiting rooms. The RN acknowledged the oversight when questioned by the surveyor. Additionally, a House Keeper (HK) was observed improperly washing hands by not following the facility's hand hygiene policy. The HK washed hands for only 12 seconds, turned off the faucet with bare hands, and dried hands on pants, contrary to the policy that requires using a towel to turn off the faucet and drying hands with a single-use towel. The Infection Preventionist (IP) confirmed that the HK had been educated on proper hand hygiene. The facility's policies on medication administration and hand hygiene were reviewed and found to be in line with CDC guidelines, which emphasize the importance of hand hygiene to prevent infection spread. The Director of Nursing (DON) acknowledged the expectation for staff to perform hand hygiene as per the guidelines, especially when dealing with residents on precautions.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for residents, as evidenced by observations of dark, dirty areas in the hallways and doorways of the 400 hallway over several days. The porter responsible for cleaning stated that he had not yet cleaned the 400 wing and was usually the only porter, with a floor technician working only on weekends. The Director of Housekeeping acknowledged the issue, attributing it to years of wax buildup and stated that the floors had only been waxed once in the past three years. She also admitted to not having seen a policy regarding floor maintenance. Additionally, the shower room on the 400 wing was found in an unsanitary condition with used towels, gloves, a clothing item, a used mask, and an opened adult brief left on a shower chair. Interviews with a CNA and an LPN revealed that CNAs were expected to clean up after showers, but there was uncertainty about how often the shower room was checked. The Director of Housekeeping and the Maintenance Director both acknowledged the poor condition of the shower room, with the Director of Housekeeping suggesting the need for new tiles and caulking. Despite some maintenance efforts, dark brown areas remained in the shower stall.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments of residents using the Minimum Data Set (MDS) assessment tool, as evidenced by deficiencies identified in three residents. Resident #94 was observed with chronic moisture-associated skin damage (MASD) in the sacral area, yet the MDS assessment on 7/14/24 inaccurately indicated no skin conditions were present. The MDS Coordinator acknowledged the error, noting that the MASD should have been documented. Resident #37, diagnosed with rectal cancer, had an MDS assessment on 5/17/24 that failed to reflect cancer as an active diagnosis, despite medical records and care plans indicating its presence. The MDS Coordinator admitted the oversight in coding the cancer diagnosis. Resident #586, who suffered a left femur fracture due to an unwitnessed fall, had a discharge MDS on 3/26/24 that incorrectly reported no falls since the prior assessment. Progress notes and a facility investigation confirmed the fall, yet the MDS did not reflect this incident. The MDS Coordinator was informed of the discrepancy and acknowledged the need to address the coding error. These inaccuracies in MDS assessments highlight a pattern of oversight in documenting residents' conditions accurately.
Failure to Develop Care Plan for Anticoagulant Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed an anticoagulant medication. During an observation, the resident confirmed taking an anticoagulant medication. A review of the resident's Electronic Medical Records showed that the resident was admitted with a diagnosis of Atrial Fibrillation and had a physician's order for Apixaban, an anticoagulant, to be taken orally every two days. However, the surveyor found no care plan addressing the resident's anticoagulant medication needs. An interview with an LPN revealed that the Unit Manager is responsible for completing care plans, and there should have been a care plan for the resident receiving anticoagulant medication. The LPN was unsure why the care plan was not created. The issue was discussed with the Administrator and Director of Nursing, but no additional information was provided.
Failure to Assess and Plan for High-Risk Skin Breakdown
Penalty
Summary
The facility failed to thoroughly assess a skin discoloration identified on an admission assessment and did not implement a care plan for a resident at high risk for skin breakdown. Resident #585 was admitted with conditions including spinal stenosis, muscle wasting, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) indicated the resident was frequently incontinent and required maximum assistance with activities of daily living. Despite being identified as at risk for pressure ulcers, no skin or ulcer injury treatments were documented. The admission assessment noted discolorations on the resident's groin and sacrum, but lacked details such as size and color. The Braden scale score indicated a high risk for skin breakdown, necessitating immediate prevention protocols and care plan documentation. However, the care plan did not include interventions to prevent skin deterioration. The Treatment Administration Record (TAR) lacked documentation of preventive skin care treatments, and a physician's order for weekly skin checks was not properly documented in the electronic medical record. Interviews with facility staff, including the wound care nurse, Director of Nursing (DON), and other nursing staff, revealed a lack of detailed documentation and care planning. The DON confirmed that the admission nurse should have provided a more descriptive assessment and initiated a care plan with preventive interventions. The facility's policy required a pressure risk injury assessment and a full body skin assessment upon admission, with findings documented in the medical record, but these protocols were not followed for Resident #585.
Failure to Sign Monthly Medication Orders
Penalty
Summary
The facility failed to ensure that physicians signed and dated monthly medication orders for five residents over a three-month period. Specifically, the medical records for five residents showed that their physicians did not hand sign or electronically sign the monthly physician's orders for April, May, or June 2024. This deficiency was identified during a review of hybrid medical records for the residents. The Wing 2 Unit Manager and the Director of Nursing confirmed to the surveyor that physicians should be signing their monthly orders electronically, but this was not done for the specified months.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,347 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cranford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cranford Park Care | 1.1 mi | ★★★★★ | 12 | 0 |
| Cornell Hall Care & Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Mountainside Skilled Nursing And Rehab | 3 mi | ★★★★★ | 2 | 0 |
| Complete Care At Clark Llc | 3.2 mi | ★★★★★ | 1 | 0 |
| Plaza Healthcare & Rehabilitation Center | 3.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Birchwood Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.