Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severely impaired cognition was not given a SNF ABN when discharged from Medicare Part A skilled services before their covered days were exhausted. Although the resident's representative was verbally informed about potential non-covered services, this was not documented on the required form, and staff interviews confirmed the omission and lack of a facility policy regarding SNF ABNs.
Two residents were admitted to hospice services, but the facility did not complete the required Significant Change in Status MDS Assessments within 14 days of their hospice admission. The MDS Coordinator, responsible for these assessments, was unaware that hospice admission alone required an SCSA and did not complete them for either resident. Staff interviews confirmed the oversight, and the facility lacked a specific policy, relying instead on the RAI manual.
The facility did not refer two residents for PASRR evaluation after they received new diagnoses of mental illness, including psychotic disorder and PTSD. Staff did not submit required forms or update care plans to reflect the new diagnoses, and interviews revealed confusion about qualifying conditions and a lack of policy regarding PASRR procedures.
A medication aide failed to administer Artificial Tears and incorrectly gave Moxifloxacin eye drops in both eyes instead of only the left eye to a resident with dementia and a fungal infection, resulting in a medication error rate above 5%. Interviews confirmed the errors occurred due to misreading orders and distraction during medication preparation.
A licensed nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with an open facial lesion and moderate cognitive impairment. Despite facility policy and prior training on proper handwashing, the nurse did not cleanse hands or use sanitizer during the procedure, as confirmed by observation and staff interviews.
The facility failed to maintain a clean and homelike environment in the dining room and shower room. A resident reported dead flies and cobwebs in the dining room, which were confirmed by observations. The Housekeeping Supervisor was unaware of the issue, and the Administrator acknowledged lapses in the cleaning schedule. In the shower room, pink and black grime was observed, and cleaning had not been performed as required due to short staffing. The facility's policy emphasizes the importance of a clean environment, which was not upheld in these instances.
A resident with severe cognitive impairment and frequent incontinence did not receive proper incontinent care, as a CNA used the same wipe multiple times and did not change gloves or perform hand hygiene before applying a clean brief. This failure to follow the facility's perineal care policy was observed by an LVN and confirmed by the CNA, LVN, Administrator, and DON, posing a potential risk of urinary tract infections.
A facility failed to maintain an infection prevention and control program when a CNA did not change gloves or perform hand hygiene during incontinent care for a resident with severe cognitive impairment. The CNA also used the same wipe multiple times to clean the resident's peri area, contrary to facility policies.
A resident with a history of abnormal weight loss did not receive the ordered double protein portions during a meal, despite it being documented in their care plan. The DON and Dietary Manager acknowledged the oversight, emphasizing the importance of following dietary preferences to prevent weight loss. The facility's policy allowed for larger portions, but this was not followed.
The facility failed to follow its smoking policy by improperly disposing of cigarette butts in a plastic-lined trashcan instead of a metal container. The Housekeeping Supervisor, new to her role, was unsure of the correct procedure and mistakenly took on the task meant for the Maintenance Supervisor. This miscommunication led to a potential safety risk in the smoking area.
Failure to Provide SNF ABN Notification Upon Discharge from Skilled Services
Penalty
Summary
The facility failed to ensure that a resident was properly informed about Medicare/Medicaid coverage and potential financial liability for services not covered. Specifically, the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who was being discharged from Medicare Part A skilled services before their covered days were exhausted. The resident, who had a diagnosis of pneumonitis due to inhalation of food and vomit and was assessed as having severely impaired cognition, continued to reside in the facility after skilled services ended. Although the resident's representative was verbally informed about services that might not be covered, this was not documented on the required SNF ABN form. Interviews with facility staff revealed that the MDS Coordinator was responsible for issuing the SNF ABN and acknowledged that the form should have been provided in this situation. The Administrator also confirmed the expectation that the SNF ABN be given when a resident with remaining benefit days is discharged from Part A services. Additionally, it was noted that the facility did not have a policy regarding the issuance of SNF ABNs.
Failure to Complete Significant Change MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days after two residents were admitted to hospice services. For one male resident with diagnoses including encephalopathy and protein-calorie malnutrition, records showed he was admitted to hospice services, and his care plan was updated to reflect a terminal prognosis. However, there was no documentation of a Significant Change in Status MDS Assessment being completed following his hospice admission. The MDS Coordinator acknowledged responsibility for completing the assessment but stated she did not think it was necessary and missed completing it. Similarly, a female resident with dementia and post-traumatic stress disorder was admitted to hospice services, and her care plan was revised to reflect her terminal prognosis and hospice care. Despite this, her electronic health record did not show that a Significant Change in Status MDS Assessment was completed after her hospice admission. The MDS Coordinator stated she was unaware that admission to hospice alone required a Significant Change in Status MDS Assessment and believed two qualifying changes were necessary. She also indicated she had not received education on this requirement. Interviews with facility staff, including the Regional Reimbursement Nurse and the Administrator, confirmed that the MDS Coordinator was responsible for completing these assessments and that the assessments were not completed as required. The facility did not have a specific policy on MDS assessment completion and followed the RAI manual, which mandates an SCSA when a resident enrolls in hospice. The failure to complete these assessments was directly linked to a lack of understanding and oversight regarding regulatory requirements.
Failure to Refer Residents for PASRR Evaluation After New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that residents with new diagnoses of mental illness were properly referred for Preadmission Screening and Resident Review (PASRR) evaluations. In the case of one male resident with a new diagnosis of psychotic disorder with delusions, the initial PASRR Level 1 screening and MDS assessment did not indicate a mental illness. However, after admission, the resident was prescribed psychiatric medication and received a new diagnosis of psychotic disorder. Despite this change, neither a Form 1012 nor a new PASRR Level 1 screening was submitted to notify the local authority, as confirmed by the PASRR Manager, MDS Coordinator, and Administrator during interviews. The care plan for this resident also did not address PASRR needs. Similarly, a female resident with a new diagnosis of post-traumatic stress disorder (PTSD) was not referred for a PASRR review. Her initial PASRR Level 1 screening indicated no evidence of mental illness, and her care plan addressed trauma history but not PASRR requirements. The MDS Coordinator believed that PTSD was not a qualifying mental illness for PASRR and therefore did not complete the necessary forms. However, the PASRR Program Manager clarified that PTSD is a qualifying diagnosis and that a Form 1012 should have been completed. The Regional Reimbursement Nurse also acknowledged that the omission could have resulted from the diagnosis not being explicitly listed on the PASRR forms. These deficiencies were identified through record reviews and staff interviews, which revealed that the facility did not have a policy regarding PASRRs and that staff responsible for PASRR referrals were not consistently submitting required documentation when residents received new qualifying mental health diagnoses. This failure affected at least two residents reviewed for PASRR, as neither was referred for further evaluation or services following the identification of a new mental illness diagnosis.
Medication Error Rate Exceeds 5% Due to Incorrect Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by a 5.56% error rate resulting from 2 errors out of 36 observed opportunities. Specifically, a medication aide (MA) did not administer Artificial Tears as ordered and incorrectly administered Moxifloxacin Ophthalmic Solution in both eyes instead of only the left eye for a resident. The errors were observed during a medication pass, and the MA later confirmed she misread the order and omitted the Artificial Tears due to being distracted while preparing medications. The resident involved was an older female with dementia and candidiasis of the skin and nail, who had physician orders for both Artificial Tears and Moxifloxacin eye drops. The resident's care plan and medication administration record reflected these orders, but the observed administration did not follow them. Interviews with the MA, DON, ADON, and Administrator confirmed the errors and acknowledged the importance of adhering to physician orders during medication administration. The facility's policy required strict adherence to the six rights of medication administration, which was not followed in this instance.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to perform proper hand hygiene while providing wound care to a resident. During the observed wound care procedure, the LVN repeatedly changed gloves without cleansing her hands or using hand sanitizer between glove changes. The LVN acknowledged during the interview that she should have performed hand washing between glove changes but did not provide a reason for the omission. The Director of Nursing (DON), who also serves as the Infection Control Preventionist, confirmed that the expectation is for staff to sanitize hands between each glove change and that the LVN had previously been checked off on proper handwashing technique. The resident involved was an older adult male with a history of hypothyroidism and a moderately impaired cognitive status, as indicated by a BIMS score of 9. He had an open lesion on his right cheek, for which there was an active physician's order for daily wound care. The resident's care plan included interventions to maintain skin integrity and prevent infection. The facility's infection control policy required hand hygiene after removing gloves, but this protocol was not followed during the observed wound care procedure.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment in both the dining room and the shower room on the secured unit. In the dining room, a resident reported dead flies and cobwebs on the ceiling and walls, which had been present since her admission. Despite multiple reports to staff, the issue remained unaddressed. Observations confirmed the presence of crane flies and numerous cobwebs. The Housekeeping Supervisor, new to the position, was unaware of the issue, and the Administrator acknowledged that the deep cleaning schedule had not been followed due to a transition in supervision. The Administrator admitted that the dining room should be cleaned daily to maintain cleanliness and a homelike environment. In the secured unit's shower room, pink and black grime was observed on the grout of the walls. The Housekeeping Supervisor, also new to the position, stated that the showers should be cleaned every other day unless scheduled for use. However, due to short staffing, the cleaning had not been performed as required. Housekeeper C confirmed the grime's presence and indicated that the showers should have been cleaned by the Housekeeping Supervisor. The Administrator, responsible for housekeeping oversight, stated that showers should be cleaned daily to prevent infections but had not noticed the grime during his rounds. The facility's policy on resident rights emphasizes the importance of a safe, clean, and comfortable environment, including necessary housekeeping and maintenance services. The failure to adhere to this policy in both the dining room and shower room resulted in unsanitary conditions that could potentially impact the residents' quality of life and health. The report highlights the need for consistent and thorough cleaning practices to ensure a safe and homelike environment for all residents.
Improper Incontinent Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a CNA did not follow proper incontinent care procedures for a resident with severe cognitive impairment and frequent incontinence. The CNA used the same wipe multiple times to clean the resident's peri area and did not change gloves or perform hand hygiene before applying a clean brief. This improper technique was observed by an LVN who attempted to prompt the CNA but was unsuccessful. The resident involved was a [AGE] year-old female with dementia and other behavioral disturbances, who was always incontinent of urine and frequently incontinent of bowel. Her care plan required assistance with toileting and personal hygiene, and she had a potential for pressure ulcer development, necessitating proper incontinent care and the application of a moisture barrier. Despite these requirements, the CNA's actions did not align with the facility's policy on perineal care, which mandates using a clean area of the wipe for each stroke and changing gloves between dirty and clean tasks. Interviews with the CNA, LVN, Administrator, and DON confirmed the improper care provided. The CNA admitted to not following proper procedures due to being in a hurry and nervous. The LVN and DON emphasized the importance of proper incontinent care to prevent infections, and the Administrator acknowledged the need for CNAs to adhere to the facility's policies. The facility's policy on perineal care clearly outlines the correct procedures, which were not followed in this instance, leading to a potential risk of urinary tract infections for the resident.
Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of CNA B while providing incontinent care to a resident. During the observation, CNA B did not change gloves or perform hand hygiene after removing the resident's soiled brief and before applying a clean one. Additionally, CNA B used the same wipe multiple times to clean the resident's peri area, which had stool on it, instead of using a clean wipe for each stroke. These actions were confirmed by CNA B, who admitted to not following proper procedures due to being in a hurry and nervous. The resident involved was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 00 on her MDS assessment. She was always incontinent of urine and frequently incontinent of bowel, requiring substantial assistance with personal hygiene. The resident was also on a course of antibiotics for a urinary tract infection at the time of the incident. The care plan for the resident specified the need for proper incontinent care to prevent pressure ulcers and infections. Interviews with LVN A, the Administrator, and the DON confirmed that the facility's policies for hand hygiene and perineal care were not followed. LVN A attempted to prompt CNA B during the care but was unsuccessful. The Administrator and DON emphasized the importance of changing gloves, performing hand hygiene, and using clean wipes to prevent infections. The facility's policies clearly outlined the correct procedures for hand hygiene and perineal care, which were not adhered to during the observed incident.
Failure to Provide Double Protein Portions as Ordered
Penalty
Summary
The facility failed to accommodate a resident's food preferences, specifically the preference for double protein portions, which was documented in the resident's care plan and meal orders. The resident, who was at risk for malnutrition and had a history of abnormal weight loss, was observed receiving only a single portion of meat loaf during a meal, despite having an order for double protein portions. This oversight was noted by the surveyor and confirmed by the Director of Nursing (DON) and the Dietary Manager, who acknowledged the error and the importance of adhering to the resident's dietary preferences to prevent weight loss. Interviews with the staff revealed that the responsibility for ensuring correct meal portions was assigned to a specific staff member, who mistakenly believed the portion served was adequate. The Dietary Manager admitted to not noticing the issue previously and stated that staff had been verbally in-serviced following the incident. The Administrator emphasized the expectation for meal tickets and food preferences to be followed, highlighting the importance of respecting residents' rights and ensuring their well-being. The facility's policy allowed for larger portions if requested, but this was not adhered to in this instance.
Improper Disposal of Cigarette Butts in Smoking Area
Penalty
Summary
The facility failed to adhere to its established smoking policy in one of the two smoking areas reviewed. The policy, revised on November 1, 2017, mandates that ashtrays should be metal containers with self-closing covers. However, during an observation, it was found that the main building's smoking area had a plastic-lined trashcan containing approximately 30 red-tipped cigarette butts. The Housekeeping Supervisor, who was present, stated she was responsible for emptying the ashtrays and the red metal trashcan, but she had been disposing of the cigarette butts into the plastic-lined trashcan instead. Further interviews revealed that the Housekeeping Supervisor had only been in her position for two days and was unsure of the proper procedure for disposing of cigarette butts. She mentioned that no one had instructed her on the correct method, and she had taken it upon herself to empty the red metal trashcans. The Administrator confirmed that the cigarette butts should not have been disposed of in the plastic-lined trashcan and that the Maintenance Supervisor was actually responsible for this task. This miscommunication and lack of clarity in roles led to the improper disposal of cigarette butts, potentially creating an unsafe smoking environment.
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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.
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Nursing homes near Cooper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Commerce | 15.2 mi | ★★★★★ | 19 | 0 |
| Sulphur Springs Health And Rehabilitation | 16 mi | ★★★★★ | 16 | 0 |
| Carriage House Manor | 16.2 mi | ★★★★★ | 0 | 0 |
| Sunny Springs Nursing & Rehab | 16.4 mi | ★★★★★ | 15 | 0 |
| Rock Creek Health And Rehabilitation | 18.1 mi | ★★★★★ | 15 | 1 |
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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.