Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birch Hill Health Services during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall resulting in injury. Despite facility policy requiring notification, the resident's Guardian was not informed of the fall or the change in condition. The Guardian only discovered the injury during a later visit, and the DON confirmed that notification should have occurred.
A resident with severe cognitive impairment and a history of fractures was found to have a new, unexplained fracture in the right arm. Despite ongoing pain and no documented cause for the injury, the facility did not report the injury of unknown origin to the State Agency as required by policy.
A resident with severe cognitive impairment and a history of fractures developed a new fracture above a previously repaired site, but the facility did not conduct an investigation into the injury of unknown origin as required by policy. The resident was unable to communicate the cause of the injury, and the NHA confirmed that no investigation was performed.
A resident with severe cognitive impairment and multiple medical conditions sustained a fall from bed, after which only a portion of the required neurological checks were performed. Although the IDT recommended a bolster mattress to prevent future falls, this intervention was not added to the care plan. The DON confirmed these omissions were not in line with facility policy.
A resident was found barricaded behind the nurses' station by a CNA, restricting movement and resulting in observed bruising and bleeding. The incident was reported internally but not to the State Agency or local police within required timeframes, despite facility policy and staff awareness that involuntary seclusion is considered abuse. The accused CNA continued working until the allegation was reported days later.
A CNA was reported to have barricaded a resident in the nurses' station using a treatment cart, preventing the resident from moving freely. Despite the allegation of involuntary seclusion, which is considered abuse under facility policy, the CNA continued to work unsupervised for several days after the incident was reported to the DON and NHA. The facility did not initiate a full investigation or suspend the CNA until the concern was raised again by another staff member. The resident involved was found with a skin tear and bruising on the leg, which was attributed to a previous fall.
The facility failed to update care plans for three residents who began hospice care and another resident on a restorative walking program. Hospice care plans were missing, and staff were unaware of the walking requirements, leading to inconsistencies in care. The DON confirmed the need for updated care plans.
A facility failed to maintain proper storage conditions for medications, with one refrigerator not consistently kept at the required temperature and medications for several residents not dated when opened. Expired items were also found in the medication storage room and on a medication cart, indicating non-compliance with the facility's policies. The DON confirmed these issues but lacked documentation of corrective actions.
A resident took inhalers to a dialysis appointment without a self-administration assessment or physician's order, contrary to facility policy. The resident, admitted for rehab with asthma, was observed missing inhalers from the medication cart. A subsequent physician notification allowed self-administration, but the required assessment was delayed.
A resident with a history of bowel obstruction went five days without a documented bowel movement, and the facility failed to follow its bowel management protocol. Despite having physician orders for as-needed constipation medications, the resident was not offered these during the period without a bowel movement. The facility lacked a written bowel management policy, and the resident did not have a bowel elimination care plan. Staff interviews revealed inconsistencies in monitoring and documentation practices.
A resident with a pressure ulcer and other medical conditions did not receive appropriate wound care as the DON failed to apply iodine during a dressing change, contrary to the physician's order. This was confirmed by an LPN and the DON during interviews.
A resident with dementia and behavioral disturbances was prescribed Seroquel, an antipsychotic medication, without a baseline AIMS assessment being conducted. The facility's policy requires such assessments to monitor for adverse reactions, but the resident's medical record lacked this crucial evaluation. The DON acknowledged the importance of a baseline assessment for comparison in future evaluations.
A resident with MRSA was not properly managed under contact precautions, as staff failed to post necessary signage and did not consistently wear gowns and gloves during care. Observations revealed therapy staff did not adhere to infection control protocols, and the DON confirmed the need for gowns to prevent exposure.
Failure to Notify Guardian of Resident Fall and Change in Condition
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, experienced a fall with injury. The resident, who had diagnoses including acute metabolic encephalopathy, myxedema coma, hypothyroidism, and urinary tract infection, was found on the floor next to the bed, entangled in bedding, with a bruise on the right temporal region and stool present on the chest and bed. The resident was unresponsive to questions and refused to open their mouth for medications. Neuro checks were completed with no concerns noted at the time. Despite facility policy requiring notification of the physician and family or responsible party after a fall, the resident's Guardian, who had been appointed prior to the incident, was not informed of the fall or the resulting injury. The Guardian only became aware of the bruise during a subsequent visit and had not been notified by staff. The Director of Nursing confirmed that the Guardian should have been notified of the fall and change in condition, but this did not occur.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse, Neglect, and Exploitation policy. A resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and osteoporosis with a history of pathological fractures, was found to have an additional fracture in the right humerus above a previously repaired site. The new fracture was discovered after the resident continued to experience significant pain despite receiving scheduled and as-needed pain medication. There was no documented fall or other incident to explain the new injury. The facility's policy mandates reporting all physical injuries of unknown source to the Administrator, State Agency, and other required agencies within specified timeframes. Despite this, the injury was not reported to the State Agency. The deficiency was identified during a surveyor's review of the resident's medical record and confirmed through staff interviews, including with the Nursing Home Administrator, who acknowledged the reporting requirement for injuries of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident, who had severe cognitive impairment and a history of Alzheimer's disease, dementia, and multiple fractures, was admitted with a surgically repaired right humerus fracture. After returning from the hospital with a cast, the resident continued to experience significant pain in the right arm, which was documented in progress notes. Despite ongoing pain and a new fracture being discovered above the previously repaired site, there was no documented investigation by the facility into how the new injury occurred. The facility's policy required immediate investigation of any physical injury of unknown source to rule out abuse, neglect, or exploitation. However, when the new fracture was identified, the facility did not initiate or document an investigation as required by their own policy. The resident was unable to communicate how the injury occurred due to severe cognitive impairment, and the Nursing Home Administrator confirmed that no investigation was conducted for the injury of unknown origin.
Failure to Complete Required Neuro Checks and Update Care Plan After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including acute metabolic encephalopathy, myxedema coma, hypothyroidism, and UTI, experienced a fall from bed that resulted in injury. The fall was unwitnessed, and the resident was found on the floor entangled in bedding, with a dark bruise observed on the right temporal region. Facility policy required a specific schedule of neurological checks following such an event, but only 5 out of the 15 required checks were completed, as confirmed by record review and staff interview. Additionally, the Interdisciplinary Team (IDT) identified the need for a bolster mattress as an intervention to help prevent future falls. However, this intervention was not added to the resident's care plan. The Director of Nursing verified that both the neurological checks and the care plan update were not completed in accordance with facility policy and IDT recommendations.
Failure to Timely Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving involuntary seclusion in a timely manner to the State Agency (SA) and did not notify the local police department as required. A Certified Nursing Assistant (CNA) reported to the Nursing Home Administrator (NHA) that another CNA had barricaded a resident behind the nurses' station using a treatment cart, restricting the resident's movement. This incident was observed when the reporting CNA arrived for their shift and found the resident unable to leave the area without assistance. The resident was also found to have blood and bruising on the left lower leg, which was reported to a Registered Nurse (RN) and treated at that time. Staff interviews and record reviews revealed that the incident was initially reported to the NHA and Director of Nursing (DON) on the same day it occurred, and statements were collected from involved staff. Despite being aware of the allegation and recognizing that involuntary seclusion constitutes abuse, the NHA and DON did not report the incident to the SA until several days later. The CNA accused of the action continued to work during this period, and the facility did not notify the local police department about the allegation. The facility's own Abuse Prevention Program required immediate reporting of abuse allegations to the Administrator or designee, and to the SA and other authorities within specified timeframes. However, the NHA and DON delayed reporting because they believed the incident did not constitute abuse based on their internal investigation. The delay in reporting and failure to notify law enforcement were identified as deficiencies during the survey.
Failure to Immediately Investigate and Protect Resident After Alleged Involuntary Seclusion
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of abuse involving a resident who was reportedly barricaded in the nurses' station by a CNA. On the night in question, a CNA was observed by another CNA with a resident positioned at the CNA desk, with a treatment cart placed in such a way that the resident could not freely leave the area. The CNA explained that the resident was placed there because they had been entering other residents' rooms. When the observing CNA moved the treatment cart, they were able to take the resident for toileting and observed blood and bruising on the resident's leg, which was reported to a nurse and attributed to a previous fall. Despite the report of possible involuntary seclusion, which is considered a form of abuse according to the facility's own policy, the CNA accused of the action was not immediately removed from resident care or placed under supervision. The CNA continued to work several shifts after the initial allegation was reported to both the DON and NHA. The facility did not initiate a full investigation or suspend the CNA until a week after the initial report, when the concerns were raised again by another staff member. Staff interviews and documentation confirmed that the facility's leadership was aware of the allegation but chose not to act immediately, citing their belief that the incident did not occur as described. The facility's abuse prevention policy requires immediate action to protect residents and a thorough analysis of the occurrence, but these steps were not taken in a timely manner. The resident involved had a history of falls, and at the time of the incident, was found with a skin tear and bruising on the leg.
Failure to Update Care Plans for Hospice and Restorative Care
Penalty
Summary
The facility failed to revise care plans to reflect the current care needs of four residents, leading to deficiencies in care. Three residents who began receiving hospice care did not have their care plans updated to include hospice services. This oversight was confirmed through record reviews and staff interviews, where it was noted that the medical records of these residents lacked hospice care plans despite having orders for hospice evaluation and treatment. The Director of Nursing confirmed that residents receiving hospice services should have a care plan that reflects their needs. Additionally, the care plan for another resident, who was on a restorative walking program, was not updated to reflect changes in their ambulation schedule. The care plan indicated that the resident should be walked to meals, but staff were not aware of this requirement and instead transported the resident in a wheelchair. Interviews with various staff members revealed a lack of awareness regarding the resident's care plan, and documentation showed inconsistencies in the resident's walking schedule. The Director of Nursing verified the care plan's requirements and noted that the resident was walked at different times of the day, not just during meals.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to maintain appropriate storage conditions for medications, specifically in one of the two refrigerators in the medication storage room. The refrigerator, which contained vaccines and insulin, was not consistently maintained at the required temperature range as per the facility's policy. The temperature log indicated that temperatures were recorded only once per day, contrary to the policy that required twice-daily checks. Additionally, 8 out of 22 recorded temperatures were out of the acceptable range, and there was no documentation of corrective actions taken when temperatures were out of range. Furthermore, the facility did not ensure that medications for seven residents were dated appropriately when opened. The surveyor observed multiple medications, including inhalers and eye drops, on a medication cart that were not dated upon opening. This is a violation of the facility's policy, which requires medications to be dated when opened to ensure they are used within their effective period. The Director of Nursing confirmed that medications should be dated when opened and discarded by their expiration or beyond-use date. The surveyor also found expired items in the medication storage room and on the medication cart. These included various medications, vaccines, and medical supplies that were past their expiration dates. The presence of expired items and the failure to date opened medications indicate a lack of adherence to the facility's medication storage and administration policies. The Director of Nursing acknowledged these deficiencies but did not provide documentation of any actions taken to address the out-of-range refrigerator temperatures.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to self-administer medication. The resident, who was admitted for rehabilitation following a patellar tendon rupture and had a diagnosis of unspecified asthma, was observed taking inhalers to a dialysis appointment without a self-administration assessment or a physician's order. The facility's policy requires an interdisciplinary team assessment and a prescriber's order to determine if a resident can safely self-administer medications. However, the resident's medical record indicated that either the resident did not wish to self-administer medication or was unable to make their own decision, and thus, was not permitted to self-administer medication. The deficiency was identified when a surveyor noted the resident's inhalers were missing from the medication cart, and a Licensed Practical Nurse confirmed that the resident had taken them to dialysis. Subsequently, a physician notification indicated the resident's desire to self-administer inhalers and keep them at bedside, with the provider's response allowing for self-administration pending a nursing assessment. However, the self-administration assessment was not completed until after the incident, indicating a lapse in following the facility's policy and procedures for medication self-administration.
Failure to Monitor Bowel Movements for Resident with History of Obstruction
Penalty
Summary
The facility failed to monitor bowel movements for a resident with a history of bowel obstruction, as per the facility's protocol. The resident, who had intact cognition and was their own decision-maker, went five days without a documented bowel movement. During this period, the resident continued to take scheduled Benefiber but was not offered any as-needed medication for constipation, despite having physician orders for such medications. The facility lacked a written bowel management policy, and the resident did not have a bowel elimination care plan. Interviews with staff revealed inconsistencies in the monitoring and documentation of the resident's bowel movements. A Certified Nursing Assistant (CNA) indicated that bowel movements were documented in CNA charting and that nursing staff provided a list of residents on watch for bowel movements. However, the CNA could not recall if the resident was on the list during the five days without a documented bowel movement. The Director of Nursing (DON) confirmed that the resident should have had a bowel elimination care plan due to their history of bowel obstruction and acknowledged the absence of a bowel management policy. The facility's protocol, as described by the DON, involved offering prune juice on day three without a bowel movement, Milk of Magnesia on day four, and a suppository on day five, with physician contact if there were no results by day five. However, this protocol was not followed for the resident in question. The DON suggested that the resident might have gone to the bathroom without informing staff or that staff might have provided medication without documenting it, but confirmed that bowel movements and medications should be documented in the resident's medical record.
Failure to Apply Iodine During Dressing Change
Penalty
Summary
The facility failed to ensure that a resident received appropriate care and services to promote healing and prevent pressure injuries. The resident, who had intact cognition and was responsible for their healthcare decisions, had a wound care order to apply iodine and a Xeroform dressing on a stitch area on the left foot. During a dressing change observed by a surveyor, the Director of Nursing (DON) did not apply iodine as ordered by the physician. This omission was confirmed by both the Licensed Practical Nurse (LPN) present during the dressing change and the DON during subsequent interviews. The resident had been admitted with diagnoses including rhabdomyolysis, sepsis due to MRSA, a pressure ulcer of the foot, and diabetes.
Failure to Conduct Baseline AIMS Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was monitored for adverse reactions to an antipsychotic medication. The resident, who had been diagnosed with dementia with behavioral disturbances, was prescribed Seroquel, an antipsychotic medication. However, the facility did not complete a baseline Abnormal Involuntary Movement Scale (AIMS) assessment for the resident prior to the initiation of the medication. This assessment is crucial for identifying any involuntary movements that could indicate adverse reactions to the medication. The facility's policy on psychotropic medications, reviewed on 10/24/22, requires that residents receiving antipsychotic medications have an AIMS test performed on admission, at least every six months, when the medication is changed, and as needed. Despite this policy, the resident's medical record lacked a baseline AIMS assessment. The Director of Nursing acknowledged that a baseline AIMS assessment provides a necessary comparison for future assessments, but the facility's policy did not specify the need for a baseline assessment before starting antipsychotic medication.
Inadequate Infection Control for Resident on Contact Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of proper transmission-based precautions for a resident diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). The resident, who had a Charcot foot wound infected with MRSA, was not properly identified with a transmission-based precautions sign outside their room. This oversight was confirmed by the Licensed Practical Nurse and the Director of Nursing, who acknowledged that the sign should have been posted. Additionally, staff were observed providing care without adhering to the necessary precautions, such as wearing gowns and gloves, which are required by the facility's infection control policy and CDC guidelines. During observations, it was noted that therapy staff, including a Physical Therapist Assistant and an Occupational Therapist Assistant, did not wear gowns while providing care to the resident, despite the resident being on contact precautions. The Physical Therapist Assistant was also seen with a mask improperly worn around the neck while providing therapy. Interviews with the therapy staff revealed a misunderstanding of the requirements for wearing gowns during physical contact with the resident. The Director of Nursing confirmed that therapy staff should have worn gowns to prevent accidental exposure, especially given the resident's wound and drainage issues.
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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 Shawano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Health Services | 0.5 mi | — | 3 | 1 |
| Shawano Health Services | 0.8 mi | — | 14 | 0 |
| The Pines Post Acute And Memory Care | 7.7 mi | — | 0 | 0 |
| Greentree Health And Rehabilitation Center | 12.3 mi | — | 2 | 0 |
| Suring Health And Rehab Center | 19.6 mi | — | 6 | 1 |
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