All citations for Birchaven Retirement Village

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

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Last standard health inspection on record

January 9, 2025

Showing 1 to 25 of 45 citations

No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Widespread (many residents). CMS level F.
Fire safety citation K-0211, Egress Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
Widespread (many residents). CMS level F.
Fire safety citation K-0511, Services Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Widespread (many residents). CMS level F.
Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
Widespread (many residents). CMS level F.
Fire safety citation K-0324, Smoke Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (December 9, 2022).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (December 9, 2022).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (December 9, 2022).
No harm, with potential for more than minimal harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Pattern (more than a few residents). CMS level E.
Health citation F-0803, Nutrition and Dietary Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Pattern (more than a few residents). CMS level E.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Pattern (more than a few residents). CMS level E.
Health citation F-0880, Infection Control Deficiencies. Inspection of January 9, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Pattern (more than a few residents). CMS level E.
Health citation F-0887, Infection Control Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Have proper power supply for life support equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0915, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
A waiver was granted (February 10, 2025).
No harm, with potential for more than minimal harm
Have proper medical gas storage and administration areas.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 10, 2025).
No harm, with potential for more than minimal harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0222, Egress Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.
A waiver was granted (February 17, 2023).
No harm, with potential for more than minimal harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0362, Smoke Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (December 9, 2022).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (December 9, 2022).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pattern (more than a few residents). CMS level E.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of December 18, 2019. Found during a standard inspection.
The home gave a date the problem would be corrected (February 3, 2020).
No harm, with potential for more than minimal harm
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Pattern (more than a few residents). CMS level E.
Health citation F-0920, Environmental Deficiencies. Inspection of December 18, 2019. Found during a standard inspection.
The home gave a date the problem would be corrected (February 3, 2020).
No harm, with potential for more than minimal harm
Have exits that are accessible at all times.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0271, Egress Deficiencies. Inspection of December 18, 2019. Found during a standard inspection.
The home gave a date the problem would be corrected (February 3, 2020).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of December 18, 2019. Found during a standard inspection.
The home gave a date the problem would be corrected (February 3, 2020).
No harm, with potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Isolated (one or a few residents). CMS level D.
Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 19, 2026. Found during a complaint inspection.
Past non-compliance: already corrected by the time of the inspection.
No harm, with potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Isolated (one or a few residents). CMS level D.
Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of April 9, 2026. Found during a complaint inspection.
The home gave a date the problem would be corrected (May 11, 2026).
No harm, with potential for more than minimal harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Isolated (one or a few residents). CMS level D.
Health citation F-0607, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of April 9, 2026. Found during a complaint inspection.
The home gave a date the problem would be corrected (May 11, 2026).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.