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.

Back to Birchaven Retirement Village

Last standard health inspection on record

January 9, 2025

Showing 1 to 25 of 26 citations

  1. 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).

  2. 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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

  9. 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).

  10. 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).

  11. 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).

  12. 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).

  13. 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.

  14. 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).

  15. 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).

  16. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, 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).

  17. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, 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).

  18. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 10, 2025).

  19. No harm, with potential for more than minimal harm

    Keep residents' personal and medical records private and confidential.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0583, Resident Rights Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 10, 2025).

  20. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 10, 2025).

  21. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation 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).

  22. No harm, with potential for more than minimal harm

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0676, Quality of Life and Care Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 10, 2025).

  23. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 10, 2025).

  24. No harm, with potential for more than minimal harm

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0693, Quality of Life and Care Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 10, 2025).

  25. No harm, with potential for more than minimal harm

    Provide safe and appropriate respiratory care for a resident when needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of January 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 10, 2025).

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.