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 12 of 12 citations

  1. 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).

  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 November 7, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 9, 2022).

  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 November 7, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 9, 2022).

  4. 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).

  5. 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).

  6. 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).

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

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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

    Health citation F-0561, Resident Rights Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 9, 2022).

  8. 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 November 7, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 9, 2022).

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

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 9, 2022).

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

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 9, 2022).

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

    Provide and implement an infection prevention and control program.

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

    Health citation F-0880, Infection Control Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 9, 2022).

  12. No harm, with potential for minimal harm

    Post nurse staffing information every day.

    Widespread (many residents). CMS level C.

    Health citation F-0732, Nursing and Physician Services Deficiencies. Inspection of November 7, 2022. Found during a standard inspection.

    The home has a plan to correct it (December 9, 2022).

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.