Birch Hill Health Services

Inspection findings

1. Jul 1, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jul 29, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 29, 2026 · CMS health inspection

2. Feb 11, 2026 Health · 7 findings
   • Not serious Scope/severity D

     F0551 Resident Rights Deficiencies

     Give the resident's representative the ability to exercise the resident's rights.

     Corrected Mar 11, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Mar 11, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Mar 11, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Mar 11, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 11, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Mar 9, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Mar 9, 2026 · CMS fire safety

3. Nov 10, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Dec 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Dec 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 18, 2025 · CMS health inspection

4. May 20, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Jun 13, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jun 13, 2025 · CMS health inspection

5. Sep 25, 2024 Health · 11 findings
   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Oct 25, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Oct 25, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Oct 25, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Oct 25, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Oct 25, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Oct 25, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 25, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Oct 25, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Oct 25, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Oct 25, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Oct 25, 2024 · CMS fire safety

6. Aug 30, 2023 Health · 11 findings
   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Sep 30, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 30, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0343 Smoke Deficiencies

     Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Sep 30, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Sep 30, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• BAUMANN, TROY — adp of the snf, NOT APPLICABLE, since 12/01/2019
• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 10/01/2019
• BELONGIA, CHRISTINA — adp of the snf, NOT APPLICABLE, since 11/01/2019
• BELONGIA, CHRISTINA — operational/managerial control, NOT APPLICABLE, since 11/01/2019
• BOWEN, LANE — indirect ownership interest, NOT APPLICABLE, since 12/11/2019
• BRUNO, JAMES — operational/managerial control, NOT APPLICABLE, since 06/01/2026
• BRUNO, JAMES — adp of the snf, NOT APPLICABLE, since 06/01/2026
• GEE, DARREN — adp of the snf, NOT APPLICABLE, since 12/01/2019
• GEE, DARREN — operational/managerial control, NOT APPLICABLE, since 11/30/2021
• GREER, LAUREN — adp of the snf, NOT APPLICABLE, since 11/29/2023
• GREER, LAUREN — operational/managerial control, NOT APPLICABLE, since 11/29/2023
• HOEHN, JEFFREY — adp of the snf, NOT APPLICABLE, since 12/01/2019
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 10/01/2019
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• JASHINSKY, CHERYL — operational/managerial control, NOT APPLICABLE, since 05/04/2016
• JASHINSKY, CHERYL — adp of the snf, NOT APPLICABLE, since 05/04/2016
• MILLS, DAVID — 5% or greater indirect ownership interest, 18%, since 10/01/2019
• PATZER, COLLEEN — adp of the snf, NOT APPLICABLE, since 02/14/2023
• PATZER, COLLEEN — operational/managerial control, NOT APPLICABLE, since 02/14/2023
• PURTELL, BRIAN — operational/managerial control, NOT APPLICABLE, since 06/01/2018
• PURTELL, BRIAN — adp of the snf, NOT APPLICABLE, since 06/01/2018
• ARROWHEAD 123 LLC — 5% or greater indirect ownership interest, 10%, since 10/01/2019
• ARROWHEAD 123 LLC — adp of the snf, NOT APPLICABLE, since 12/01/2019
• CIBC BANK USA — 5% or greater mortgage interest, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 12/31/2024
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 05/23/2025
• CONTINUUM THERAPY PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• CONTINUUM THERAPY PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 05/23/2025
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• NORTH SHORE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 05/15/2025
• NSH 1475 BIRCH HILL LANE LLC — adp of the snf, NOT APPLICABLE, since 12/01/2019
• NSH REHAB LLC — adp of the snf, NOT APPLICABLE, since 05/23/2025
• NSH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NSHR OPERATIONS LLC — 5% or greater direct ownership interest, 100%, since 10/01/2019
• THE LANE MORRELL BOWEN TRUST — adp of the snf, NOT APPLICABLE, since 12/01/2019
• THE LANE MORRELL BOWEN TRUST — 5% or greater indirect ownership interest, 10%, since 10/01/2019
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 02/01/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 05/23/2025