Birch Hill Health Services

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

41.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 50 beds and averages 41.9 residents a day — about 84% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 3.45 on weekdays — 16% thinner on weekends. RN hours go from 0.71 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

• Potential for harm · D2026-07-01 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure the security and privacy of medical information for 1 resident (R) (R7) of 3 sampled residents. R7's care plan was posted in R1's room. Family Member (FM)-C observed the care plan and informed staff. Findings include: The facility's Resident Rights document indicates: .Privacy: Residents have the right .to confidentiality concerning their personal and medical information . The facility's Health Insurance Portability and Accountability Act (HIPAA) document indicates: .HIPAA-Prohibited Activities: .Leaving resident information accessible to people who have no right to see it . On 7/1/26 at 10:26 AM and 7/2/26 at 10:54 AM, Surveyor interviewed FM-C who stated R7's care plan was posted inside the door of R1's closet. FM-C did not recall the date they observed the care plan but verified they saw R7's name and care plan content. FM-C stated R1's care plan had been posted, but then went missing and R7's care plan was posted instead. FM-C informed Director of Nursing (DON)-B when they left the facility that day. When FM-C…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-07-01 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R3) of 3 sampled residents. R3 was on contact precautions. Multiple staff provided care for R3 without donning the appropriate personal protective equipment (PPE). Findings include: The facility's Transmission Based (Isolation) Precautions policy, revised 3/2026, indicates: .9. Initiation of Transmission-Based Precautions (TBP) (isolation precautions): a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on TBP/isolation empirically while awaiting confirmation. b. The physicians of the resident requiring TBP will be notified of the need for TBP and any other pertinent clinical information .c. The TBP will be the least restrictive possible for the resident under the circumstances. Duration will depend…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-11 · tag F0551 — isolated
  Give the resident's representative the ability to exercise the resident's rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R36) of 3 sampled residents. R36 had a Guardian. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R36's nursing home stay exceeded 60 days. R36 also did not receive an annual review to determine appropriate placement. Findings include: From 2/9/26 to 2/11/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease (COPD), anxiety, and major depression. R36's Minimum Data Set (MDS) assessment, dated 12/3/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R36 had severely impaired cognition. R36 had a Guardian that was activated on 4/17/20. R36's medical record did not contain protective placement paperwork. On 2/10/26 at 8:15 AM, Surveyor…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-11 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an allegation of sexual abuse was reported to the State Agency (SA) for 2 residents (R) (R42 and R8) of 2 sampled residents.Staff witnessed R42 kiss R8 in the hallway on 1/24/26. R42 then followed R8 into R8's room. Licensed Practical Nurse (LPN)-F entered R8's room and observed R42 unzipping R42's pants in front of R8 who was lying on the bed with a book and appeared confused. The allegation of sexual abuse was not reported to the SA. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not thoroughly investigate an allegation of sexual abuse for 2 residents (R) (R42 and R8) of 2 sampled residents.Staff witnessed R42 kiss R8 in the hallway on 1/24/26 then follow R8 into R8's room. Licensed Practical Nurse (LPN)-F entered R8's room and observed R42 unzipping R42's pants in front of R8 who was lying on the bed with a book and appeared confused. The allegation of sexual abuse was not thoroughly investigated.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.From 2/9/26 to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure appropriate weight monitoring was provided for 2 residents (R) (R9 and R29) of 4 sampled residents.R9's provider and Power of Attorney for Healthcare (POAHC) were not notified of weight loss or gain greater than 3 pounds (lbs) from 11/4/25 to 1/30/26. In addition, R9 was not re-weighed for weight loss or gain greater than 3 lbs. R9's daily weights were not documented as ordered and were not obtained with a consistent device.R29's provider and Guardian were not notified regarding weight loss or gain greater than 3 lbs from 9/1/25 to 2/1/26. In addition, R29 was not re-weighed for weight loss or gain greater than 3 lbs.Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: The Interdisciplinary Team (IDT) will strive to prevent, monitor, and intervene for undesirable weight changes for residents .Weight Monitoring .5. Team members will follow a consistent approach to weighing and use an appropriately calibrated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-11 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R41, R32, and R43) of 3 sampled residents.R41 was on enhanced barrier precautions (EBP) for an indwelling catheter. Certified Nursing Assistant (CNA)-D did not wear a gown while emptying R41's catheter.Registered Nurse (RN)-E did not complete proper hand hygiene during medication pass for R32 and R43.Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, revised 8/8/24, indicates: EBP refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities. High-contact resident care includes if a resident has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-10 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not notify a Guardian of a fall and change in condition for 1 resident (R) (R5) of 5 sampled residents.R5 had a fall with injury on 10/30/25. R5's Guardian was not notified of the fall or change in condition.Findings include:The facility's Fall Prevention and Management Guidelines policy, dated 7/2024, indicates: .7. When any resident experiences a fall, the facility will: .c. Notify the physician and family/responsible party .On 11/10/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including acute metabolic encephalopathy, myxedema coma, hypothyroidism, and urinary tract infection (UTI). R5's Minimum Data Set (MDS) assessment, dated 11/4/25, contained a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R5 had severe cognitive impairment. R5 had a Guardian for healthcare decisions. On 11/10/25 at 12:40 PM, Surveyor observed R5 in a wheelchair…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-10 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 resident (R) (R3) of 1 sampled resident. On 11/7/25, a fracture was discovered in R3's right arm under a cast and above where R3 had a previous fracture repaired on 10/22/25. The facility did not report the injury of unknown origin to the SA.Findings include:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Identification of Abuse, Neglect, and Exploitation: .B. Possible indicators of abuse include, but are not limited to: .3. Physical Injury of a resident, of unknown source .VII. Reporting/Response: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. On 11/10/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] from home and had diagnoses…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 resident (R) (R3) of 1 sampled resident.On 11/7/25, a fracture was discovered in R3's right arm under a cast and above where R3 had a previous fracture repaired on 10/22/25. The facility did not thoroughly investigate the injury of unknown origin.Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Identification of Abuse, Neglect, and Exploitation: .B. Possible indicators of abuse include, but are not limited to: .3. Physical injury of a resident of unknown source. V. Investigation of Alleged Abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. On 11/10/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] from home and had diagnoses including Alzheimer's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 41 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $204K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI