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THE BIRCHES AT TRILLIUM WOODS Inspection Report, Violations & Safety Grade (PLYMOUTH, Minnesota)

14585 59TH AVENUE NORTH, PLYMOUTH, Minnesota 55446

Phone: 7635191350

CMS Overall:5/5

Overview & Bed Count

Certified Beds
44
Avg Residents/Day
39
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Hennepin
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health4/5
Staffing5/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityMinnesota AvgDifference
RN Hours per Resident per Day1.491.08+0.41
Total Nurse Hours per Resident per Day5.794.27+1.52
CMS Staffing Rating5/54.2/5-
Nursing Staff Turnover16.9%42.1%-

Health Citation History

6 health citations on record

DateCategoryDescriptionSeverity
2026-05-27Resident Rights DeficienciesGive residents a notice of rights, rules, services and charges.F – Moderate Harm Potential
2026-05-27Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.D – Moderate Harm Potential
2026-05-27Quality of Life and Care DeficienciesProvide safe, appropriate pain management for a resident who requires such services.D – Moderate Harm Potential
2026-05-27Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2024-09-12Pharmacy Service DeficienciesImplement 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.D – Moderate Harm Potential
2024-09-12Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential

Fire Safety Citation History

10 fire safety citations on record

DateCategoryDescriptionSeverity
2026-05-27Gas, Vacuum, and Electrical Systems DeficienciesEnsure that testing and maintenance of electrical equipment is performed.F – Moderate Harm Potential
2024-09-12Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.F – Moderate Harm Potential
2024-09-12Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.F – Moderate Harm Potential
2024-09-12Egress DeficienciesHave stairways and smokeproof enclosures used as exits that meet safety requirements.E – Moderate Harm Potential
2024-09-12Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.D – Moderate Harm Potential
2023-08-17Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.F – Moderate Harm Potential
2023-08-17Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2023-08-17Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.E – Moderate Harm Potential
2023-08-17Emergency Preparedness DeficienciesImplement emergency and standby power systems.C – Minimal Harm Potential
2023-08-17Electrical DeficienciesEnsure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.C – Minimal Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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