Inspection Report
Complaint Investigation
Deficiencies: 18
Jul 8, 2025
Visit Reason
State-compiled facility profile showing 24 inspections from 2021-08-01 to 2025-07-31 with deficiency history
Findings
Across 24 inspections from August 2021 through July 2025, Birchwood Suites had 23 violations with 15 inspections resulting in no violations. Deficiencies primarily involved medication management, environmental standards, personnel, and recordkeeping.
Complaint Details
This page includes multiple complaint surveys as the inspection type for all inspections listed.
Deficiencies (18)
| Description |
|---|
| 402.4(a)(1) — General requirements: Criminal history information must be requested, reviewed, and acted upon timely with designated authorized persons. |
| 487.11 (f) (12) — Environmental standards: Required exit doors must meet specific height, hardware, and accessibility standards. |
| 487.12 (g) — Disaster and emergency planning: Residents must participate in quarterly fire drills with at least one total evacuation annually. |
| 1001.11 (c) (2) (i-iv) — Personnel: Resident aides must receive initial and ongoing training and annual performance assessments. |
| 487.7 (f) (5) — Resident services: System for medication supervision and observation must be established. |
| 487.4 (a) — Admission standards: Only individuals not requiring services beyond permitted levels shall be admitted and retained. |
| 487.7 (f) (11) (iii) — Resident services: Controlled substance prescriptions require a class 3a controlled substance license and proper storage. |
| 487.7 (f) (12) (iii) — Resident services: Medication assistance must be recorded at the time of assistance with staff and resident details. |
| 487.8 (e) (1) — Food service: Compliance with sanitation, safety, and health regulations for food service is required. |
| 487.11 (h) (11) — Environmental standards: Water temperature at faucets must be between 95°F and 110°F. |
| 487.3 (b) — General provisions: Facility must operate in compliance with department regulations and applicable statutes. |
| 487.7 (f) (11) (i-v) — Resident services: Medication storage must be secure and separate from food/beverages. |
| 487.8 (d) (1-2) — Food service: Menus must provide sufficient nutrients and calories with specified food groups included. |
| 487.9 (a) (4) — Personnel: Ongoing in-service training must be provided to employees and volunteers. |
| 487.10 (d) (5) — Records and reports: Operator must maintain comprehensive records including resident, program, food service, maintenance, and staff records. |
| 487.11 (f) (11) — Environmental standards: Means of egress must be remote, unobstructed, and not pass through bedrooms or bathrooms. |
| 487.11 (h) (3) — Environmental standards: Devices inhibiting exit access or free movement of residents are prohibited. |
| 485.11 (b) — Records and reports: Operators must supply and provide access to information and records as determined by the department. |
Report Facts
Inspections on page: 24
Total violations: 23
No-violation inspections: 15
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