The Birches at Trillium Woods

In the surveyor’s words

From the most serious findings on record at The Birches at Trillium Woods, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF572May 27, 2026

  Based on observation and interview, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors and staff to review. This had the potential to affect all 40 residents currently residing in the facility as well as all staff and visitors.Findings include: On 5/27/26 at 7:27 a.m. displayed next to double doors to enter first floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 7:52 a.m. displayed next to double doors to enter second floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 7:56 a.m. displayed next to double doors to enter third floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 8:26 a.m. […]

• No harm, potential for more than minimal, isolatedF628May 27, 2026

  Based on document review and interview, the facility failed to ensure all residents were offered written notice for bed hold for 1 of 3 residents (R7) who were reviewed for discharges / transfers from the facility. Findings include - In review of R7's admission Record (print date 5/27/26), documented were the following diagnoses: effusion right elbow (a buildup of excess fluid within the elbow joint capsule), peripheral vascular disease, and end stage real disease with dependence on dialysis. A review of R7's most recent quarterly Minimum Data Set (MDS) dated [DATE], documented R7 was cognitively intact and required substantial - maximal assistance with activities of daily living. […]

• No harm, potential for more than minimal, isolatedF697May 27, 2026

  Based on observation, interview and document review the facility failed to ensure provider orders were followed which caused pain for 1 of 1 residents (R58) reviewed.Findings include: R58's admission Minimum Data Set (MDS) dated [DATE], indicated R58 had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs). R58's diagnoses included presence of artificial hip joint, anxiety, pain, femur fracture, and Alzheimers disease R58's care plan revised 5/6/26, indicated R58 was on pain medication therapy related to hip surgery, the care plan included an intervention to administer medications as ordered. During interview on 5/26/26, at 3:37 p.m. […]

• No harm, potential for more than minimal, isolatedF759May 27, 2026

  Based on observation, interview and document review, the facility failed to ensure residents were free of medication errors of less than 5% for 1 of 2 residents (R58) observed for medication administration resulting in a 7.69% error rate.Findings include: R58's electronic medical record (EMR) was reviewed, the EMR indicated R58 had orders for:Lidocaine external gel 4% (local anesthetic applied to the skin to temporarily numb the area) apply thin layer to the area enoxaparin injection thirty minutes prior to injection once daily.Enoxaparin sodium injection solution prefilled syringe 40millegram(mg)/0.4milliliters (ml) (prescription blood thinner) inject 0.4ml subcutaneously (subq) one time daily administer lidocaine prior to injection. R58 was observed on 5/27/26, at 9:54 a.m. […]

• No harm, potential for more than minimal, isolatedF758Sep 12, 2024

  Based on interview and document review, the facility failed to ensure orthostatic blood pressure monitoring was in place for 2 of 5 residents (R27, R30) reviewed for unnecessary medications. Findings include: R27 R27's quarterly Minimum Data Set (MDS), indicated he had moderate cognitive impairment and exhibited physical behavioral symptoms 1-3 days during the lookback period. Additionally, R27's MDS listed his diagnoses as Parkinson's disease (a progressive movement disorder of the nervous system) with dyskinesia (involuntary muscle movements and reduced voluntary movement), dementia (a loss of cognitive function, like thinking, remembering, and reasoning), anxiety, depression, bradycardia (slow heart rate), and psychotic disorder (severe mental illness causing a person to lose touch… […]