Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchwood Plaza during CMS and state inspections, most recent first.
Staff at the facility failed to maintain residents' dignity by feeding them while standing, contrary to policy. Observations showed CNAs and the DON standing over residents in wheelchairs during meals, affecting four residents with varying cognitive and physical impairments. The facility's policy requires staff to sit while feeding to ensure respect and dignity.
The facility failed to implement adequate fall prevention measures for residents at risk, leading to repeated falls for three residents and potential risk for another. Residents were observed without proper footwear, such as non-skid socks, despite care plans indicating their necessity. The facility's policy requires such measures, but they were not consistently applied, contributing to the deficiency.
The facility failed to ensure call light devices were within reach for two residents, leading to a deficiency. One resident with Alzheimer's and other conditions had a call light cord on the floor, while another with multiple diagnoses had the call light behind the bed. Staff confirmed the devices should be accessible, aligning with the facility's policy.
The facility failed to coordinate PASARR assessments and refer residents for Level II reviews upon significant changes in mental status, affecting three residents and potentially impacting 34 others. A resident's bipolar disorder was not reflected in the PASARR form, and another resident with a new diagnosis of schizoaffective disorder did not receive a Level II screening. The receptionist responsible for PASARR screenings was not informed of new diagnoses, leading to a lack of necessary assessments.
A facility failed to include a resident's psychiatric diagnoses in the PASARR screening, affecting the accuracy of the pre-admission process. The resident had documented diagnoses of schizoaffective disorder and schizophrenia, which were omitted by the non-clinical staff responsible for the PASARR. This led to an incorrect initial determination that no Level II screening was needed, later corrected to require further evaluation.
The facility failed to provide timely oral care and personal hygiene shaving for two dependent residents. One resident had significant facial hair and was not offered shaving assistance, despite requiring substantial help due to cognitive impairment. Another resident had visible dental plaque, indicating a lack of oral care, and reported not receiving assistance for a long time. These deficiencies reflect lapses in adhering to facility policies on grooming and hygiene.
The facility failed to implement pressure ulcer prevention interventions for three residents with dementia who were at risk for pressure ulcers. Observations revealed that these residents were seated in wheelchairs without pressure-relieving cushions, contrary to their care plans and the facility's policy. An LPN acknowledged the issue, noting that cushions were sometimes sent to the laundry, but did not ensure their immediate use.
A resident with severe malnutrition and quadriplegia did not receive the correct amount of Enteral g-tube feeding due to the feeding machine being turned off. The LPN on duty was unaware of the machine's status, resulting in the resident receiving only 100 ml instead of the expected 280 ml over four hours. The facility's policy requires adherence to physician orders for tube feeding to ensure proper nutrition and hydration.
The facility failed to label and change respiratory equipment for two residents receiving oxygen therapy. A resident with COPD had a nasal cannula that was not dated, and the oxygen tubing and humidifier bottle were not changed weekly as required. Another resident with multiple diagnoses also had a nasal cannula that was not dated, and the humidification bottle was overdue for a change. These lapses were identified during a survey, affecting the quality of care.
Staff at the facility failed to perform proper hand hygiene during resident feeding, potentially spreading infections. CNAs were observed not sanitizing hands between feeding different residents and after touching personal body parts. Residents with cognitive impairments and requiring assistance with eating were affected. The DON acknowledged the importance of hand hygiene, but facility policies were not followed.
The facility did not meet the required 80 square feet per resident in multiple resident bedrooms for 19 rooms, affecting 29 residents. Despite having an annual waiver from the State Department of Public Health, the facility confirmed that some rooms are below the required square footage, although all necessary furnishings and equipment are provided.
The facility failed to secure medication and treatment carts, posing a potential hazard to 40 residents. A medication cart was left unattended and unlocked in the hallway, contrary to facility policy requiring carts to be locked when not in use or out of sight. Similarly, a treatment cart was found unattended and unlocked with resident medications. The DON confirmed the policy mandates all medication storage areas be locked unless in use and under direct observation.
The facility failed to properly store and label food, with dented cans mixed with undented ones, unlabeled beef patties, and expired pastrami. The ice machine was also found dirty, lacking cleaning records. These issues could affect all 145 residents consuming meals from the facility's kitchen.
Failure to Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that staff were feeding residents from a seated position during dining service, which affected four residents. Observations revealed that staff members, including CNAs and the Director of Nursing, were feeding residents while standing, contrary to the facility's policy that requires staff to be seated to maintain the residents' dignity. This practice was observed during lunch service, where staff were seen standing over residents in wheelchairs while feeding them, which is considered authoritative and not respectful of the residents' rights to dignity. The residents involved had various medical conditions that required assistance with eating. For instance, one resident had severe cognitive impairment and required partial to moderate assistance with meals, while another had moderate cognitive impairment and required extensive assistance. Another resident was cognitively intact but dependent on staff for feeding, and the last resident had severe cognitive impairment and required substantial assistance. Despite these needs, staff did not adhere to the policy of sitting while feeding, which is intended to promote dignity and respect. The facility's policy on feeding clearly states that staff should sit beside the resident to feed them, ensuring a respectful and dignified interaction. The Director of Nursing acknowledged the importance of this practice and admitted to standing while feeding a resident, which was against the facility's guidelines. The failure to follow this policy was observed and documented, highlighting a deficiency in maintaining the residents' rights to dignity and respect during meal times.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate fall prevention interventions for residents at risk for falls, resulting in repeated falls for three residents and potential risk for another. Resident R23 was observed sitting at the edge of the bed without proper footwear, despite having a history of falls and being at risk for falls due to poor safety awareness and mild cognitive impairment. The care plan for R23 indicated the need for proper footwear, yet the resident was found without non-skid socks, which are necessary to prevent falls. Resident R43, who also had a history of repeated falls, was observed in a wheelchair without proper footwear. The care plan for R43, who has mild cognitive impairment and difficulty walking, also required well-maintained footwear to prevent falls. Despite this, the resident was not wearing non-skid socks, which are part of the facility's fall prevention policy. Resident R58, with severe cognitive impairment and a history of falls, was observed walking with a walker without the necessary fall prevention measures in place. The facility's policy requires non-skid socks or shoes for residents at risk of falls, but this was not consistently implemented. Additionally, Resident R34, who is at high risk for falls due to cognitive and functional impairments, was observed without non-skid socks, contrary to the care plan's requirements. The facility's failure to ensure that residents at risk for falls were wearing appropriate footwear and receiving adequate supervision contributed to the repeated falls and potential risk for further incidents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident R103, diagnosed with Alzheimer's Disease, Type 2 Diabetes Mellitus, Hypertension, Abnormalities of Gait and Mobility, and Muscle Weakness, was observed with a call light cord hanging from the wall on the floor, out of reach. R103's care plan emphasized the importance of using the call light for assistance, yet the device was not accessible. Similarly, Resident R301, with diagnoses including Metabolic Encephalopathy, Pyothorax, Sepsis, Retention of Urine, and Hypertension, was found with the call light hanging behind the bed, also out of reach. R301 expressed unawareness of the call light's location and a need for instruction on its use. Interviews with facility staff, including a Registered Nurse (V26) and a Certified Nursing Assistant (V9), confirmed that the call light cords should be within reach of the residents. The Director of Nursing (V2) also stated that the call light device should be clipped to the resident and accessible. The facility's call lights policy, revised in January 2019, mandates that residents capable of using the call light should have it accessible within reach. The observations and staff interviews indicate a failure to adhere to this policy, resulting in the deficiency noted by the surveyors.
Failure to Coordinate PASARR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program and did not refer residents for Level II reviews upon significant changes in mental status. This deficiency affected three residents and potentially impacted an additional 34 residents with mental disorders or intellectual/developmental disabilities. Specifically, one resident was admitted with multiple mental health diagnoses, including bipolar disorder, which was not reflected in the PASARR form. Another resident had a new diagnosis of schizoaffective disorder, but no PASARR Level II screening was conducted following this significant change. The report highlights that the facility's receptionist, responsible for completing PASARR screenings, was not informed of new diagnoses by the nursing staff, leading to a lack of necessary Level II screenings. This oversight was evident in the cases of residents with serious mental health conditions, such as schizoaffective disorder and bipolar disorder, who did not receive the required assessments. The failure to update PASARR screenings upon significant changes in residents' mental health status indicates a breakdown in communication and procedural adherence within the facility.
Failure to Include Psychiatric Diagnoses in PASARR Screening
Penalty
Summary
The facility failed to ensure that a resident's psychiatric diagnoses were accurately included in the pre-admission screening, specifically the PASARR (Pre-Admission Screening and Resident Review) process. This deficiency affected one resident, identified as R109, who had documented diagnoses of schizoaffective disorder and schizophrenia. Despite these diagnoses being present in the resident's medical records and active medication orders, they were not included in the PASARR Level I screening. As a result, the initial determination incorrectly indicated that no Level II screening was required, which could have impacted the assessment of the resident's needs. The error occurred because the receptionist/office manager, who was responsible for completing the PASARR, did not include the necessary psychiatric diagnoses. The associate administrator acknowledged that the receptionist/office manager, being non-clinical, should have been guided by the nursing and social service departments regarding the resident's diagnoses and medications. This oversight was later corrected when a subsequent PASARR Level I screen identified the need for a Level II evaluation, citing the resident's mental health disabilities, including schizophrenia and schizoaffective disorder.
Deficiencies in Personal Hygiene and Oral Care
Penalty
Summary
The facility failed to provide timely oral care and personal hygiene shaving care for two dependent residents. One resident was observed with significant facial hair, including a mustache and chin hair, which she expressed a preference to have removed. Despite requiring substantial assistance with personal hygiene due to moderate cognitive impairment and other health conditions, the resident reported not being offered shaving assistance by the CNAs. The facility's policy and the Director of Nursing confirmed that shaving is part of the daily grooming routine for all residents, including females, and should be documented if refused. Another resident was observed with a creamy brown substance on her teeth, indicating a lack of oral care. When questioned, the resident stated that it had been a long time since staff assisted with mouth care. The CNA present acknowledged not having provided mouth care to the resident but indicated an intention to do so later. The resident's care plan noted a self-care deficit requiring assistance with ADLs, and the facility's policy mandates daily oral hygiene. These deficiencies highlight a failure in the facility's adherence to its policies regarding personal hygiene and oral care, impacting the residents' dignity and quality of life. The facility's policies and job descriptions emphasize the importance of maintaining residents' grooming and hygiene, yet the observations and resident interviews indicate lapses in the execution of these duties.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions as outlined in the care plans for three residents with dementia who are at risk for pressure ulcers. On March 31, 2025, three residents were observed sitting in wheelchairs without any pressure-relieving devices, such as cushions, during activities in the dining room. This observation was made twice, first at 11:08 AM and again at 12:15 PM. A Licensed Practical Nurse (LPN) acknowledged the absence of cushions and mentioned that sometimes staff send the cushions to the laundry, promising to ensure the residents receive the necessary cushions. The records for the three residents indicated that they were at risk for pressure ulcers, as documented in their respective care plans and Minimum Data Set (MDS) assessments. Each care plan specified the use of pressure-relieving cushions when the residents were seated in chairs. The facility's policy on pressure ulcer prevention also emphasized the importance of using pressure-relieving devices for at-risk residents. Despite these documented interventions, the facility did not adhere to the care plans, resulting in the deficiency noted by the surveyors.
Failure to Administer Correct Enteral Feeding Amount
Penalty
Summary
The facility failed to ensure that a resident receiving Enteral g-tube feeding was administered the correct amount of feeding as per the physician's orders. On March 31, 2025, a resident was observed with their Enteral g-tube feeding machine turned off and not connected, despite the feeding bottle being dated for that day. The Licensed Practical Nurse (LPN) on duty was unaware of who turned off the machine or for how long it had been off. The resident, who is alert and talkative, was supposed to receive continuous feeding at a rate of 70 ml/hr for 20 hours, but only 100 ml had been infused over a four-hour period, instead of the expected 280 ml. The resident involved has multiple diagnoses, including severe protein-calorie malnutrition and quadriplegia, and relies entirely on tube feeding for nutrition. The Director of Nursing (DON) confirmed that the feeding should have been running according to the physician's orders and that the resident should have received the full amount of feeding to meet their caloric needs. The facility's policy and job descriptions emphasize the importance of maintaining proper nutrition and hydration through tube feeding, yet the deficiency occurred due to a lapse in following these procedures.
Failure to Label and Change Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of respiratory equipment for two residents receiving oxygen therapy. Resident R11 was observed using a nasal cannula that was not labeled with the date it was changed, and the oxygen tubing and humidifier bottle were not changed weekly as required. The Director of Nursing confirmed that the facility's policy mandates labeling the humidifier bottle with the date of change and replacing the nasal cannula weekly to prevent infection. R11, who has a diagnosis of shortness of breath and chronic obstructive pulmonary disease, was receiving oxygen therapy at 2-3 liters per minute, and the facility's policy requires changing the equipment every Wednesday night shift. Similarly, Resident R79, diagnosed with metabolic encephalopathy, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia, was found with a nasal cannula that was not dated, and the humidification bottle was last dated over a week prior. The Registered Nurse confirmed that the oxygen tubing and humidification bottle should be changed weekly on the night shift and dated accordingly. These lapses in following the facility's oxygen therapy policy were identified during the survey, affecting the quality of care provided to the residents.
Inadequate Hand Hygiene During Resident Feeding
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident dining services, which could potentially lead to the spread of infectious microorganisms. Observations revealed that a Certified Nursing Assistant (CNA), identified as V13, did not perform hand hygiene after touching a resident's meal tray and before feeding another resident. Similarly, another CNA, V11, was observed not sanitizing hands between feeding different residents and after touching personal body parts, such as the face and ears, while feeding a resident. The report highlights specific instances involving residents R28, R43, and R77, who were affected by these lapses in infection control. R43, with a diagnosis of severe protein-calorie malnutrition and moderate cognitive impairment, required partial assistance with eating. R77, with severe cognitive impairment and a dependency on staff for feeding, was also at risk. R28, with severe cognitive impairment and requiring substantial assistance with eating, was observed being fed by V11, who did not perform hand hygiene at various points during the feeding process. The Director of Nursing (DON), identified as V2, acknowledged the importance of hand hygiene in preventing infection transmission and stated that staff are expected to perform hand hygiene before and after resident contact, especially when feeding residents. The facility's policies on infection control and hand hygiene were not adhered to, as evidenced by the observations of CNAs not washing or sanitizing their hands between resident interactions and after touching potentially contaminated surfaces or their own body parts.
Facility Fails to Meet Room Size Requirements Despite Waiver
Penalty
Summary
The facility failed to provide the required square footage of 80 square feet per resident in multiple resident bedrooms for 19 rooms out of 86 in the facility. This deficiency affected 29 residents in the total sample of 75 residents. During the entrance conference, the Administrative Consultant mentioned that the facility has an annual waiver for room sizes, which is renewed every year. The Associate Administrator confirmed that some rooms have less than the required square footage for each resident, but stated that all required furnishings and equipment are provided. The facility has an annual waiver from the State Department of Public Health, allowing them to bypass the federal requirement for room size under 42 CFR 483.90. This waiver is granted for specific rooms and is subject to annual review. The facility's policy on Resident Room Waivers indicates compliance with both IDPH and CMS federal requirements for these waivers. The waiver covers the rooms identified in the report, which do not meet the 80 square feet per bed requirement in multi-patient rooms.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that medication and treatment carts were secured, leading to a potential accident hazard for all 40 residents on the 1st floor. On December 24, at 10:30 AM, a medication cart was observed unattended and unlocked in the hallway without a nurse present. The LPN responsible for the cart admitted to leaving it to pick up something, acknowledging that the facility policy requires the cart to be locked when not in use or out of the nurse's sight. Additionally, at 10:40 AM, a treatment cart was found unattended and unlocked with resident treatment medications inside. The DON confirmed that the facility policy mandates that all medication storage areas, including carts, must be locked unless in use and under direct observation by the medication nurse. The facility's policy, revised in November 2011, clearly states these security requirements.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, which could potentially affect all 145 residents consuming meals from the facility's kitchen. During an inspection, dented cans of banana pudding and diced peaches were found co-mingled with undented cans in the dry storage room, contrary to the facility's policy that requires dented cans to be stored separately. Additionally, a white bucket labeled breadcrumbs lacked an open date and a use-by date. In the walk-in freezer, beef patties were found without open or use-by dates and were not in their original manufacturer's container. A tray of sliced pastrami was noted to be 13 days over the seven-day storage limit, and other food items in the refrigerator, such as pureed chicken and baked salmon, were also found to be past their allowed storage time without proper labeling. The ice machine in the kitchen was observed to be in an unsanitary condition, with blackish and brownish particles inside and whitish splashes on the outside. The Dietary Manager admitted that the machine should be cleaned monthly but could not provide a cleaning log or confirm the last cleaning date. The facility's policies on food labeling and ice machine cleaning were not followed, as evidenced by the lack of proper labeling and cleaning records. The Dietary Manager acknowledged the confusion caused by new labeling practices and the need for staff education to prevent foodborne illnesses.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fargo Health Care Center | 0.1 mi | ★★★★★ | 21 | 0 |
| Waterford Care Center, The | 0.1 mi | ★★★★★ | 12 | 0 |
| Lakefront Nursing & Rehab Ctr | 0.1 mi | ★★★★★ | 0 | 0 |
| Chalet Living & Rehab | 0.2 mi | ★★★★★ | 19 | 1 |
| Clark Manor | 0.4 mi | ★★★★★ | 1 | 0 |
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