Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 The Birches At Trillium Woods during CMS and state inspections, most recent first.
The facility failed to ensure the current RBOR was provided to residents and posted for residents, visitors, and staff to review. The RBOR displayed at the entrances to the first, second, and third floor units was dated 4/14/09. The administrator stated they were not aware of changes to the RBOR, and the facility had not yet ordered new postings for the units.
A resident with ESRD on dialysis, PVD, and right elbow effusion was transferred to the ER and then admitted to the hospital for further testing and MRI. Although the facility’s admission packet and bed hold policy stated that a bed hold notice should be provided before transfer and acknowledged by signature, the EMR and hard chart had no written bed hold for the transfer. The resident could not recall being offered one, and the LSW, DON, and ADM could not locate documentation that a written bed hold was offered.
A resident with severe cognitive impairment and orders for lidocaine to be applied before a daily enoxaparin injection experienced pain when staff did not follow the order consistently. A family member reported the lidocaine was sometimes applied after the injection or not at all, and an LPN and RN both administered injections without first applying the topical anesthetic, leading to the resident screaming, resisting care, and striking out at staff. The DON stated nurses were expected to review orders before giving medications, and that applying lidocaine after the injection would not relieve the pain from the injection.
A resident had orders for lidocaine gel to be applied before an enoxaparin injection, but an RN gave the injection first and then stated she would apply the gel afterward. The RN later acknowledged the gel should have been applied before the injection and that she did not do it. The DON stated nurses were expected to review orders before giving medications to ensure they were administered as ordered.
The facility failed to ensure proper orthostatic blood pressure monitoring for two residents on psychotropic medications. One resident, with a history of falls and on medications like Seroquel, lacked documented monitoring despite weekly orders. Another resident, also on Seroquel, had missing documentation for monthly monitoring. Interviews confirmed the absence of records, and the facility's policy required such monitoring to prevent adverse effects.
A resident with severe cognitive impairment and diabetes received insulin contrary to physician orders, which specified holding insulin if blood glucose was below 200. Insulin was administered twice when levels were 194 and 191. Staff interviews confirmed the errors, and the consultant pharmacist noted a mild risk to the resident.
Outdated Resident Rights Notices Posted
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. On observation, the RBOR posted next to the double doors entering the first floor unit, second floor unit, and third floor unit was dated 4/14/09. During interview, the administrator stated at 8:26 a.m. that they were not aware there were changes to the RBOR, and later stated at 9:21 a.m. that they had started the process of providing updates to residents and resident representatives, but new postings for the units had not yet been ordered. The facility Resident Rights policy dated 10/24 indicated copies of resident rights were posted throughout the facility, but it did not address when the facility would provide notification of changes in State or Federal laws related to resident rights or facility rules during the residents' stay.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to ensure all residents were offered written notice for bed hold for 1 of 3 residents reviewed for discharges/transfers, R7. R7 had diagnoses including effusion of the right elbow, peripheral vascular disease, and end stage renal disease with dependence on dialysis. Her most recent quarterly MDS documented that she was cognitively intact and required substantial to maximal assistance with activities of daily living. According to progress notes, the facility received a call from R7’s dialysis unit stating she should be seen in the ER due to pain in her right arm, and her primary clinic was updated with orders to send her to the ER upon return to the facility. After R7 returned to the facility, she was sent to the ER for further evaluation and later admitted to Methodist Hospital for additional testing and MRI. She returned to the facility 3 days later. During interview, R7 stated she had gone to the hospital earlier in the month but could not remember whether she had been offered or signed a bed hold for the transfer. Review of the EMR and hard paper chart found no evidence that the facility offered R7 a bed hold in writing. The LSW stated residents and their family/significant other are offered a bed hold when transferred to the hospital and that it is signed if requested, while the DON stated staff might not have offered a bed hold. The DON and ADM were unable to locate a signed or written bed hold for R7’s hospitalization, despite the admission packet and bed hold policy stating that a copy of the bed hold policy is to be provided before transfer and that the resident and/or representative acknowledge receipt by signature.
Failure to Follow Ordered Pain Relief Before Injection
Penalty
Summary
The facility failed to follow provider orders for pain management for a resident with severe cognitive impairment who was dependent on staff for ADLs and had diagnoses including an artificial hip joint, anxiety, pain, femur fracture, and Alzheimer’s disease. The resident’s care plan identified pain medication therapy related to hip surgery and directed staff to administer medications as ordered. The resident had an order for lidocaine external gel 4% to be applied in a thin layer to the enoxaparin injection area 30 minutes prior to the daily subcutaneous injection. During interview, the resident’s family member stated staff were not consistently applying the lidocaine before the injection, and sometimes applied it after or not at all. On one occasion, an LPN told the family member the lidocaine was put on after the injection, then administered the injection, after which the resident screamed out and struck out at the nurse. On another occasion, an RN gave the enoxaparin injection without applying the lidocaine first; the resident screamed out, grabbed the RN’s arm, and scratched the back of the RN’s hand. The RN later stated the lidocaine should have been applied before the injection and acknowledged it was not done. The DON stated nurses were expected to review residents’ orders before administering medications and that applying lidocaine after the injection would not help with the pain from administration.
Medication Administration Error With Enoxaparin and Lidocaine Timing
Penalty
Summary
The facility failed to ensure medication error rates remained below 5% for 1 of 2 residents observed for medication administration, resulting in a 7.69% error rate. Resident R58 had EMR orders for lidocaine external gel 4% to be applied in a thin layer to the area 30 minutes prior to enoxaparin injection, and for enoxaparin sodium injection 40 mg/0.4 ml to be administered subcutaneously once daily with lidocaine prior to injection. During a medication pass, RN-A removed the enoxaparin syringe from R58's medication cabinet and administered the injection into the resident's abdomen. Afterward, RN-A stated she would apply the lidocaine gel about five minutes later, then reviewed the EMR and acknowledged that the gel should have been applied before the injection and that she did not do it. The DON stated the expectation was for nurses to review residents' orders before administering medications to ensure medications were given as ordered by the provider.
Failure to Monitor Orthostatic Blood Pressure in Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper orthostatic blood pressure monitoring for two residents who were receiving psychotropic medications. Resident R27, who had a history of falls and was on medications such as Seroquel, citalopram, and buspirone, did not have documented orthostatic blood pressure monitoring despite orders for weekly assessments. The resident's care plan indicated a need for such monitoring due to the risk of falls, yet the electronic health record lacked documentation for the required dates. Interviews with nursing staff confirmed the absence of documentation and highlighted a change in the resident's transfer status, which could have impacted the ability to perform standing blood pressure measurements. Resident R30, who was also on Seroquel for dementia and sleep issues, had orders for monthly orthostatic blood pressure monitoring. However, the electronic health record lacked documentation for several months, with only one instance of recorded measurements. Interviews with nursing staff revealed that orthostatic blood pressures should be assessed monthly for residents on antipsychotic medications, but documentation was missing for multiple months. The facility's director of nursing acknowledged the importance of monitoring for side effects of psychotropic medications, including orthostatic blood pressures, to prevent missing critical information. The facility's policy on antipsychotic medication use required monitoring for side effects such as orthostatic hypotension, yet the documentation was not consistently maintained. The lack of proper monitoring and documentation for residents on psychotropic medications represents a deficiency in the facility's adherence to its own policies and procedures, potentially increasing the risk of adverse effects and falls among residents.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of insulin for a resident with severe cognitive impairment and multiple health conditions, including diabetes mellitus. The resident's medication administration record (MAR) indicated that insulin was administered on two occasions when the resident's blood glucose levels were below the threshold of 200, as specified in the physician's orders. Specifically, insulin was given on the morning of September 8th and the evening of September 11th, despite blood glucose readings of 194 and 191, respectively. These actions were contrary to the physician's directive to hold insulin if blood glucose levels were less than 200. Interviews with facility staff, including an LPN, an RN, the director of nursing, and a consultant pharmacist, confirmed the medication errors. The LPN and RN acknowledged that insulin was administered incorrectly, and the director of nursing emphasized the expectation for staff to follow physician orders. The consultant pharmacist highlighted the importance of adhering to insulin administration parameters to maintain appropriate blood glucose levels and noted that the errors posed a mild risk to the resident. The facility's policy on insulin administration required staff to verify insulin orders and blood glucose levels before administration, which was not followed in these instances.
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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 Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allina Health Restorative Suites | 3.6 mi | ★★★★★ | 3 | 1 |
| North Ridge Health And Rehab | 3.8 mi | ★★★★★ | 5 | 0 |
| Mission Nursing Home | 3.8 mi | ★★★★★ | 11 | 0 |
| Woodlake Healthcare And Rehabilitation Center | 4.2 mi | ★★★★★ | 10 | 0 |
| The Villas At Osseo Llc | 5.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.