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 Birch Pointe Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to store food items in accordance with professional standards, as expired foods were found in kitchen storage areas. Observations with the Certified Director of Food Service revealed expired cottage cheese, evaporated milk, and unsliced ham in various storage locations. This indicates non-compliance with the facility's policy on food receiving and storage.
The facility failed to provide scheduled showers and document refusals for several residents, impacting their right to self-determination. Staffing shortages often led to the shower aide being reassigned, resulting in missed showers. Despite policies requiring documentation and re-offering of showers, these were not consistently followed, affecting residents' care preferences.
The facility failed to provide scheduled showers to several residents due to staffing shortages, affecting their quality of life and dignity. Residents reported receiving fewer showers than scheduled, and documentation did not reflect refusals or re-offers. Staff interviews confirmed that shower aides were often reassigned to other duties, leading to missed showers.
Expired medications were found in a facility's medication storage rooms and carts, including Assure Prism blood glucose control solutions and Docusate Sodium Liquid. LPNs confirmed the expiration and removed the items. Staff interviews revealed a lack of awareness and responsibility for checking expiration dates, despite monthly pharmacy audits and established procedures.
The facility failed to ensure proper cleaning and disinfection of patient care equipment between uses, as CMTs were observed using a wrist cuff and pulse oximeter on multiple residents without cleaning them. Despite training and reminders, staff admitted to not following the facility's infection control policy, which requires cleaning equipment between residents. This deficiency was noted in residents with cognitive impairments and those on contact precautions.
The facility failed to document and resolve grievances for two residents, as required by their grievance policy. A family member reported a persistent issue with a malfunctioning door alarm for over a year, with no documented resolution. Another resident's family reported missing personal belongings, with grievances filed but not addressed. The Administrator denied access to grievance records, indicating a deficiency in the facility's grievance handling process.
A resident with chronic pain syndrome received opioid medication without proper assessment and documentation. The facility failed to document non-pharmacological interventions before administering hydrocodone-acetaminophen and did not monitor for adverse effects, as required by policy. The DON confirmed the lack of documentation, leading to a deficiency in ensuring the resident's drug regimen was free from unnecessary medications.
A resident's surgical incision was neglected due to the facility's failure to follow hospital discharge instructions and document necessary care. Staff were unaware or did not assess the incision, leading to the wound dehiscing with drainage. The care plan lacked specifics for monitoring the incision.
A resident with severe cognitive impairment and behavioral disturbances engaged in multiple aggressive incidents with other residents and staff. Despite being on medication and having a care plan, the facility failed to implement effective interventions, resulting in continued altercations. The care plan was not adequately updated, and interventions such as 15-minute checks were insufficient in preventing further incidents.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
The facility failed to adhere to professional standards of practice for food service safety by storing expired food items in the kitchen storage areas. During observations and interviews conducted with the Certified Director of Food Service (CDFS), it was found that a refrigerator in the main kitchen contained an opened five-pound container of cottage cheese with a best by date that had already passed. Additionally, the dry storage room housed 15 cans of evaporated milk, all of which were past their best by dates. Furthermore, the walk-in refrigerator contained unsliced ham stored in a clear plastic bag with a use-by date that had expired. The CDFS confirmed the expiration of these food items, indicating a failure to comply with the facility's policy on food receiving and storage, which mandates that all foods be covered, labeled, and dated with a use-by date.
Failure to Provide Scheduled Showers and Document Refusals
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing showers as preferred and care planned for six residents. The facility's policy required staff to document each bathing and notify the supervisor if any resident refused the shower or tub bath. However, the documentation showed that residents did not receive their scheduled showers or bed baths on multiple occasions, and there was no documentation of resident refusals or reasons for missed showers. Resident #10, who was moderately cognitively impaired and dependent on staff for showering, reported receiving only one shower a week instead of the preferred two. Similarly, Resident #30, who was cognitively intact and dependent on staff for showers, also reported receiving only one shower a week. Resident #66, who was cognitively intact, reported not receiving showers as scheduled and described an instance where a shower was rushed and inadequate. Other residents, including Resident #39, Resident #7, and Resident #6, also experienced similar issues with missed showers and inadequate documentation of refusals or re-offers. Interviews with staff, including CNAs and the DON, revealed that staffing shortages often led to the shower aide being pulled to work on the floor, resulting in missed showers for residents. Despite the facility's policy to re-offer showers and document refusals, this was not consistently done, leading to a failure in promoting resident choice and self-determination in their care.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents received their scheduled showers, affecting six residents out of a sample of 34. The facility's policy requires staff to document each bathing session and notify supervisors if a resident refuses a shower or bath. However, the documentation showed that several residents did not receive their scheduled showers or bed baths on multiple occasions, and there was no record of refusals or re-offers being documented. This lack of adherence to policy could lead to a decreased quality of life and dignity for the residents. Resident #10, who was assessed as moderately cognitively impaired and dependent on staff for showering, reported receiving only one shower a week instead of the scheduled two. The resident expressed a desire for more frequent showers, but the shower aide was often reassigned to other duties due to staffing shortages. Similarly, Resident #30, who was cognitively intact but dependent on staff for showers, also reported receiving only one shower per week, citing the same staffing issues. Other residents, such as Resident #66, Resident #39, Resident #7, and Resident #6, also experienced missed showers or baths, with no documentation of refusals or re-offers. Interviews with staff, including CNAs and the DON, revealed that staffing shortages often led to the reassignment of shower aides, resulting in missed showers. The DON acknowledged the lack of documentation and stated that staff should re-offer showers and document any refusals, but this was not consistently done.
Expired Medications Found in Storage Rooms and Carts
Penalty
Summary
The facility failed to ensure proper storage and removal of expired medications and supplies, as observed in one of two medication storage rooms and two of four medication carts. During an inspection, expired Assure Prism blood glucose control solutions with an expiration date of 12/07/24 were found in the medication carts at the nurses' stations on Hall 400 and Hall 300. Licensed Practical Nurses (LPNs) confirmed the expiration and removed the items from the carts. Additionally, an open bottle of Docusate Sodium Liquid with an expiration date of 06/2024 was found in the medication room on Hall 300 without a labeled open date, and it was also confirmed as expired and removed. Interviews with staff revealed a lack of awareness and responsibility regarding the checking of expiration dates. LPN5 admitted to not knowing how long the expired Docusate Sodium Liquid had been on the shelf and stated that it is everyone's job to check for expired medications. The Director of Nursing (DON) confirmed that all certified medication techs (CMTs) and nurses are responsible for checking expiration dates, and that the pharmacy conducts monthly audits to remove expired medications. Despite these procedures, expired medications were still found during the survey, indicating a lapse in adherence to the facility's policy on medication labeling and storage.
Inadequate Cleaning of Patient Care Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper cleaning and disinfection of patient care equipment between resident uses. Certified Medication Technicians (CMTs) were observed using a wrist cuff and pulse oximeter on multiple residents without cleaning or disinfecting the equipment between uses. This practice was observed with several residents, including those with cognitive impairments and those on contact precautions due to conditions like sepsis. During observations, CMTs were seen placing unclean equipment on medication carts without barriers and proceeding to use the same equipment on subsequent residents. Despite receiving monthly training and reminders on infection control, CMTs admitted to not cleaning the equipment between residents unless they were on isolation or precautions. This was contrary to the facility's policy, which required cleaning and disinfection of reusable items between residents according to CDC recommendations and OSHA standards. Interviews with staff, including a Registered Nurse and the Infection Preventionist, confirmed that the expectation was for all patient care equipment to be cleaned between uses. The Director of Nursing also emphasized that infection control was a shared responsibility among staff. However, the observations indicated a lapse in adherence to these protocols, leading to the identified deficiency in infection control practices.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and resolve grievances for two residents, as required by their grievance policy. The policy mandates that grievances be documented, investigated, and resolved promptly, with the complainant being informed of the outcome. However, for Resident #60, a family member reported a persistent issue with a malfunctioning door alarm that had been ongoing for over a year. Despite filing a grievance, no documented resolution was provided, and the issue remained unresolved. Interviews with staff confirmed awareness of the problem, but no formal grievance documentation or resolution was available for review. For Resident #91, the facility did not properly document grievances related to missing personal belongings. The resident's family reported several missing clothing items and stated that grievances were filed but not addressed. The facility's policy requires personal belongings to be inventoried and documented, but the family did not receive any follow-up or resolution to their grievances. Interviews with staff revealed a lack of clarity in the process for labeling and tracking personal items, and the family was not offered the opportunity to file a grievance during a care plan meeting. The facility's Administrator denied the survey team access to grievance records and documented resolutions, further indicating a failure to adhere to the grievance policy. This lack of documentation and follow-up on grievances for both residents highlights a deficiency in the facility's grievance handling process, as they did not provide evidence of addressing and resolving the issues raised by residents and their families.
Failure to Ensure Resident's Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically opioid pain medication, without proper assessment and documentation. The resident, who was admitted with chronic pain syndrome, received hydrocodone-acetaminophen (Norco) tablets frequently, even when experiencing no pain or mild to moderate pain. The facility's policy required that each resident's medication regimen include only necessary medications and that staff assess pain levels and document non-pharmacological interventions before administering medication. However, the resident's records showed that Norco was administered without documentation of non-pharmacological interventions being attempted first. Additionally, there was no documentation of monitoring for potential adverse effects of the opioid medication, as required by the facility's policy and national guidelines. The Director of Nursing confirmed during an interview that there was no documentation of monitoring for opioid adverse effects or offering non-pharmacological interventions for pain. This lack of documentation and adherence to policy led to the deficiency in ensuring the resident's drug regimen was free from unnecessary medications.
Neglect in Surgical Incision Care for Resident
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident's surgical incision following a cervical spine surgery. The resident was admitted to the facility with a neck brace and specific discharge instructions from the hospital, which included cleaning the incision daily and monitoring for signs of infection. However, the facility staff did not document any orders to assess, monitor, or treat the resident's surgical incision, and the resident's care plan did not include specifics related to the care or monitoring of the surgical incision. Interviews with facility staff revealed a lack of awareness and action regarding the resident's surgical incision. Several nurses and staff members, including LPNs and CNAs, were either unaware of the incision or did not perform necessary assessments due to the resident's refusal to remove the neck collar. The wound nurse, responsible for skin treatments, was not informed of any issues with the resident's incision, and no staff member documented any attempts to clarify or obtain orders for the incision's care. The deficiency was further highlighted when a home health nurse discovered the resident's original surgical dressing was saturated with drainage, and the incision had dehisced with greenish-white drainage. The facility's failure to follow hospital discharge instructions, assess the incision, and document necessary care and monitoring led to the resident's surgical wound being neglected during their stay at the facility.
Failure to Implement Effective Interventions for Aggressive Resident
Penalty
Summary
The facility staff failed to implement consistent and effective interventions for a resident with severe cognitive impairment and behavioral disturbances, leading to multiple resident-to-resident altercations. The resident, diagnosed with dementia, anxiety disorder, and major depressive disorder, exhibited physical and verbal aggressive behaviors towards other residents and staff. Despite being on medication and having a care plan in place, the resident continued to engage in aggressive incidents, including slapping, yelling, and striking others with a walker. The facility's policies on preventing resident abuse and comprehensive care planning were not effectively followed. The resident's care plan was not adequately updated to address the ongoing aggressive behaviors, and interventions such as 15-minute checks and medication adjustments were insufficient in preventing further incidents. The resident's aggressive actions persisted, resulting in multiple altercations with other residents, some of whom expressed fear and distress due to the resident's behavior. The facility's failure to adequately assess, monitor, and revise the care plan for the resident contributed to the continued safety risks for other residents. Despite attempts to separate the resident from others and implement monitoring, the interventions were not effective in preventing further aggressive incidents. The lack of timely and appropriate care plan updates and interventions highlights a deficiency in the facility's ability to maintain a safe environment for all residents.
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What surveyors actually found near you
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cox Medical Centers Meyer Orthopedic And Surgical | 0.8 mi | ★★★★★ | 1 | 0 |
| Springfield Villa | 0.9 mi | ★★★★★ | 10 | 1 |
| Maples Health And Rehabilitation, The | 1.4 mi | ★★★★★ | 0 | 0 |
| Neighborhoods At Quail Creek, The | 1.4 mi | ★★★★★ | 0 | 0 |
| Spring Valley Health & Rehabilitation Center | 1.4 mi | ★★★★★ | 33 | 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.