Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, depression, and cognitive communication deficit was prescribed trazodone, risperidone, and sertraline for insomnia and depression, but the medical record had no evidence that the resident and/or representative was informed of the risks and benefits of these psychotropic medications before they were started. An RN confirmed the finding.
Failure to Report Alleged Abuse to SSA: A resident reported a verbal and physical altercation with another resident in which the other resident grabbed the resident’s arm, used derogatory language, and told the resident to die. The report was shared with the Rehab Director, Social Services, the Administrator, and the DON, but the allegation was not reported to the SSA within the required timeframe per facility policy.
Missed Scheduled Medication on Dialysis Days: A resident with Stage 5 kidney disease who attended dialysis three times weekly did not receive a scheduled afternoon dose of Doxazosin on multiple dialysis days. Staff stated the medication was not given on dialysis days, and the UM confirmed there was no documentation that the provider was notified when doses were missed; the NP also stated he/she was not aware the medication was being withheld.
The facility did not label open injectable medications as per the manufacturer's instructions. An observation revealed that a vial of Lantus (Insulin Glargine) Solution on a medication cart lacked an open date and expiration/discard date. This was confirmed by an LPN, despite the manufacturer's guidance to discard vials after 28 days.
The facility failed to follow CDC guidelines for PPE use under Enhanced Barrier Precautions for a resident with an infected wound, as a staff member assisted the resident without wearing a gown and gloves. Additionally, a Medication Nurse Assistant did not perform hand hygiene between administering medications to three residents, violating the facility's policies.
A resident suffered a lumbar fracture after falling during a transfer with a Hoyer lift due to improper equipment use. Staff used an incorrect sling size and were unaware of specific size requirements, leading to the incident. The facility's policy on mechanical lifts was not followed.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to document that a resident and/or the resident’s representative was fully informed of the risks and benefits of psychotropic medications before those medications were started. Resident #10 had diagnoses of dementia, depression, and cognitive communication deficit. Review of the physician orders showed that the resident was prescribed trazodone 100 mg at bedtime for insomnia, risperidone 0.5 mg twice daily for depression, and sertraline 50 mg daily for depression. Review of the medical record found no evidence that the resident was informed of the risks and benefits of these medications prior to initiation. A clinical resource nurse confirmed these findings during interview.
Failure to Report Alleged Abuse to SSA
Penalty
Summary
The facility failed to report an alleged abuse violation to the State Survey Agency within the required timeframe for one resident involved in a resident-to-resident altercation. Resident #67 reported that on 9/14/25, after Bingo, Resident #68 grabbed the resident’s upper arm, swore at the resident, and told the resident to die. Resident #67 stated that the incident was reported to Staff F, the Rehabilitation Director, on 9/15/25. Staff F confirmed that Resident #67 informed them about the verbal and physical altercation and that Staff E, the Social Service Director, and Staff G, the Administrator, were notified. Staff G confirmed awareness of the incident on 9/15/25, and Staff H, the DON, stated that the resident-to-resident incident was reported to her on 9/15/25. Staff H also confirmed that she had not spoken to both residents involved, and both Staff G and Staff H confirmed that the allegation of abuse was not reported to the SSA. The facility policy titled Reporting Alleged Violations stated that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, and abuse allegations must be reported immediately but no later than 2 hours after the allegation is made.
Missed Scheduled Medication on Dialysis Days
Penalty
Summary
The facility failed to ensure that a resident who attended dialysis on Mondays, Wednesdays, and Fridays received scheduled medications on dialysis days. The resident had Stage 5 Kidney Disease and an order for Doxazosin Mesylate 1 mg by mouth in the afternoon for hypertension, dated 6/5/25. Review of the medication administration record showed that the Doxazosin was not given on multiple dates in August and September 2025, including 8/6, 8/8, 8/10, 8/13, 8/15, 8/18, 8/22, 8/25, 8/27, 9/1, 9/3, and 9/17. Staff stated that Doxazosin was not given on dialysis days, and the Unit Manager confirmed there was no documentation that the provider was notified when the resident missed the medication. The Nurse Practitioner stated that he/she was not aware the Doxazosin was not given on dialysis days and was not notified.
Failure to Label Open Injectable Medications Properly
Penalty
Summary
The facility failed to ensure that open injectable medications were labeled according to the manufacturer's instructions. During an observation of the orange medication cart on the B wing, it was found that a multiple-dose vial of Lantus (Insulin Glargine) Solution, which was being used for a resident, did not have an open date or an open expiration/discard date. This observation was confirmed by an LPN during an interview. The manufacturer's instructions for Lantus specify that vials should be discarded after 28 days, even if insulin remains in the vial.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to CDC guidelines for wearing Personal Protective Equipment (PPE) under Enhanced Barrier Precautions (EBP) for a resident with an infected wound and a peripheral line. During an observation, a Licensed Nurse Aide was seen assisting the resident with transfers and positioning without wearing the required gown and gloves, despite the presence of an EBP sign and PPE in the resident's room. The staff member confirmed awareness of the EBP order for the resident, indicating a lapse in following the established infection control protocols. Additionally, the facility did not ensure proper hand hygiene during medication administration for three residents. A Medication Nurse Assistant was observed administering medications without performing hand hygiene between each resident. This was confirmed by the staff member, highlighting a failure to comply with the facility's hand hygiene and medication administration policies, which are designed to prevent contamination and infection.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure proper use of equipment during resident transfers, resulting in a fall and subsequent injury. A resident was being transferred from bed to chair using a Hoyer lift when the resident slid off the Hoyer pad and fell to the floor, leading to a lumbar fracture and a tiny avulsive fracture in the right foot. The incident occurred because the top Hoyer pad strap was twisted, and staff used an incorrect sling size for the resident, who weighed 153 pounds and required an extra-large sling according to the transfer/mobility assessment. Interviews with staff revealed a lack of awareness regarding the specific Hoyer pad sizes required for individual residents. Staff members admitted to using any available Hoyer pad or relying on visual judgment to determine the appropriate size, rather than following the resident's assessed needs. The facility's policy required staff to perform mechanical lifts according to the manufacturer's instructions, which were not adhered to in this case. The Director of Nursing confirmed that the resident was in the wrong Hoyer sling at the time of the incident.
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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 Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rochester Manor | 0.4 mi | ★★★★★ | 4 | 0 |
| Riverside Rest Home | 5.2 mi | ★★★★★ | 12 | 0 |
| Dover Center For Health & Rehabilitation | 6.4 mi | ★★★★★ | 0 | 0 |
| Langdon Place Of Dover | 9.1 mi | ★★★★★ | 0 | 0 |
| Pinnacle Health & Rehab At N Berwick | 10.8 mi | ★★★★★ | 5 | 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.