Plymouth, MN

The Birches at Trillium Woods

5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

14585 59th Avenue North, Plymouth, MN

(763) 519-1350

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

44

Certified beds

Average residents

40

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Life Care Services

Operator or chain grouping

Approved since

2015-09-30

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.19

Registered nurse staffing

LPN hours / resident day

0.82

Licensed practical nurse staffing

Aide hours / resident day

2.95

Nurse aide staffing

Weekend hours

4.53

Weekend nurse staffing

RN turnover

25%

Annual RN turnover

Total nurse turnover

25%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.3	1.7 1.6 pts worse	1.9 1.4 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	2.5	2.0 0.5 pts worse	1.8 0.7 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.3% 2.7 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	96.1% 3.9 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	8.3%	3.9% 4.4 pts worse	3.3% 5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	9.4%	4.3% 5.1 pts worse	11.4% 2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	1.9%	4.1% 2.2 pts better	5.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.9%	12.4% 1.5 pts better	19.6% 8.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	17.9%	17.5% 0.4 pts worse	16.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	11.5%	22.5% 11 pts better	16.3% 4.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	28.0%	18.6% 9.4 pts worse	14.9% 13.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.2%	2.3% 0.1 pts better	1.0% 1.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	1.4%	2.6% 1.2 pts better	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	35.0%	24.8% 10.2 pts worse	19.8% 15.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	0.0%	5.4% 5.4 pts better	5.1% 5.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	88.6% 11.4 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	12.3%	14.0% 1.7 pts better	12.0% 0.3 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.9% 1 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.8%	82.7% 11.1 pts better	79.7% 14.1 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	10.9%	23.1% 12.2 pts better	23.9% 13 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-12 · Fire 2024-09-12

2 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-08-17 · Fire 2023-08-17

0 health deficiencies

No concentrated health issue counts in this cycle.

5 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-06-02 · Fire 2022-06-02

2 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-12

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-09-26

F · Potential for more than minimal harm 2024-09-12

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-09-27

E · Potential for more than minimal harm 2024-09-12

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-09-24

D · Potential for more than minimal harm 2024-09-12

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-24

F · Potential for more than minimal harm 2023-08-17

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-08-21

F · Potential for more than minimal harm 2023-08-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-09-13

E · Potential for more than minimal harm 2023-08-17

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-08-18

C · Minimal harm 2023-08-17

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-09-13

C · Minimal harm 2023-08-17

K901 · Electrical Deficiencies

Fire Safety

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

Corrected 2023-09-06

F · Potential for more than minimal harm 2022-06-02

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-06-03

F · Potential for more than minimal harm 2022-06-02

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-06-04

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-09-12

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-10-03

D · Potential for more than minimal harm 2024-09-12

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-10-03

D · Potential for more than minimal harm 2022-06-02

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-06-29

C · Minimal harm 2022-06-02

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2022-07-31

Penalties and ownership

What sits behind the stars

Ownership

Lcs Trillium Woods Jv LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2021-12-10

Amend-Marshall, Joseph

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01

Bank Of America Corp

5% Or Greater Security Interest · Organization

0% 6 facilities 2025-01-01

Bank Of America Corp

5% Or Greater Mortgage Interest · Organization

0% 6 facilities 2025-01-01

Lcs Holding Company LLC