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)
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
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
Chain footprint
20 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.19
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.95
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.53
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.48
CMS adjusted RN staffing hours
Adjusted total hours
6.19
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
994
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0163
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.72
Baseline 18.00% · Performance 19.71% · Measure score 3.72 · Achievement 3.72 · Improvement 0
Healthcare-associated infections
1.74
Baseline 6.94% · Performance 7.32% · Measure score 1.74 · Achievement 1.74 · Improvement 0
Total nurse turnover
9.03
Baseline 67.71% · Performance 26.79% · Measure score 9.03 · Achievement 9.03 · Improvement 9
Adjusted total nurse staffing
10
Baseline 6.05 hours · Performance 6.29 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 7.69% · Lower 95% interval 7.2% |
| Discharge to community | 71.01% |
50.57%
20.4 pts better
|
Better than the National Rate · Eligible stays 109 · Observed rate 71.56% · Lower 95% interval 61.55% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 90.24% |
95.27%
5 pts worse
|
Numerator 37 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 19 · Denominator 38 |
| Discharge mobility score | 39.47% |
50.94%
11.5 pts worse
|
Numerator 15 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 6.35% |
8.2%
1.8 pts worse
|
Numerator 12 · Denominator 189 |
| Staff flu vaccination coverage | 30.86% |
42%
11.1 pts worse
|
Numerator 54 · Denominator 175 |
| Discharge function score | 60.53% |
56.45%
4.1 pts better
|
Numerator 23 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
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 · Adjusted 3.3 · Observed 1.9 · Expected 1.1 · Used in QM five-star |
| 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 · Adjusted 2.5 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 11.4% · Q2 10.5% · Q3 7.9% · Q4 3.0% · 4Q avg 8.3% · Used in QM five-star |
| 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 · Q1 6.5% · Q2 18.2% · Q3 8.8% · Q4 3.3% · 4Q avg 9.4% |
| 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 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 3.8% · 4Q avg 1.9% |
| 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 · Q1 13.3% · Q2 10.7% · Q3 7.7% · Q4 11.5% · 4Q avg 10.9% |
| 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 · Q1 24.0% · Q2 16.0% · Q3 19.0% · Q4 12.5% · 4Q avg 17.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q2 16.9% · Q3 11.9% · 4Q avg 11.5% · Used in QM five-star |
| 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 · Q1 20.7% · Q2 37.0% · Q3 28.0% · Q4 26.9% · 4Q avg 28.0% · Used in QM five-star |
| 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 · Q1 3.3% · Q2 2.8% · Q3 2.5% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 3.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 22.7% · Q2 32.1% · Q3 33.4% · Q4 52.1% · 4Q avg 35.0% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · Adjusted 12.3% · Observed 10.3% · Expected 9.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.9% · Used in QM five-star |
| 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 · 4Q avg 93.8% |
| 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 · Adjusted 10.9% · Observed 7.7% · Expected 16.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Amend-Marshall, Joseph
Operational/Managerial Control · Individual
Bank Of America Corp
5% Or Greater Security Interest · Organization
Bank Of America Corp
5% Or Greater Mortgage Interest · Organization
Lcs Holding Company LLC
5% Or Greater Indirect Ownership Interest · Organization
Lcs Management Holding Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Lcs Minneapolis LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Companies LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services Communities, LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services LLC
Operational/Managerial Control · Organization
Mccarthy Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Mpm Senior Living Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Mujir, Ibrahim
Operational/Managerial Control · Individual
Oak Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Paider, Samantha
Operational/Managerial Control · Individual
Rci Legacy Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Redwood Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Victor, Jason
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Allina Health Restorative Suites
Plymouth, MN
5-star overall rating with 3-star inspections with 3 recent health deficiencies
#2
North Ridge Health And Rehab
New Hope, MN
1-star overall rating with 1-star inspections with Special Focus status with $25,480 in total fines with 30 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Mission Nursing Home
Plymouth, MN
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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