The Birches At Trillium Woods
THE BIRCHES AT TRILLIUM WOODS in PLYMOUTH, MN — inspection on May 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
displayed for residents, visitors and staff to review.
This had the potential to affect all 40 residents
a.m. displayed next to double doors to enter first floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 7:52 a.m. displayed next to double doors to enter second floor unit was the RBOR, dated 4/14/09.
On 5/27/26 at 7:56 a.m. displayed next to double doors to enter third floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 8:26 a.m. administrator stated they were not aware there were changes to the RBOR. At 9:21 a.m. administrator returned, stated they have now started the process of providing updates to the residents and resident representatives.
They have not yet ordered new postings for the units.
Facility Resident Resident Rights policy dated 10/24, indicated copies of the resident rights was posted throughout the facility, however, the policy did not indicate when the facility would provide notification of any changes in any State of Federal laws related to resident rights or facility rules during the residents stay in the facility.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245627 05/27/2026
The Birches at Trillium Woods 14585 59th Avenue North Plymouth, MN 55446
During an interview on 05/26/2026 at 2:05 p.m., R7 stated she had gone to the hospital earlier in the month but could not remember if she had been offered or signed a bed hold for the transfer. In further review of R7's EMR, there was no evidence the facility had offered resident a bed hold in writing.
During interview on 5/27/26 at 10:21 a.m., the facilities licensed social worker (LSW) stated, when residents are transferred to the hospital, the resident, family / significant other are offered a bed hold, which is reviewed with them and is signed if a bed hold is requested. LSW stated until the forms are scanned into the EMR, they are located in the resident's paper hard chart at the nurses station. A review of R7's hard paper chart lacked evidence R7 and / or her family were offered a bed hold in writing. In a interview on 5/27/26 at 2:10 p.m., the director of nursing (DON) stated the staff might not have offered a bed hold while it is the courtesy of the corporation to hold a bed when someone goes to the hospital.
During an interview on 5/27/26 at 3:43 p.m., both the DON and the administrator (ADM) stated they were unable to locate a signed / written bed hold for the 5/6/26 hospitalization of R7.
Both the DON and ADM stated it would be the facility's expectation a bed hold be offered either to the resident and/or their family. In review of the facility's admission Packet (undated), the following was documented: Section 6. BED HOLD POLICY, if you are absent from the Health Center, we shall hold your bed in accordance with our current bed hold policy. A copy of the current bed hold policy is included in these documents listed in the attached Checklist, We reserve the right to change our bed hold policy from time to time in accordance with applicable laws and regulations. A copy of the current bed hold policy shall be provided to you and your family member or legal Representative, Responsible party, or Resident Representative before your transfer. In review of the facility's Policy and Procedure form, entitled: Trillium Woods Policy and Procedure - Bed Hold / Leave of Absence Policy and Acknowledgement (undated), documented three types of resident stays, each with different requirements and time lines for bed hold: Medicare or Private Pay Resident, Medicaid Resident and Life Care Resident on the same form.
However, for each resident stay type, the document read, Resident (and/or Resident's legal Representative, if applicable) hereby acknowledge(s) receipt of the Health Center Bed Hold Policy, with a line for a signature and date signed.
245627 05/27/2026
The Birches at Trillium Woods 14585 59th Avenue North Plymouth, MN 55446
During interview on 5/26/26, at 3:37 p.m. family member (FM)-A stated they had asked for lidocaine to be applied to R58's skin before she was given her injection to help decrease the pain it caused her. FM-A stated the nurses were not consistently doing the lidocaine before the injection, some were doing it after, some were not doing it at all, some would put it on one area then do the injection somewhere else. On 5/26/26, at 3:51 p.m. licensed practical nurse (LPN)-A entered R58's room to administer R58's injection, FM-A asked LPN-A if the lidocaine was going to be applied before the injection was given so she has less pain, LPN-A stated to FM-A no, we put it on after to take away the pain FM-A stated no, the lidocaine was supposed to be put on at least fifteen minutes before so she doesn't feel the injection, LPN-A repeated the lidocaine was put on after. LPN-A proceeded to give the injection, R58 screamed out ouch, ouch don't do that you jerk' while striking out at the nurse. R58's electronic medical record (EMR) was reviewed, the EMR indicated R58 had orders for:Lidocaine external gel 4% (local anesthetic applied to the skin to temporarily numb the area) apply thin layer to the area enoxaparin injection thirty minutes prior to injection once daily.Enoxaparin sodium injection solution prefilled syringe 40millegram(mg)/0.4milliliters (ml) (prescription blood thinner) inject 0.4ml subcutaneously (subq) one time daily. On 5/27/26, at 9:54 a.m. registered nurse (RN) - A removed an enoxaparin sodium injection solution prefilled syringe from R58's medication cabinet, RN-A administered the injection into R58's abdomen, R58 screamed out ouch, damn it you jerk, that hurt resident continued yelling at RN-A, grabbed RN-As arm then scratched the back of RN-A's hand.
Staff offered R58 breakfast, R58 stated I don't want breakfast damn it.
When interviewed on 5/27/26, at 10:22 a.m. RN-A stated they would reapproach R58 to apply the lidocaine gel to the injection site after R58 had time to calm down from getting upset after the injection. RN-A stated it would not be a good idea to try it now due to R58 was too upset and would not allow her to apply the gel. RN-A reviewed R58's EMR then stated oh I should have applied that before the injection was done, I did not do it.
When interviewed on 5/27/26, at 2:19 p.m. director of nursing (DON) stated the expectation was for nurses to review the residents' orders prior to administering medications to ensure they were correctly administering the medications as they were ordered by the provider. DON stated applying the lidocaine after the injection would not help R58 with the pain from administration.
Facility policy Pain Assessment and Management dated 2001. indicated staff to observe from behavioral signs of pain which included negative verbalizations and vocalizations such as groaning, crying and screaming; be3havior such as resisting care, irritability decreased participation in usual physical/social activities.
245627 05/27/2026
The Birches at Trillium Woods 14585 59th Avenue North Plymouth, MN 55446
administration resulting in a 7.69% error rate.Findings include: R58's electronic medical record (EMR)
applied to the skin to temporarily numb the area) apply thin layer to the area enoxaparin injection thirty minutes prior to injection once daily.Enoxaparin sodium injection solution prefilled syringe 40millegram(mg)/0.4milliliters (ml) (prescription blood thinner) inject 0.4ml subcutaneously (subq) one time daily administer lidocaine prior to injection. R58 was observed on 5/27/26, at 9:54 a.m. during a medication pass.
Registered nurse (RN) - A removed an enoxaparin sodium injection solution prefilled syringe from R58's medication cabinet, RN-A administered the injection into R58's abdomen. On 5/27/26, at 10:22 a.m. RN-A stated she would approach R58 in about five minutes and apply the lidocaine gel. RN-A reviewed R58's EMR and stated, oh I should have applied that before the injection was done, I did not do it.
When interviewed on 5/27/26, at 2:19 p.m. director of nursing (DON) stated the expectation was for nurses to review the residents' orders prior to administering medications to ensure they were correctly administering the medications as they were ordered by the provider.
Facility Administering Medications policy stated 4/19, indicated medications were administered in accordance with prescriber orders, this included any required time frame.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.