Birch Hill Health Services
Open-data reference.
Birch Hill Health Services is a for profit - limited liability company facility in Shawano, WI with 50 certified beds and a 2-star overall CMS rating. The facility has 16 deficiency records on file.
1475 Birch Hill Lane, Shawano, WI 54166
Phone: 7155263161
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525412
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 50
- Residents
- 43
- In Hospital
- No
- County
- Shawano
- Last Inspection
- Sep 25, 2024
Staffing Data
- RN Hours
- 0.52 (nat'l avg: 0.68)
- LPN Hours
- 0.70
- CNA Hours
- 2.17
- Total Nursing Hours
- 3.39 (nat'l avg: 3.89)
- PT Hours
- 0.02
- Nursing Turnover
- 32.5%
- RN Turnover
- 28.6%
What the CMS Record Reveals About Birch Hill Health Services
Birch Hill Health Services operates 50 certified beds in Shawano, WI with approximately 43 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (3★), and quality measures (1★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 16 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.39 total nursing hours per resident day (national average 3.89), with RN coverage at 0.52 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Birch Hill Health Services falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 32.5%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (16 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 18, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 18, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 13, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 13, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 25, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 25, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Oct 25, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 25, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 25, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 25, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Oct 25, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 30, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 30, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 12, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 31.6% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 1.7% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 3.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 9.9% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 94.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 20.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.6% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 94.9% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 82.1% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.8% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 35.9% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 44.9% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for Birch Hill Health Services?
What are the staffing levels at Birch Hill Health Services?
How many beds does Birch Hill Health Services have?
Does Birch Hill Health Services have any deficiencies on record?
Has Birch Hill Health Services received any fines or penalties?
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When was Birch Hill Health Services last inspected?
What quality measures are tracked for Birch Hill Health Services?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.