Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Birch Hill Health Services

Shawano, WI · 50 certified beds · Last Life Safety survey February 11, 2026

CMS Certification Number 525412 · first certified June 1988

Ownership

Operated by NORTH SHORE HEALTHCARE · For profit - Limited Liability company

  • Ownership changed December 1, 2019 (change of ownership)from BIRCH HILL CARE CENTER LLC
15
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
6
Inspection & testing records
Of the citations on file

Position within WI

15 citations — more than 38% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens March 2027 — about 6 months from now. This facility’s last Life Safety survey was February 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

This facility15WI median17National median11
Citations on file over three years, compared
MeasureCitations
This facility15
Median facility in WI17
Median facility nationally11

Survey history

Citations at each Life Safety survey
92023-0842024-0922026-02
Citations at each Life Safety survey
Survey dateCitations
August 30, 20239
September 25, 20244
February 11, 20262

Most-cited tags

Most-cited tags at this facility
K-03212K-03742K-09191K-09231K-03431K-03621K-03531K-03241
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22024-09-25
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.22024-09-25
K-0919Meet requirements for the use of electrical equipment.12026-02-11
K-0923Have proper medical gas storage and administration areas.12023-08-30
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.12023-08-30
K-0362Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.12023-08-30
K-0353Inspect, test, and maintain automatic sprinkler systems.12024-09-25
K-0324Provide properly protected cooking facilities.12023-08-30

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 9
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Services Deficiencies 1
  • Egress Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies9
Gas, Vacuum, and Electrical Systems Deficiencies4
Services Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 11, 2026 — 2 citations

Citations issued on February 11, 2026
TagWhat the surveyor checksStatus
K-0912Have power receptacles that are properly grounded.Deficient, Provider has date of correction (March 9, 2026)
K-0919Meet requirements for the use of electrical equipment.Deficient, Provider has date of correction (March 9, 2026)

September 25, 2024 — 4 citations

Citations issued on September 25, 2024
TagWhat the surveyor checksStatus
K-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.Deficient, Provider has date of correction (October 25, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (October 25, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 25, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (October 25, 2024)

August 30, 2023 — 9 citations

Citations issued on August 30, 2023
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (September 30, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (September 30, 2023)
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.Deficient, Provider has date of correction (September 30, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 30, 2023)
K-0362Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.Deficient, Provider has date of correction (September 30, 2023)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (September 30, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (September 30, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 30, 2023)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (September 30, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.