Birchwood Health And Rehabilitation Center
3250 12th St, Sarasota, FL 34237 · For profit - Corporation · 87 certified beds · (941) 365-4185 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.5% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 5.2% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.8% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.6% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.1% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.3% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 7.3% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 65.5% | 94.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.0% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.4% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.84 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.57 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 107 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 48% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.9%CMS range 34.1–53.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.5–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 47.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 27.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.4–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 87 beds and averages 74.8 residents a day — about 86% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.550 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.57 on weekdays — 13% thinner on weekends. RN hours go from 0.65 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · G2023-08-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident representative and staff interview, the facility failed to assess, and implement individualized, appropriate interventions to prevent the development and worsening of pressure ulcers for 1 (Resident #28) of 2 sampled residents with in-house acquired pressure ulcers. The findings included: The facility's policy and procedure for Prevention of skin impairments revised in April 2020 noted, The purpose of this procedure is to provide information regarding identification of skin impairments and interventions for specific risk factors . Risk assessment. Assess the resident on admission for existing skin impairments. Repeat the assessment weekly and upon any changes in condition . Nutrition . Conduct nutritional screenings for residents at risk. Conduct a comprehensive nutritional assessment for any resident at risk of pressure injury who is screened to be at risk for malnutrition; and for all adult residents with a pressure injury . The facility's policy and procedure for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-04 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of the grievance log, review of facility's policy and procedure, residents and staff interviews, the facility failed to ensure sufficient nursing staffing to meet the needs of 10 (Residents #1, #2, #3, #4,#5, #6, #7, #8, #9 and #10) of 10 dependents residents reviewed.The findings included:Review of the facility's policy and procedure titled, Standards and Guidelines: Call lights issued 03/2018 and revised 01/2024 revealed, Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. Guideline: Resident's call light is to be within reach and answered promptly by facility personnel . Answer call light promptly. All facility personnel are expected to respond to call lights . Call lights must remain functional and within reach of each resident. On 5/4/26 at 8:45a.m., during an initial tour of the facility, Residents #10, #6, #7, #8 and #9 were observed in their bed. The residents' call lights were on the floor and not accessible to the residents. Photographic evidence obtainedOn 5/4/26 at 9:00 a.m., in an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-12 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and facility policy the facility failed to ensure the safe storage of medications for 3 (Residents #1, #2, and #3) of 3 residents observed with unsecured medications at bedside.The findings included:On 2/11/26 at 10:08 a.m., during the initial tour of the facility, and on 2/12/26 at 9:10 a.m., observation of Resident #1's room revealed a bottle of Melatonin 10 mg (milligrams) gummies and a bottle of (brand name) eye vitamins soft gels stored unlocked on the resident's nightstand. Photographic evidence obtainedOn 2/12/26 at 9:26 a.m., in an interview Licensed Practical Nurse (LPN) Staff B said the medications should not be on the resident's nightstand. She said medications should be locked in the medication cart at all times.On 2/11/25 at 9:05 a.m. during initial tour of the facility, and on 2/12/26 at 9:06 a.m., observation of Resident #2's room revealed a bottle of Allergy Nasal Mist Oxymetazoline HCl 0/05% nasal decongestant stored unsecured on the resident's overbed table. Photographic evidence obtainedOn 2/12/26 at 9:08 a.m., in an interview LPN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-07 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to provide appropriate treatment and services to prevent the decline in range of motion for 1 (Resident #31) of 2 residents reviewed with limited range of motion.The findings included:Review of the facility's policy and procedure titled, Standards and Guidelines: ADL (Activities of Daily Living) Care and Services with a revised date of 01/2024 revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . splint/brace.On 8/4/25 at 10:50 a.m., Resident #31 was observed with right hand/wrist contracture (Fingers permanently flexed towards the palm). Resident #31 was not able to answer interview questions. Review of the clinical record for Resident #31 revealed an admission date of 1/4/23. Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-07 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews the facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours for 2 of 14 days of staffing reviewed (7/20/25 and 7/27/25).The findings included:Review of the facility provided form Calculating state Minimum Nursing Staff for Long Term Care Facilities for 7/20/25 through 8/2/25 revealed on 7/20/25 and 7/27/25 the facility fell below the required 8 consecutive hours worked for Registered Nursed.The form noted:On 7/20/25, the number of Registered Nurse hours worked was 7.87 hours.On 7/27/25, the number of Registered Nurse hours worked was 5.42 hours.On 8/7/2025 at 12:58 p.m., in an interview Labor Coordinator Staff D said the facility has a Registered Nurse 8 hours a day and provided Registered Nurse Staff E's time sheet for 7/19/25, 7/20/25, and 7/27/25.Review of Registered Nurse Staff E's time sheets revealed on 7/19/25 RN Staff E clocked in at 2:47 p.m., and clocked out on 7/20/25 at 7:06 a.m. The total number of hours worked on 7/20/25 from 12:00 a.m. to 7:06 a.m. were 7 hours and 6 minutes.On 7/27/2025,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-07 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, interviews and records review the facility failed to ensure expired medications were removed from 2 (Colonial 1 and Heritage) of 4 medication carts reviewed for medication storage.The findings included:Review of facility Standards and Guidelines: Medication Administration policy (last revised 1/2024) states the expiration/beyond use date on the medication label is checked prior to administering.On 8/5/2025 at 9:00 a.m., observation of the Colonial 1 medication cart revealed one bottle of Acetaminophen with an expiration date of 5/2025. Photographic evidence obtained.On 8/5/2025 at 9:28 a.m., observation of the Heritage medication cart revealed one bottle of Lorazepam topical gel 0.5 milligram per milliliter for Resident #4. The packaging specified, Do not use after 7/10/25. Photographic evidence obtained. On 8/5/25 in an interview the Director of Nursing said there should not be expired medications in the medication carts. She said they check the medication carts on Sundays and will have to work on following through with the medication carts checks.
- Potential for harm · Dcited before2025-08-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure a medication error rate below 5%. The facility medication error rate was 8% out of 25 opportunities.Review of facility Standards and Guidelines: Medication Administration policy (last revised 1/2024) states medications are administered in accordance with prescriber orders, including any required time limit. The policy further states if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.Review of facility Standards and Guidelines: Physician Orders policy (last revised 1/2024) states Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to provide adequate supervision and assistance to prevent falls for 1 (Resident #850) 3 residents reviewed with history of falls, including a fall with major injury requiring a transfer to a higher level of care. The findings included: The facility policy Standards and Guidelines: Falls- Managing, Preventing, and Documentation initiated 4/20 (revised 4/25) documented, Each resident will have an individualized plan of care that will be reviewed and modified as needed to include fall preventions most appropriate to their individual needs and diagnosis. The staff will implement a resident centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. The residents care plan should be updated timely and with new interventions determined by the interdisciplinary team. Review of the clinical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide housekeeping and maintenance services to ensure a clean, sanitary and comfortable environment for 4 ( Rooms #210, #214, #115, #110) of 13 rooms observed, 1(200 hall) of 4 halls observed, and 1 (Resident #1) of 3 residents interviewed. The findings included: 1. During a tour of the facility on 3/6/25, multiple environmental issues were observed with wallpaper, flooring, cove base, and walls including: Floors in the activity room in the 200 hall were stained and cracked. photographic evidence obtained room [ROOM NUMBER] had cove base missing and peeling away from the walls. photographic evidence obtained Handrail in the 200 hall had a dried black substance on it. photographic evidence obtained Common hallways had peeling wallpaper with orange discoloration in spots. photographic evidence obtained room [ROOM NUMBER]'s wall was cracking, missing plaster and paint, cove based peeling from wall in which someone had placed a screw to hold it in.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and facility policy and record review, the facility failed to store food in a manner to prevent possible contamination from dirty ceiling tiles and air vents and to monitor refrigeration logs and three compartment sink sanitizer check logs. The findings included: The Kitchen Operations Sanitization Policy revised July 2023 provided by the facility states the food service area shall be maintained in a clean and sanitary manner. Number 16 of the policy state kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . the Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. The Food Receiving and Storage Policy revised July 2023 states Foods shall be received and stored in a manner that complies with safe food handling practices. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day be the food and nutrition services manager or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-17 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of policy and procedures, staff and residents interviews, the facility failed to honor the right to choose preferred method and frequency of bathing for 3 (Residents #48, #39 and #28) of 4 sampled residents dependent on staff for activities of living. The findings included: The facility's Bathing/Showers policy and procedure revised February 2018 noted, The purposes of this procedure are to promote cleanliness, provide comfort and to observe the condition of the resident's skin . Procedure . Perform bath/shower per resident preference as tolerated . The shower sheets utilized by the facility noted, All Residents must be offered and provided a shower unless they request a bed bath . The form noted areas to place a check mark to indicate whether a shower, or bed bath was given, or the resident refused. The instructions included the nurse must verify refusal of shower, notify the responsible party and document in the electronic clinical record. 1. Review of the clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · E2023-08-17 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure completion of the Quarterly Minimum Data Set (MDS) within the required timeframe for 13 (Resident #1, #2, #8, #11, #25, #27, #28, #36, #45, #46, #48, #52 and #54) of 15 residents sampled. This had the potential to delay assessment and revision of the plan of care. The findings included: On 8/17/23, record review for Resident #1 revealed the assessment reference date of the last completed Quarterly MDS was 3/14/23. As of 8/17/23, 133 days later, the required quarterly MDS was not completed. The quarterly MDS was completed and locked on day 134. On 8/17/23, record review for Resident #2 revealed the assessment reference date of the last completed quarterly MDS was 3/15/23. As of 8/17/23, 152 days later, the required quarterly MDS was not completed. The quarterly MDS was completed and locked on day 153. On 8/17/23, record review for Resident #8 revealed the assessment reference date of the last completed quarterly MDS was 3/6/23. As of 8/17/23, 160 days later, the required quarterly MDS was not completed. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-17 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to provide care and services to maintain and prevent avoidable decline in range of motion for 1 (Resident #48) of 2 sampled residents with limited range of motion. The findings included: Review of the clinical record revealed Resident #48 was an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included history of Cerebral Vascular Accident (CVA) with right sided weakness. The Quarterly Minimum Data Set (MDS) assessment with a target date of 3/9/23 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS noted impaired functional limitation in range of motion on one side of the upper and lower extremities. The resident was totally dependent on the physical assistance of two people for transfers, and walking had not occurred during the assessment period. On 8/14/21 at 8:50 a.m., Resident #48 was observed in the bed. The resident's hand was flaccid, and the arm flexed at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-17 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, family and staff interviews, the facility failed to ensure the availability of sufficient nursing staffing to meet the needs of 4 (Residents #48, #39, #28, #119, and #7) of 22 sampled residents. The failure to ensure sufficient nursing staffing to provide timely care and services could prevent residents from attaining, or maintaining their highest practicable physical, mental, and psychosocial well-being. The findings included: The facility's assessment with a date reviewed by the Quality Assurance and Performance Improvement committee on June 21, 2023, noted, Staff Assignments . meets this requirement by considering census, individual and overall unit acuity, routine/consistent staffing assignments per unit for both licensed nurses and CNAs (Certified Nursing Assistants), and resident preferences for staff assignments . The facility assessment noted the monthly average of residents requiring assistance of 1-2 staff with activities of daily living was 60%…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-17 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interview, the facility failed to follow the physician's orders repeatedly and regularly for 4 (Residents #902, #12, #905 and #906) of 4 residents reviewed for blood pressure medications with parameters. The findings included: 1. On 10/10/23 at 8:50 a.m., Licensed Practical Nurse (LPN) Staff B was observed preparing to administer medications to Resident #902, including Midodrine(a medication to increase blood pressure(bp). Staff B placed all of the medications in a medicine cup including the Midodrine. The Medication Administration record (MAR) order dated 9/13/23 read: Midodrine HCL Oral Tablet 5 mg (milligrams), give 1 tablet by mouth two times a day for low blood pressure for systolic (top number) bp below 110. Staff B entered Resident #902's room to administer the medication. When asked about the resident's blood pressure, Staff B said, Oh yeah, I have to check that. Staff B checked the blood pressure which was 140/68. Staff B handed the medication cup to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the medication error rate was less than 5%. This was evidenced by three medication errors out of 27 opportunities, resulting in a medication error rate of 11.11%. The findings included: A review of facility policy titled, Administering Oral Medications, revised October 2010, indicated, verify that there is a physician's medication order for the procedure. Check the label on the medication and confirm the medication name and dose with the Medication administration record (MAR). Prepare the correct dose. 1. On 8/16/23 at 8:02 a.m., observation of Registered Nurse (RN) staff A preparing to give medications to Resident #69, including an injection of Depo-Medrol (steroid) 40 milligrams. The label specified the Physician Assistant to administer. The nurse informed the resident the injection was for pain. Resident #69 said she thought the doctor was supposed to come in and inject a steroid in the shoulder joint for pain. RN staff A asked the resident if she wanted the injection in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-21 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, policy review and resident and staff interviews, the facility failed to complete and document an assessment for entrapment, alternatives attempted, discuss risks versus benefits and obtain informed consent prior to the installation of bed rails for 1 resident (Resident # 63) of 1 resident reviewed for use of bed rails. This has the potential to lead to serious negative consequences for the resident. The findings included: Review of the facility Bed Rail Guidelines Policy dated 4/2014 and updated 11/2016 and 3/2020 revealed Prior to the utilization of a bed rail, the interdisciplinary team completes . resident assessment for risk of entrapment The utilization of bed rails requires the interdisciplinary team to complete a patient evaluation of the risks versus benefits of the bed rail identification of previous interventions utilized the potential negative consequences of bed rail use are explained, and informed consent is obtained. On 10/18/21 10:30 a.m. Resident #63 was observed in bed with four bed rails noted in the up position. On 10/18/2021…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BIRCHWOOD REHAB HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/04/2023 |
| BP BIRCHWOOD TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 05/05/2023 |
| LF BIRCHWOOD TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 05/05/2023 |
| WILDES, DONNA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/28/2025 |
| DAVIS, ELIJAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/12/2024 |
| JOHNSON, BRENDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/11/2024 |
| MARTINEZ IRIZARRY, AXEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/10/2025 |
| WILLIAMS, TAMMARA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2024 |
| ASTON HEALTHCARE LLC | Organization | ADP OF THE SNF | — | since 05/05/2023 |
CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $270K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105389. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.