Cycle 1
Health 2025-08-07 · Fire 2025-08-07
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Sarasota, FL
Birchwood Health And Rehabilitation Center
2-star overall rating with 2-star inspections with $49,680 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3250 12th St, Sarasota, FL
(941) 365-4185
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.49
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,601
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.97
Baseline 22.84% · Performance 18.50% · Measure score 6.97 · Achievement 6.33 · Improvement 6.97
Healthcare-associated infections
0.68
Baseline 7.91% · Performance 7.63% · Measure score 0.68 · Achievement 0.68 · Improvement 0.45
Total nurse turnover
2.89
Baseline 53.03% · Performance 51.85% · Measure score 2.89 · Achievement 2.89 · Improvement 0
Adjusted total nurse staffing
2.37
Baseline 3.63 hours · Performance 3.75 hours · Measure score 2.37 · Achievement 2.37 · Improvement 0.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.96% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 7.92% · Lower 95% interval 7.5% |
| Discharge to community | 43.85% |
50.57%
6.7 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 38.32% · Lower 95% interval 34.08% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.65% |
95.27%
3.4 pts better
|
Numerator 73 · Denominator 74 |
| Falls with major injury | 2.7% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 74 |
| Discharge self-care score | 36.96% |
53.69%
16.7 pts worse
|
Numerator 17 · Denominator 46 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 20 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 2 · Denominator 74 · Adjusted rate 2.21% |
| Healthcare-associated infections requiring hospitalization | 7.63% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 9.8% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 23.21% |
8.2%
15 pts better
|
Numerator 26 · Denominator 112 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 23 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.6 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.6 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.3% |
97.8%
11.5 pts worse
|
93.4%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.8% · Q2 84.8% · Q3 90.9% · Q4 86.8% · 4Q avg 86.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 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 | 7.2% |
2.6%
4.6 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.1% · Q3 7.6% · Q4 3.8% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
3.7%
0.1 pts worse
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 1.9% · Q3 3.8% · Q4 4.3% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 12.3% |
5.9%
6.4 pts worse
|
5.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.8% · Q3 17.5% · Q4 14.0% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
15.7%
3.5 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 21.8% · Q3 17.2% · Q4 20.0% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
9.8%
3.7 pts worse
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.3% · Q3 11.6% · Q4 14.3% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 13.5% |
11.7%
1.8 pts worse
|
16.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
9.8%
0.2 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 18.8% · Q3 6.1% · Q4 4.7% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
12.5%
6.8 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 17.7% · Q3 13.0% · Q4 12.4% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.1%
0.5 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.1% · Q3 4.7% · Q4 3.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.0% |
94.3%
29.3 pts worse
|
81.7%
16.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.7% · Q2 63.1% · Q3 69.5% · Q4 67.6% · 4Q avg 65.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
9.3%
2.5 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 7.5% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.9% |
1.5%
6.4 pts worse
|
1.6%
6.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.1% · Q3 9.3% · Q4 12.2% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.5% |
94.7%
29.2 pts worse
|
79.7%
14.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.0% |
26.2%
0.8 pts worse
|
23.9%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 30.2% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-10-21 · Fire 2021-10-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-05
F · Potential for more than minimal harm
2023-08-17
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-08-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-08-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-16
F · Potential for more than minimal harm
2023-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-17
F · Potential for more than minimal harm
2023-08-17
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 2023-09-17
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 2023-09-17
D · Potential for more than minimal harm
2023-08-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-16
F · Potential for more than minimal harm
2021-10-21
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2021-11-13
F · Potential for more than minimal harm
2021-10-21
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2021-11-13
F · Potential for more than minimal harm
2021-10-21
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2021-11-13
F · Potential for more than minimal harm
2021-10-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-13
F · Potential for more than minimal harm
2021-10-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-11-13
F · Potential for more than minimal harm
2021-10-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-13
F · Potential for more than minimal harm
2021-10-21
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 2021-11-13
F · Potential for more than minimal harm
2021-10-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-13
E · Potential for more than minimal harm
2021-10-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-11-13
D · Potential for more than minimal harm
2021-10-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-13
D · Potential for more than minimal harm
2021-10-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-11-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-07
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2025-09-07
D · Potential for more than minimal harm
2025-08-07
F727 · Nursing and Physician Services Deficiencies
Health
Have 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.
Corrected 2025-09-07
D · Potential for more than minimal harm
2025-08-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-07
D · Potential for more than minimal harm
2025-08-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-07
D · Potential for more than minimal harm
2025-05-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-04-06
G · Actual harm
2023-08-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-17
F · Potential for more than minimal harm
2023-08-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-17
E · Potential for more than minimal harm
2023-08-17
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-12
E · Potential for more than minimal harm
2023-08-17
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-09-17
E · Potential for more than minimal harm
2023-08-17
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2023-09-17
E · Potential for more than minimal harm
2023-08-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-11-12
E · Potential for more than minimal harm
2023-08-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-12
D · Potential for more than minimal harm
2023-08-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-17
D · Potential for more than minimal harm
2021-10-21
F700 · Quality of Life and Care Deficiencies
Health
Try 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.
Corrected 2021-11-13
Penalties and ownership
What sits behind the stars
$49,680
2023-08-17
Fine
Fine · fine $49,680
Fine
Ownership
Birchwood Rehab Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bp Birchwood Trust
5% Or Greater Indirect Ownership Interest · Organization
Lf Birchwood Trust
5% Or Greater Indirect Ownership Interest · Organization
Davis, Elijah
Operational/Managerial Control · Individual
Johnson, Brenda
Operational/Managerial Control · Individual
Martinez Irizarry, Axel
Operational/Managerial Control · Individual
Wildes, Donna
Operational/Managerial Control · Individual
Wildes, Donna
Corporate Officer · Individual
Williams, Tammara
Operational/Managerial Control · Individual
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