Cycle 1
Health 2025-04-10 · Fire 2025-04-10
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Forest Lake, MN
Birchwood Health Care Center
2-star overall rating with 1-star inspections with $132,781 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
604 1st Street Ne, Forest Lake, MN
(651) 464-5600
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespark
Operator or chain grouping
Approved since
1974-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 1 overall / 1 health / 3 staffing / 4 quality stars
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
0.80
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,280
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9983
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.56
Baseline 20.14% · Performance 21.17% · Measure score 0.56 · Achievement 0.56 · Improvement 0
Healthcare-associated infections
7.08
Baseline 5.73% · Performance 5.72% · Measure score 7.08 · Achievement 7.08 · Improvement 0
Total nurse turnover
7.18
Baseline 35.44% · Performance 34.33% · Measure score 7.18 · Achievement 7.18 · Improvement 0.55
Adjusted total nurse staffing
3.21
Baseline 3.57 hours · Performance 3.99 hours · Measure score 3.21 · Achievement 3.21 · Improvement 1.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.75% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 6.67% · Lower 95% interval 6.86% |
| Discharge to community | 58.11% |
50.57%
7.5 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 55.84% · Lower 95% interval 48.68% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 62 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 53.85% |
53.69%
0.2 pts better
|
Numerator 21 · Denominator 39 |
| Discharge mobility score | 41.03% |
50.94%
9.9 pts worse
|
Numerator 16 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 62 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.72% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 0% · Lower 95% interval 3.03% |
| Staff COVID-19 vaccination coverage | 33.04% |
8.2%
24.8 pts better
|
Numerator 37 · Denominator 112 |
| Staff flu vaccination coverage | 40% |
42%
2 pts worse
|
Numerator 62 · Denominator 155 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 24 · Denominator 39 |
| Transfer of health information to provider | 84.62% |
95.95%
11.3 pts worse
|
Numerator 22 · Denominator 26 |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 22.5% |
25.2%
2.7 pts worse
|
Numerator 9 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
96.1%
2 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.9%
2.1 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.7% · Q4 1.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.9% |
4.3%
3.6 pts worse
|
11.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 10.8% · Q3 6.2% · Q4 9.8% · 4Q avg 7.9% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
4.1%
1.5 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 5.9% · Q4 1.9% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
12.4%
2.9 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.1% · Q3 7.8% · Q4 11.1% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
17.5%
3.8 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 13.9% · Q3 13.0% · Q4 13.0% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
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 | 15.5% |
22.5%
7 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 29.7% · Q3 13.1% · Q4 6.9% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
18.6%
3.1 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 12.8% · Q3 8.9% · Q4 16.0% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.6%
1.7 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
24.8%
0.2 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 24.4% · Q3 30.6% · Q4 19.8% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.4%
2.8 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 4.8% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
88.6%
10 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.6% · Q3 100.0% · Q4 98.2% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
14.0%
1.7 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.9% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.9%
0.4 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.5% · Q3 0.0% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.7% |
82.7%
6 pts better
|
79.7%
9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
23.1%
2.3 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 25.4% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-10
K222 · Egress Deficiencies
Fire Safety
Add 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.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-04-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-27
E · Potential for more than minimal harm
2024-02-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-03-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-23
J · Immediate jeopardy
2025-11-13
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 2025-11-09
D · Potential for more than minimal harm
2025-11-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-27
G · Actual harm
2024-02-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-11
F · Potential for more than minimal harm
2024-02-09
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 2024-03-11
F · Potential for more than minimal harm
2024-02-09
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 2024-03-11
F · Potential for more than minimal harm
2024-02-09
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-03-11
F · Potential for more than minimal harm
2024-02-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
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 2024-03-11
D · Potential for more than minimal harm
2024-02-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-11
C · Minimal harm
2024-02-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-11
G · Actual harm
2024-01-10
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 2024-02-03
D · Potential for more than minimal harm
2024-01-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-04
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 2024-02-03
D · Potential for more than minimal harm
2023-12-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-09-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-27
J · Immediate jeopardy
2023-06-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-06-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-06-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-03-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-21
D · Potential for more than minimal harm
2022-08-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-25
Penalties and ownership
What sits behind the stars
$29,234
2024-02-09
Fine
Fine · fine $29,234
Fine
$9,103
2024-01-04
Fine
Fine · fine $9,103
Fine
$94,444
2023-06-07
Fine
Fine · fine $94,444
Fine
Ownership
Hesse, Sandra
Corporate Director · Individual
Johnson, Amanda
W-2 Managing Employee · Individual
Marshall, John
Corporate Officer · Individual
Marshall, Susan
Corporate Director · Individual
Martin, Richard
Corporate Director · Individual
Montez, Jim
Corporate Officer · Individual
Senior Care Communities
5% Or Greater Direct Ownership Interest · Organization
Senior Care Forest Lake, LLC
5% Or Greater Direct Ownership Interest · Organization
Toulouse, Molly
Corporate Officer · Individual
Toulouse, Molly
W-2 Managing Employee · Individual
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