| Ownership | For profit - Corporation | Certified beds | 87 |
|---|---|---|---|
| Estimated occupancy | 86.0% | Latest inspection | 2025-08-07 |
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 2 of 5 | 2 of 5 | 3 of 5 |
| Health-inspection score | 60.0 points | 54.0 points | 38.5 points |
| Total nurse staffing | 3.44 hours/day | 3.68 hours/day | 3.63 hours/day |
| RN staffing | 0.55 hours/day | 0.59 hours/day | 0.62 hours/day |
| Staff turnover | 43.8% | 49.2% | 41.8% |
| Latest health deficiencies | 6 deficiencies | 6 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Immediate-jeopardy citations: 0
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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-09-07Have 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.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction 2025-09-07Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-09-07Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-09-07Immediate-jeopardy citations: 0
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-09-17Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2023-09-17Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2023-11-12Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-09-17Provide 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-09-17Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction 2023-11-12Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2023-11-12Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2023-09-17Immediate-jeopardy citations: 0
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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2021-11-13Reported averages, not a real-time staffing schedule.
These group measures do not predict an individual resident’s experience.
How many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingWhat fall-prevention program is used, and how are families notified after a fall?
Suggested because of: falls major injuryHow are antipsychotic medications reviewed, reduced when appropriate, and discussed with families?
Suggested because of: antipsychotic useHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.11467 |
| Lpn hours | 0.77251 |
| Rn hours | 0.54955 |
| Reported total hours | 3.43673 |
| Weekend total hours | 3.11106 |
| Weekend rn hours | 0.31387 |
| Adjusted total hours | 3.71188 |
| Total turnover percent | 43.8 |
| Rn turnover percent | 42.9 |
| Administrators left | 0 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
1
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
| Name | Role | Share |
|---|---|---|
| BIRCHWOOD REHAB HOLDINGS LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| BP BIRCHWOOD TRUST | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% |
| LF BIRCHWOOD TRUST | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% |
| WILDES, DONNA | CORPORATE OFFICER | NOT APPLICABLE |
| DAVIS, ELIJAH | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| JOHNSON, BRENDA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MARTINEZ IRIZARRY, AXEL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| WILDES, DONNA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| WILLIAMS, TAMMARA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ASTON HEALTHCARE LLC | ADP OF THE SNF | NOT APPLICABLE |
| DAVIS, ELIJAH | ADP OF THE SNF | NOT APPLICABLE |
| MARTINEZ IRIZARRY, AXEL | ADP OF THE SNF | NOT APPLICABLE |
| WILDES, DONNA | ADP OF THE SNF | NOT APPLICABLE |
Educational information, not medical or legal advice. Data & methodology