Your report for Birchwood Care Home
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MinnesotaAbove only 36% of peers337 rated homes · average 3.2★
- Hennepin CountyAbove only 40% of peers53 rated homes · average 3.1★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs MN avg
- StaffingCan add or remove a star2★−2.1 vs MN avg
- Quality measuresCan add or remove a star5★+1.8 vs MN avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersMN avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 7% of peersMN avg4.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 87% of peersMN avg3.2★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff1.70hrsAbove only 1% of peersMN avg4.23Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.39hrsAbove only 1% of peersMN avg1.06Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better44%Above only 42% of peersMN avg42%RN turnover33%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$3,145Above only 40% of peersMN avg$19,953Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2023 – Jul 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jul 29, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 15, 2025
Mar 20, 2025Cycle 1worst F · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected May 2, 2025
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected May 2, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 2, 2025
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected May 2, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected May 2, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 2, 2025
Jul 3, 2024Cycle 2worst G · actual harm
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceG · isolatedCorrected Jul 1, 2024
Jun 18, 2024Cycle 2worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 10, 2024
May 3, 2024Cycle 2worst F · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jun 20, 2024
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jun 20, 2024
- F803Ensure 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.Nutrition and DietaryD · isolatedCorrected Jun 20, 2024
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationF · widespreadCorrected Jun 20, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Jun 20, 2024
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Jun 20, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Jun 20, 2024
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Jun 20, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jun 20, 2024
- F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsC · widespreadCorrected Jun 20, 2024
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Jun 20, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 20, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 20, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jun 20, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jun 20, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 20, 2024
- F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Jun 20, 2024
Mar 22, 2024Cycle 2worst F · no actual harm
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsE · patternCorrected May 17, 2024
- F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Apr 17, 2024
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationF · widespreadCorrected Apr 19, 2024
Mar 15, 2024Cycle 2worst D · no actual harm
- F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Quality of Life and CareD · isolatedCorrected Apr 20, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 20, 2024
Jun 8, 2023Cycle 3worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 8, 2023
Feb 28, 2023Cycle 3worst J · immediate jeopardy
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Mar 22, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined1.70hrs
- Registered nursesRN hours only0.39hrs
- Licensed practical nursesLPN hours0.31hrs
- Nurse aidesCNA hours1.00hrs
- Weekend nursingAll staff on Saturdays and Sundays1.41hrs
- Minnesota average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better44%Above only 42% of peersMN avg 42%
- RN turnoverRegistered nurses only33%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy60 certified beds · ~57 residents a day95%Above 89% of peersMN avg 83%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $3,145In fines
- 1Fine
- 0Payment denials
- $19,953MN avg in fines
Actions on record
- May 15, 2023Civil money penalty$3,145
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Independent
- Certification
- Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 24E166 · 715 WEST 31ST STREET, MINNEAPOLIS, MN, 55408.
- Percentiles compare this facility with every rated nursing home in Minnesota and Hennepin County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









