Northdale Rehabilitation Center
3030 Bearss Ave, Tampa, FL 33618 · For profit - Corporation · 120 certified beds · (813) 968-8777 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- 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
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 3 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 | 3.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 5.5% | 5.4% | typical |
| 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 | 0.6% | 0.7% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.1% | 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 | 4.2% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.5% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 3.5% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.4% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 4.1% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.2% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.0% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.1% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 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.
41.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 247 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.0% 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 117 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 41.9%CMS range 36.3–47.1 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.7–14.7 | 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 | 65.0% | 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 | 67.5% | 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 | 50.4% | 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 | 99.6% | 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 | 93.9% | 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 | 0.0% | 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 | 7.5%CMS range 4.3–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 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 120 beds and averages 115.0 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.21 hrs/resident/day on weekends vs 3.78 on weekdays — 15% thinner on weekends. RN hours go from 0.50 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · E2024-05-22 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
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 record review, staff interview, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASRR) for residents with a mental disorder and individuals with intellectual disability following a qualifying mental health diagnosis for 10 (Residents #17, #36, #60, #84, #88, #10, #8, #58, #73, and #87) out of 21 residents sampled for PASRRs. Findings included: Review of Resident #17's admission record showed the resident was admitted to the facility on [DATE]. The admission record showed diagnoses to include Bipolar disorder and anxiety disorder. Review of a level I PASRR for Resident #17 dated 01/27/24 showed a blank PASRR and the qualifying diagnoses were not checked. Review of Resident #36's admission record showed the resident was admitted to the facility on [DATE]. The admission record showed diagnoses to include Major depressive disorder and anxiety disorder. Review of a level I PASRR for Resident #36 dated 11/09/23 showed a blank PASARR and 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 · E2024-05-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure proper medication storage for six (Residents #57, #60, #97, #88, #8 and #10) out of 21 residents sampled for three of three days. Findings included: During a facility tour on 05/19/24 at 11:48 a.m., Resident #57 was observed with a bottle of a medication labeled (Mucus relief) at bedside. The resident did not answer when asked how often he took the medication. Review of an admission record for Resident #57 showed he was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated his cognition was moderately impaired. Review of physician orders for Resident #57 dated 05/22/24 revealed the resident did not have self-administration orders. The orders showed the resident was not prescribed this medication. Review of a care plan dated 10/28/23 revealed Resident #57 did not have a focus to keep medications at bedside 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 · E2024-05-22 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 facility policy review, the facility failed to ensure their pest control program was effective during three of four days of survey in six (Rooms #69, #70, #133, #135, #143 and #157) out of 26 rooms and affecting one (Resident #88) out of 21 sampled residents. Findings included: During multiple facility tours on 05/19/24, 05/20/24, and 05/21/24, observations were made of live and dead insects and ants in resident rooms #69, #70, #133, #135, #143 and #157. On 05/19/24 at 11:45 a.m., the Environmental Services (EVS) manager and surveyor observed a live insect crawling outside room [ROOM NUMBER]. She stated the insect was a cockroach. She stated their process was to kill the bug and document on the maintenance log. She stated she would disinfect the area where she stomped at the insect and let maintenance know. On 05/19/24 at 11:47 a.m., an interview was conducted with Resident #88 who was alert and oriented with a BIMS (Brief Interview for Mental Status) of 15. He stated he had…
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 · D2024-05-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 reasonably accommodate the needs of one (Resident #45) of 21 residents related to not placing the call light within the resident's reach. Findings included: On 05/19/2024 at 1:00 p.m., the call light was observed on the floor, behind the headboard of Resident #45's bed. (Photographic Evidence Obtained.) On 5/20/2024 4:46 p.m., the call light was observed on the floor, behind the headboard of Resident #45's bed. The call light had not been moved from the previous day. (Photographic Evidence Obtained.) On 5/21/2024 11:57 a.m. the call light was observed on the floor, behind the headboard of Resident #45's bed. The call light had not been moved from the previous day. (Photographic Evidence Obtained.) Review of Resident #45's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to repeated falls. Review of Resident #45's Minimum Data Set (MDS),…
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 · D2024-05-22 · 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
Based on observation, interview, and facility policy review, the facility failed to ensure Air Conditioning (A/C) filters were maintained in a safe and sanitary manner in seven (69, 70, 132, 133, 135,136 and 157) of 26 resident rooms during three of three days of survey. Findings included: During multiple facility tours on 05/19/21, 05/20/21 and 05/21/24 observations were made of A/C filters with dirt and blanketed debris in rooms 69, 70, 132, 133, 135,136 and 157. (Photographic evidence was obtained). On 05/22/24 at 9:32 a.m., an interview was conducted with the Director of Maintenance (DOM) and the Nursing Home Administrator (NHA). The NHA stated they did not have a policy on A/C maintenance but would contact their corporate to obtain a copy. The DOM stated the A/C filters were last cleaned on 02/23/24. He stated they had a checklist they followed to make sure they covered all the rooms. He stated their policy was to clean the filters and change them quarterly. He stated he had just looked at some of the rooms. He said, I looked at the A/C filters. Some of them were very bad and…
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 · D2024-05-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 ensure the Comprehensive Resident Centered Care Plan was updated related to falls for one (Resident #58) of four sampled residents. Findings included: During an observation on 05/21/2024 at 1:15 p.m., Resident #58 was sitting at bedside in the wheelchair. She was dressed and groomed for the day. White, open back sliders were on her feet. A pair of tennis / enclosed shoes were next to the wall. She had fluids at the bedside. A scoop mattress was in place. The bed was in the lower position. The call light was within reach. Review of the care plans showed Resident #58 was at risk for falls as evidenced by history of repeat falls due to confusion, gait/balance problems, and generalized weakness and was initiated on 11/01/2023. Interventions included to offer / assist to watch TV in the dining room before dinner as of 05/13/2024 and anti-tippers to wheelchair as of 05/19/2024. Resident #58 was admitted on [DATE]. Review of the admission 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 · F2022-03-10 · 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 observation of the dish machine, review of the dish machine records and service provider's report, and interview with facility and service provider staff, the facility failed to ensure the dietary staff were following the manufacturer's guidelines for the dish machine, related to monitoring the temperature of the wash and rinse water, or monitoring the level of chemical sanitizer used by the dish machine. Findings included: An observation was made of the dish machine in the main kitchen on 03/07/2022 beginning at 9:30 a.m. Staff I, Dietary Aide was observed running dish racks with breakfast dishes through the dish machine. She was asked to describe the procedure she followed to ensure the dish machine was running correctly. She reported she attaches a small stick (T stick) to a dinner plate and runs the plate through the dish machine. The strip turns black when the water temperature is 160 degrees Fahrenheit (F). She confirmed she did not know the temperatures that were required for either the wash or the rinse temperature. (Instructions on the T stick read: Insert tip 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 · D2022-03-10 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 and interview the facility failed to develop baseline care plans for one residents (#196) out of 34 sampled residents, related to the provision of pain management and the prevention of falls for newly admitted residents with fall risks. Findings included: A review of Resident #196's medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnoses including dislocation of right humerus, unspecified dementia without behavioral disturbances and anxiety disorder. An observation of Resident #196 on 03/07/22 at 04:05 PM revealed the resident lying in her bed, which was noted to be in the low position. The resident was noted to be pushing her roommates over-bed table away from her and voiced that she didn't want it that close to her bed. The residents' roommate voiced that she thought Resident #196 was trying to get out of bed unassisted. An observation of Resident #196 on 03/08/22 at 10:25 AM revealed the resident was noted to be in bed. 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 · D2022-03-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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, interview, and record review the facility failed to develop a comprehensive care plan related to respiratory care and treatment for one resident (#59) of three residents reviewed for respiratory care. Findings included: A review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, morbid obesity due to excess calories, and history of sleep apnea. A review of the Evaluation Scoring Report dated 2/2/22 revealed a Brief Review for Mental Status (BIMS) score of 15, indicating intact cognition. An observation of Resident #59's room was conducted on 03/07/22 at 10:40 AM. The resident was noted to have a nebulizer machine at the bedside on the night stand. The machine was noted to have a clear clasp where the mask was noted to be clipped to. The mask was not bagged or stored to prevent contamination. Photographic evidence obtained. A review of the resident's current order summary for March 2022…
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 · D2022-03-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 record reviews, and interviews the facility failed to accurately assess the weight and to notify the physician of a significant weight gain for one resident (#12) following a transfer to an acute care facility for diuresis of fluid out of thirty-four sampled residents. Findings included: Resident #12 was admitted on [DATE] and re-admitted on [DATE] following a transfer to an acute care facility on 2/24/22. The admission Record included diagnoses not limited to unspecified heart failure, acute respiratory failure with hypoxia, and chronic pulmonary embolism. A progress note dated 2/28/22 at 2:47 p.m. identified the staff had spoken with an acute care facility regarding Resident #12. The note indicated the resident was having excessive fluid removed and had been transferred from the Intensive Care Unit (ICU) to the Cardiac Unit. A review of Resident #12's Weights and Vitals Summary indicated the resident weighed 248.2 pounds (lbs.) on 2/23/22, one day prior to the residents transfer to an acute care…
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 5 citations
- Potential for harm · D2022-03-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to appropriately monitor newly admitted residents to prevent falls for one resident (#196) of 34 sampled residents. Findings included: A review of Resident #196's medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of inferior dislocation of right humerus and other diagnoses that included unspecified dementia without behavioral disturbances and anxiety disorder. An observation of Resident #196 on 03/07/22 at 4:05 PM revealed the resident lying in her bed which was noted to be in the low position. The resident was noted to be pushing her roommates over-bed table away from her and voiced that she didn't want it that close to her bed. The resident's roommate voiced she thought Resident #196 was trying to get out of bed unassisted. An observation of Resident #196 on 03/08/22 at 10:25 AM revealed the resident was in bed. The resident's right arm was noted to be in a sling. An interview was conducted…
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 · D2022-03-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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, interviews and record reviews, the facility 1) failed to ensure one resident (#5) received respiratory care consistent with professional standards of practice, by failing to monitor the resident's respiratory treatment, leaving the face mask snuggly attached to the resident's face from approximately 8:50 a.m. to 11:05 a.m. for a dependent resident, 2) failed to ensure one resident's (#198) nebulizer mask was on appropriately to receive treatment, and 3) failed to store one resident's (#59) nebulizer mask appropriately out of three residents sampled. Findings included: 1. During a tour of the west hall on 3/7/22 at 10:29 a.m. a nebulizer treatment could be heard while walking the hall. Staff A, Licensed Practical Nurse (LPN) was observed walking toward therapy where the residents' rooms started with the wound cart and stopped at the last room. At 10:31 a.m. on 3/7/22, Resident #5 was observed wearing oxygen at 2.5 liters via nasal cannula and a face mask attached snuggly below 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 · D2022-03-10 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 and interview the facility failed to ensure pain management was provided for one resident (#194) of 34 sample residents. Findings included: A review of Resident # 194's medical record revealed she was admitted to the facility on [DATE] with the primary diagnosis of unspecified fracture of left lower leg, subsequent encounter for closed fracture with routine healing. The Social Service Evaluation dated 2/23/22 revealed a Brief Review for Mental Status (BIMS) score of 14, indicating cognitively intact. An observation of the resident was conducted on 03/07/22 at 10:20 AM. The resident was sitting up in bed holding on to her left leg below the knee and grimacing. An interview with Resident #194 was conducted at this time, she reported she is in pain and has used the call light two times to get her pain medication and the aide came in and turned the light off and said she would let the nurse know. She reported that she has been asking for the pain medication since the breakfast…
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 · D2022-03-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 interviews the facility failed to monitor the behaviors and side effects of psychotropic medications for one resident (#12) out of five residents sampled for the task of unnecessary medications. Findings included: Resident #12 was admitted on [DATE], discharged to an acute facility on 2/24/22 and re-admitted on [DATE]. The admission Record included diagnoses not limited to adjustment disorder with mixed anxiety and depressed mood. A review of Resident #12's active physician orders indicated an order for: - Duloxetine Hydrochloride (HCl) capsule Delayed Release particles 20 milligram (mg) - Give 2 capsule by mouth two times a day for depression. The order started on 2/11/22, was on hold from 3/2 to 3/3/22, and discontinued on 3/8/22. The March 2022 Medication Administration Record (MAR) identified staff documented behaviors at 8:00 a.m. and 4:00 p.m., the times in which the medication was administered. - Duloxetine Hydrochloride (HCl) capsule Delayed Particles 20 mg -…
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 · D2020-12-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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, clinical record reviews, and interviews, the facility failed to respect the right to dignity for three (#56, #59, and #60) of 16 residents receiving extensive or total assistance with eating as evidenced by staff members standing over, in front of, and to the side of the residents while assisting them with mid-day nutrition. Findings included: On 12/29/20 at 1:00 p.m., an observation was conducted of Staff Member F, Certified Nursing Assistant (CNA), standing in front of Resident #56 while assisting with eating. The observation revealed the resident was dependent on the staff member with oral intake and she did not attempt to feed herself. During this observation, Resident #56's roommate, Resident #59, was assisted with the mid-day meal by Staff Member G, CNA. Resident #59 was sitting in a wheelchair with an over-the-bed (obt) table in front of her wheelchair. The staff member was standing on the other side of the obt. Resident #59 held a carton of milk but did not attempt to use utensils…
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.
- 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.
Part of a chain
This home belongs to SOVEREIGN HEALTHCARE HOLDINGS — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 3 of 5 | 3.1 | -0.1 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 42 homes this chain runs (chain average 3.7★, per CMS)
Showing 40 of 42; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SOVEREIGN HEALTHCARE HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 09/18/2018 |
| CRONQUIST 2015 FAMILY TR | Organization | INDIRECT OWNERSHIP INTEREST | since 09/18/2018 |
| JOHN J NOTERMANN BUSINESS TR | Organization | INDIRECT OWNERSHIP INTEREST | since 11/12/2017 |
| MANGINE, JOHN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/25/2012 |
| 3030 CARROLLWOOD, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 09/18/2018 |
| HEALTH SERVICES PROPERTIES LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 01/14/2026 |
| ORIX REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER SECURITY INTEREST | since 09/18/2018 |
| CHERY, DAWN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 06/08/2017 |
| KAAR, SUSAN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 10/01/2003 |
| LANDY, FREDERICK | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 12/13/2022 |
| SOUTHERN HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/14/2026 |
| CRONQUIST, ROYCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2018 |
| MCCOY, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/16/2024 |
| MELTON, DONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/18/2018 |
| NOTERMANN, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| RIBIC, KLEMEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/15/2010 |
| NOTERMANN, BRENDA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/14/2026 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | since 09/18/2018 |
| SOVEREIGN HEALTHCARE DISBURSEMENTS LLC | Organization | ADP OF THE SNF | since 09/18/2018 |
| KELLY, MICHELLE | Individual | ADP OF THE SNF | since 02/01/2018 |
CMS files one row per role, so the 33 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
9 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 $680K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 105700. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-22, 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.