Tarpon Bayou Center
515 Chesapeake Dr, Tarpon Springs, FL 34689 · Non profit - Corporation · 114 certified beds · (727) 934-4629 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,170 in federal fines (most recent 2024-04-11)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 1 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 | 16.1% | 8.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.2% | 5.5% | 5.4% | worse |
| 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 | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| 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 | 3.3% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.9% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.0% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.3% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.6% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.4% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.20 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.79 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
34.2% 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 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 38.3% 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 47 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 0.54 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 59% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | 34.2%CMS range 27.3–43.5 | 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 | 11.2%CMS range 7.8–16.8 | 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 | 38.3% | 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 | 42.5% | 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 | 40.4% | 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 | 98.5% | 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 | 100.0% | 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 | 0.0% | 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 | 7.2%CMS range 3.9–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.23 | 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 114 beds and averages 98.3 residents a day — about 86% occupied, or roughly 16 beds typically open. It runs fairly full. 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.04 hrs/resident/day on weekends vs 3.21 on weekdays — 5% thinner on weekends. RN hours go from 0.69 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 23% is below 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 more than at the previous inspection — worsening. 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.
21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.
- Potential for harm · Fcited before2024-04-11 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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, record review, facility policy review and the Plan of Correction review, the facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) Program. The facility was actively involved in the creation, implementation and monitoring of the Plan of Correction for deficient practice during a recertification and complaint survey conducted on 04/08/2024 to 04/11/2024 and was cited at F657, F677, F690, F758, F759, F842, and F880. On 06/03/2024 to 06/04/2024 a revisit survey was conducted and the facility was recited at F657, F677, F690, F758, F759, F842, and F880. The facility had developed a Plan of Correction with a completion date of 05/10/2024. Findings include: 1. Resident #24 was admitted initially on 04/10/2023 and readmitted on [DATE]. Review of the admission Record showed diagnoses included diabetes, mood disorder, dementia, recurrent major depressive disorder, generalized anxiety disorder, and bipolar disorders. Review of the Minimum Data…
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 · F2024-04-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
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 hand hygiene was provided before and after meal service on four (100, 200, 300 and Melody-secured) of four units, and the facility failed to ensure hand hygiene was available after toileting for one unit (Melody-secured) out of four units observed. Findings included: An observation on 04/08/24 at 12:00 p.m., revealed a hydration cart was being utilized down 400 hallway. The staff provided hydration prior to meal but did not provide hand hygiene. An observation on 04/08/24 at approximately 12:30 p.m., the tray cart was delivered to 400 hallway. Staff were observed knocking on Residents' doors and delivering trays to each Resident. No hand hygiene was observed being conducted at tray delivery service. During an interview on 04/08/24 at 12:45 p.m. Staff E, Registered Nurse (RN)Unit Manager (UM) stated she did not know when hand hygiene was provided but she thought it was after lunch. During an interview on 04/08/24 at 12:50 p.m. Staff…
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 · F2024-04-11 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews and facility record review, the facility failed to ensure the kitchen's low temperature dish washing machine was operating effectively to include provision of correct chemical sanitizer during one of four days observed (4/8/2024). Findings included: On 4/8/2024 at 9:10 a.m. the main kitchen was toured with the Dietary Manager. The Dietary Manager was asked if she and her staff were at the time operating the dish washing machine. She confirmed they were and she noted the machine was a Low Temperature dish washing machine and operated with wash temperature expectation of 120 degrees F (Fahrenheit). and above, and with rinse temperature expectation of 120 degrees F. and above. She further revealed the chemical sanitizer should always test between 50 and 100 Parts Per Million (PPM). The Dietary Manager pointed out that Dietary Aide Staff A was running crates of dishes through the machine. An interview at that time with Staff A revealed she has been operating the dish washing machine for awhile and was knowledgeable on how it needs to operate.…
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 · E2024-04-11 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to maintain a homelike environment on one (300) of four units and failed to ensure one of two resident patios was not used for storage of facility housekeeping equipment, sunshade, rolled up mattresses, and an unused bed frame. Findings included: On 4/8/24 at 10:02 a.m., Resident #103 reported to this writer that the unit was cold. The observation of a hallway thermostat read 71 Fahrenheit (F). An observation of Resident #103's room revealed a bedside dresser without drawers beside the resident's bed, the window blinds in the window of room the room were broken, the string used to maneuver the blinds to an open/close position had been cut/frayed. Resident #103 was observed maneuvering the individual slats of the blinds into a closed position. The observation revealed in the bathroom shared with room [ROOM NUMBER] a roll of toilet paper on back of the toilet while a toilet paper holder attached to the wall above a safety handle on 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 · E2024-04-11 · 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 3. A review of Resident #25 admission Record shows a primary diagnosis of diffuse traumatic brain injury (TBI) with loss of unconsciousness of unspecified duration subsequent encounter with a secondary diagnosis of unspecified mood [affective] disorder both dated 11/07/2015. A review of the Minimum Data Set for Section I- Active Diagnoses dated February 05, 2024, for Neurological Section, 15500 [Traumatic Brain Injury] has a check mark. A review of the Pre-admission Screening and Annual Resident Review, dated 7/17/2023, revealed TBI or unspecified mood [affective] disorder not checked. 2. A review of the admission Record showed Resident #85 had an admission date of 10/11/23 with diagnoses that included but not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of left above the knee, lack of coordination, schizophrenia, and major depressive disorder, recurrent. A review of Resident #85's level I PASRR assessment, dated 01/05/24 revealed, under the section titled A. MI…
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 · E2024-04-11 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
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, resident/staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care, to include feet nail care for one (#163) of thirty-eight sampled residents (#163). Findings included: On 4/8/2024 at 10:20 a.m. Resident #163 was observed in her room and seated on the edge of her bed and facing the door. Upon entering the room, she was noted with both feet bare and touching the floor tiles. Further observations revealed both of her feet were swollen, red and with all ten toenails elongated and curled inward. Some of the nails were observed approximately one inch past the tip of her nail beds. All her nails were also a dark yellowish color. The resident, through interview, revealed her feet hurt as well as her hip. She confirmed both of her feet had very long nails and that her feet felt uncomfortable as a result. Resident #163 revealed she had been residing at the facility about two weeks and she planned on going back to the community after her…
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 · E2024-04-11 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 review, and interviews, the facility failed to provide activities in an appropriate and stimulating manner on one of one (secured memory care) unit. Findings included: Review of an April 2024 calendar located on the facility's secure memory care unit, revealed the activities on April 8th was 9:00 a.m. - Easy Listening, 9:30 a.m. - Arts & Crafts Time, 10:00 a.m. - Morning Social, and at 1:00 p.m. - Move and Groove. An observation on 4/8/24 at 10:18 a.m. of the secured memory care unit revealed 13 residents sitting in the common area at four 4-person tables in each corner of the room, stacks of magazines had been placed each of the tables. One female resident appeared interested in a magazine, a cooking show was playing on television which was muted and a radio was playing, no other resident appeared to be interested in any of these activities. Two tables were placed in corners on each side of the television which was hung in the center of the wall. An observation on 4/8/24 at 10:36…
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 · D2024-04-11 · 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
Based on observations, record reviews, and interviews, the facility failed to ensure 4 residents sitting at one of four tables were treated in manner of dignity and respect related to staff spraying cleaner directly onto the table in front of the residents, and failed to dress one (#107) out of 7 residents sampled on the memory care unit in clothing belonging to them. Findings included: 1. On 4/9/24 at 8:41 a.m., Staff L, Certified Nursing Assistant (CNA), was observed spraying an unknown clear liquid onto a square table in the memory care unit where Resident #24, Resident #73, and 2 unknown others were sitting. The staff member wiped a cloth through the liquid, pushing crumbs towards one of the unknown residents. and off the edge of the table. On 4/9/24 at 8:58 a.m. Staff Q, Housekeeper was observed spraying a liquid onto a table in front of Resident #24 and another unknown resident; the staff member waited a few moments then wiped the liquid away. An interview was conducted with Staff Q on 4/9/24 at 9:02 a.m., the staff member reported the liquid was a name brand broad-spectrum…
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 · D2024-04-11 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 review, the facility failed to assess, obtain physician orders, revise the person-centered comprehensive care plan and educate one resident (#32) out of three sampled residents during medication pass, related to self- administering medications. Findings included: A medication administration observation was conducted on 06/03/2024 at 8:55 a.m. with Staff J, Licensed Practical Nurse (LPN) for Resident #32 Fluticasone Propionate (Nasal) spray, and Budesonide-Formoterol Fumarate Inhaler were observed in the resident's room. The medications were in a container beside the resident's bed not secured. Latanopsin eye drops were observed in a locked container in the room. Curoxen ointment was observed sitting on the overbed table. Resident #32 stated the facility would not get her the Curoxen ointment, so she had a friend bring it in. Resident #32 stated she had been administering her nasal sprays for months. The resident stated the facility had given the medications to her to…
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 · D2024-04-11 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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, interview and review of the facility's policy titled physician notification, the facility failed to ensure one Resident (#12) out of five residents reviewed for unnecessary medications had a significant change in condition assessment completed prior to antibiotic use. Findings included: A review of the admission Record showed Resident #12 was admitted to the facility on [DATE] with diagnoses that included but was not limited to unspecified focal traumatic brain injury without loss of consciousness, major depressive disorder, other seizures, schizophrenia and anxiety disorder, unspecified. Review of the Order Summary Report revealed a physician order dated 04/03/24 for Doxycycline Hyclate Oral Tablet 100 MG [milligrams] (Doxycycline Hyclate)- Give 1 tablet by mouth every 12 hours for UTI [urinary tract infection] for 10 Days. Review of Resident #12's care plan revealed, Focus: ANTIBIOTIC: The resident is on Antibiotic Therapy r/t Has a Bacterial Infection (UTI). Goal: Minimize the risk of…
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 11 citations
- Potential for harm · D2024-04-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 and interview, the facility failed to ensure multiple Minimum Data Set (MDS) assessments accurately reflected diagnoses of one Resident (#85) out of 33 sampled residents. Findings included: A review of the admission Record showed Resident #85 had an admission date of 10/11/23 with diagnoses that included but not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of left above the knee, lack of coordination, schizophrenia, and major depressive disorder, recurrent. A review of the Order Summary Report revealed a physician order dated 04/04/24 for Doxycycline Hyclate Oral Tablet 100 MG [milligrams] (Doxycycline Hyclate)- Give 1 tablet by mouth every 12 hours for UTI [urinary tract infection] for 10 Days. Review of Resident #85's care plan revealed, Focus: PSYCHOTROPIC MED: The resident uses psychotropic medications r/t Antidepressant to manage: depression Antipsychotic to manage: schizophrenia with initiated date of 10/13/24. Goals: Resident will be…
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 · D2024-04-11 · 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 observations, record reviews, and interviews, the facility failed to revise the care plan for one (#52) of thirty-two initially sampled residents in regards to the Advance Directive of code status, failed to revise the care plan of one (#107) out of twenty-five final sampled residents, and failed to revise the care plan of one (#15) of one resident sampled for the diagnosis of Post-Traumatic Stress Disorder. Findings included: 1. On 4/8/24 at 10:39 a.m. Resident #52 was observed sitting at a table with others in the common area of the secured memory care unit. Review of Resident #52's electronic record, on 4/8/24 at 3:31 p.m., revealed a Do Not Resuscitate Order signed by resident's Power of Attorney (POA) on 3/13/24 and signed by the physician on 3/18/24. Review of Resident #52's care plan revealed a focus for Advance Directives as follows: Resident/authorized responsible party request FULL CODE wish to be honored, initiated 10/9/23. The goal was the resident's Advance Directives would be honored…
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 · D2024-04-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 ensure the catheter of one (#107) out of one resident sampled with an urinary catheter was stored in a manner that promoted proper infection control. Findings included: On 4/8/24 at 9:49 a.m., Resident #107 was observed sitting in a wheelchair at a table in the common area of the secured memory care unit. The observation revealed a urinary catheter drainage bag with a privacy device was hanging from the below the resident's wheelchair seat with the catheter tubing lying on the floor. On 4/8/24 at 10:22 a.m., Resident #107 was observed with catheter tubing coming from the end of ankle-length pant leg with the tubing lying on the floor underneath the wheelchair. On 4/8/24 at 10:46 a.m., Resident #107 was observed with catheter tubing coming from under left ankle-length swear pants with the tubing lying on the floor of the unit's common area. On 4/9/24 at 8:46 a.m., Resident #107 was observed sitting in the common area of the secured…
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 · D2024-04-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 document and monitor the behaviors of two (#24 and #83) out of five residents reviewed for unnecessary medications resulting in the physician being notified and orders for additional as needed psychotropic medications were obtained. Findings included: 1. On 4/8/24 at 10:36 a.m., Resident #24 was observed sitting at one of four tables in the common area of Melody unit, a secured memory care unit. The observation showed the resident was looking at a magazine while sitting with 3 other residents at the table. On 4/9/24 at 10:29 a.m., Resident #24 was observed sitting at table in common area coloring with markers. On 4/9/24 at 11:14 a.m., the resident's Power of Attorney (POA) was visiting with the resident. On 4/11/24 at 11:15 a.m., Resident #24 was observed sitting at table in common area with three other residents drinking coffee. Review of Resident #24's admission Record revealed the resident was re-admitted on [DATE]. The diagnoses…
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 · D2024-04-11 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and two errors were identified for two (#31 and #13) of five residents observed. These errors constituted a 7.41% medication error rate. Findings included: 1. On 4/10/24 at 8:05 a.m. an observation of medication administration with Staff E, Registered Nurse/Unit Manager (RN/UM), was conducted with Resident #31. The staff member dispensed the following medications: - chewable Aspirin 81 milligram (mg) over-the-counter (otc) (placed in separate medication cup) - Docusate sodium 100 mg otc softgel tablet - Fluticasone propionate 50 microgram (mcg) nasal spray (she documented it was administered) - Sodium chloride 1 gram (gm) otc tablet - Risperidone 3 mg tablet - Carbamazepine 100 mg chewable - Lisinopril 5 mg - 2 tablets - Benztropine 1 mg tablet - Divalproex delayed release (DR) 250 mg tablet - Spironolactone 50 mg tablet - Terazosin 5 mg capsule The staff member confirmed dispensing 11…
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 · D2024-04-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to maintain two (#107 and #31) out of fifty (50) resident records accurately related to documenting a medication was administered when refused by the resident and to obtain vital signs daily for the skilled notes. Findings included: 1. On 4/8/24 at 1:40 p.m., Resident #107 was observed sitting at a table in the secured memory care unit, Melody, with three other residents. On 4/9/24 at 8:48 a.m., Resident #107 was observed sitting a table with three other residents, no activities were occurring and the resident's catheter tubing was lying on the floor under the wheelchair. Review of Resident #107's admission Record revealed an admission date of 3/30/24 and diagnoses of metabolic encephalopathy, generalized muscle weakness, mild protein-calorie malnutrition, and multiple sites muscle wasting and atrophy not elsewhere classified. Review of Resident #107's Daily Skilled Note, dated 4/1/24 at 2:21 p.m., revealed a temperature 98.9 taken on 3/31/24 at 12:25 a.m., blood pressure 132/70 taken on 3/31/24 at 2:15 p.m.,…
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 · D2024-04-11 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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, interview and review of facility's policies titled, Infection Prevention and Control Program, Tracking: Monitoring, Antibiotic Prescribing, Use and Resistance, Individuals Accountable for Antibiotic Stewardship Activities, and Antibiotic Stewardship, the facility failed to ensure one Resident (#12) out of one Resident reviewed for antibiotics was appropriately assessed for the use of an antibiotic. Findings included: A review of the admission Record showed Resident #12 was admitted to the facility on [DATE] with diagnoses that included but was not limited to unspecified focal traumatic brain injury without loss of consciousness, major depressive disorder, recurrent , other seizures, schizophrenia and anxiety disorder, unspecified. Review of the Order Summary Report revealed a physician order dated 04/03/24 for Doxycycline Hyclate Oral Tablet 100 MG[milligrams] (Doxycycline Hyclate)- Give 1 tablet by mouth every 12 hours for UTI [urinary tract infection] for 10 Days. Review of Resident…
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 · D2022-02-04 · 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 observation, staff interviews, policy and record review, the facility failed to ensure that a safety device of a protective smoking apron was worn for one (1) resident (Resident #29) of six residents who smoke, failed to ensure the red metal smoking receptacle in the smoking area contained only smoking butts, for two of four days (02/01/2022 and 02/04/2022); and failed to follow their policy related to providing a safe smoking environment by not placing a required smoking fire blanket in the smoking area for three of four days (02/01/2022, 02/02/2022 and 02/03/2022) observed during the survey. Findings included: On 02/01/2022 at 11:02 a.m., an observation was conducted of Resident #29 seated in a chair on the smoking patio. The resident was observed to be supervised by an unidentified staff member. Resident #29 was not wearing the smoking device of a safety apron while smoking. During the observation, the red metal smoking butt receptacle located on the smoking patio, was opened by the surveyor, which…
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 · D2020-11-06 · 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 observation, interview, facility policy and record review the facility failed to ensure that a resident centered care plan was developed and implemented related to hospice care for one resident (#90) of seven residents receiving hospice care. Findings included: On 11/03/2020 at 8:00 a.m., Resident #90 was observed to be lying in bed and indicated that he was being followed by hospice, for one of many diagnoses that he was admitted into the facility with. A medical record review for Resident #90 indicated that he was admitted on [DATE] with multiple diagnoses that included amyotrophic lateral sclerosis (ALS), quadriplegia, chronic inflammatory polyneuritis, and tachycardia. A review of the November 2020 Clinical Physician Orders revealed that Resident #90 was to be on a plan of care with Hospice Provider dated 10/14/2020. Record review of the admission Minimum Data Set (MDS) dated [DATE], identified in Section C, that Resident #90's Brief Interview for Mental Status (BIMS) score was 14, which indicated…
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 · D2020-11-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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.
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 therapy devices (splints) were applied to contracted limbs to maintain, and prevent, a decrease in range of motion for two residents (#57 and #45) of thirteen residents sampled as evidenced by: 1) For Resident #57, the facility did not ensure the right-hand splint was available for use by direct care staff and applied per therapy discharge orders to prevent further wrist and hand contracture. Additionally, the facility did not evaluate and update Resident #57's care plan to determine if the ordered ankle foot orthoses was required to prevent decreased mobility in the right lower extremity, and 2) For Resident #45, the facility failed to ensure direct care staff assisted with the application of the left-hand splint to maintain range of motion. Findings included: 1) Resident #57's admission Record revealed an initial admission date of 01/11/19 with admitting medical diagnoses of phlebitis and thrombophlebitis of other deep vessels of…
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 · Dcited before2020-11-06 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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, interviews, record review, and review of the facility policy and plan of correction, the facility's Quality Assessment and Assurance committee failed to ensure that interventions for the plan of correction for splinting devices were comprehensively implemented by not ensuring the splinting devices were ordered, in place, or care planned for three residents (#1, #3 and #2) out of a total of six sampled residents. Findings included: A review of the facility's policy and procedure titled, Quality Assurance/Quality Improvement (QAPI), dated November 2019, revealed: The purpose of the Steering Committee is to review and analyze facility related data (See Agenda) and direct appropriate actions for the facility response. The appointment of a QAPI team may be necessary to explore the depth of the issue and identify the root cause so that interventions are appropriately resourced . Team members should be knowledgeable about the process/systems used that contribute to the assignment . The Steering…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- 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
$10,170 in federal fines across 1 penalty.
- $10,170 — penalty dated 2024-04-11
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to HEARTHSTONE SENIOR COMMUNITIES — 8 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 | 1 of 5 | 1.9 | -0.9 vs chain |
| Health inspection | 1 of 5 | 1.7 | -0.7 vs chain |
| Staffing | 3 of 5 | 2.6 | +0.4 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 7 homes this chain runs (chain average 1.9★, per CMS)
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 | Share | Since |
|---|---|---|---|---|
| TARPON REHABILITATION CENTER, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2009 |
| HEARTHSTONE SENIOR COMMUNITIES, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 04/01/2009 |
| GARNER, ALVIN | Individual | CORPORATE OFFICER | — | since 04/01/2009 |
| JAFFE, HOWARD | Individual | CORPORATE OFFICER | — | since 04/01/2009 |
| ROMBOLD, LORI | Individual | CORPORATE OFFICER | — | since 04/01/2009 |
| WYATT, BRIAN | Individual | CORPORATE OFFICER | — | since 04/01/2009 |
| CONSULTING SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| FACILITY SUPPORT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| KANE FINANCIAL SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| THEMIS HEALTH MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| JOSEPH, PATRICIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/20/2021 |
| MATTERN, ANDREA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/21/2021 |
| SELECT REHABILITATION, LLC | Organization | ADP OF THE SNF | — | since 08/19/2016 |
CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $212K 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 105280. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-11, 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.