Cycle 1
Health 2025-04-30 · Fire 2025-04-30
5 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Inverness, FL
Arbor Trail Rehab And Skilled Nursing Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
611 Turner Camp Rd, Inverness, FL
(352) 637-1130
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1990-04-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,370
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.10
Baseline 28.00% · Performance 24.05% · Measure score 3.10 · Achievement 0 · Improvement 3.10
Healthcare-associated infections
3.02
Baseline 9.17% · Performance 7.70% · Measure score 3.02 · Achievement 0 · Improvement 3.02
Total nurse turnover
1.12
Baseline 64.39% · Performance 59.09% · Measure score 1.12 · Achievement 1.12 · Improvement 0.84
Adjusted total nurse staffing
1.01
Baseline 3.65 hours · Performance 3.37 hours · Measure score 1.01 · Achievement 1.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.17% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 253 · Observed rate 13.04% · Lower 95% interval 8.81% |
| Discharge to community | 44.24% |
50.57%
6.3 pts worse
|
No Different than the National Rate · Eligible stays 215 · Observed rate 38.6% · Lower 95% interval 36.3% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.34% |
95.27%
4.1 pts better
|
Numerator 150 · Denominator 151 |
| Falls with major injury | 0.66% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 151 |
| Discharge self-care score | 52.87% |
53.69%
0.8 pts worse
|
Numerator 46 · Denominator 87 |
| Discharge mobility score | 56.32% |
50.94%
5.4 pts better
|
Numerator 49 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 0.66% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 151 · Adjusted rate 0.52% |
| Healthcare-associated infections requiring hospitalization | 7.7% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 7.76% · Lower 95% interval 4.82% |
| Staff COVID-19 vaccination coverage | 3.5% |
8.2%
4.7 pts worse
|
Numerator 5 · Denominator 143 |
| Staff flu vaccination coverage | 24.34% |
42%
17.7 pts worse
|
Numerator 55 · Denominator 226 |
| Discharge function score | 64.37% |
56.45%
7.9 pts better
|
Numerator 56 · Denominator 87 |
| Transfer of health information to provider | 90.11% |
95.95%
5.8 pts worse
|
Numerator 82 · Denominator 91 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24.05% |
25.2%
1.1 pts worse
|
Numerator 19 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
2.6%
0.2 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.1% · Q3 2.2% · Q4 5.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
3.7%
5.2 pts worse
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 11.9% · Q3 6.7% · Q4 10.4% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.9%
1.7 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 12.0% · Q3 9.8% · Q4 1.2% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
15.7%
5.3 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 15.1% · Q3 8.3% · Q4 3.5% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.9% |
9.8%
5.9 pts better
|
16.7%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.1% · Q3 2.6% · Q4 3.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.9% |
11.7%
2.8 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 11.5% · Q3 0.0% · Q4 6.6% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
9.8%
5.8 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.7% · Q3 3.8% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.6% |
12.5%
6.9 pts better
|
19.8%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 5.1% · Q3 1.2% · Q4 2.4% · 4Q avg 5.6% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.1%
3.6 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 1.2% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
9.3%
1.9 pts worse
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.7% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.7%
4.7 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
26.2%
5.5 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 33.0% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-30
E · Potential for more than minimal harm
2024-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-12
E · Potential for more than minimal harm
2024-02-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-12
F · Potential for more than minimal harm
2022-08-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-09-21
F · Potential for more than minimal harm
2022-08-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-09-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-30
C · Minimal harm
2025-04-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-30
D · Potential for more than minimal harm
2024-02-07
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-12
E · Potential for more than minimal harm
2022-08-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-25
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-16
C · Minimal harm
2022-08-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-09-16
Penalties and ownership
What sits behind the stars
Ownership
Sovereign Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
John J Notermann Business Tr
5% Or Greater Indirect Ownership Interest · Organization
Cronquist 2015 Family Tr
5% Or Greater Indirect Ownership Interest · Organization
Berkadia Commercial Mortgage LLC
5% Or Greater Security Interest · Organization
Cronquist, Royce
Corporate Director · Individual
Healthcare Financial Solutions LLC
5% Or Greater Security Interest · Organization
Jones, Daniel
W-2 Managing Employee · Individual
Melton, Donald
Corporate Officer · Individual
Melton, Donald
Contracted Managing Employee · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
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#3
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