Cycle 1
Health 2024-01-25 · Fire 2024-01-25
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Land O Lakes, FL
Baldomero Lopez Memorial Veterans Nursing Home
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
6919 Parkway Blvd, Land O Lakes, FL
(813) 558-5000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Florida Department Of Veterans' Affairs
Operator or chain grouping
Approved since
1999-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 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
0.89
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.82
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.37
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
644
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0201
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.21
Baseline 64.46% · Performance 50.55% · Measure score 3.21 · Achievement 3.21 · Improvement 3.01
Adjusted total nurse staffing
10
Baseline 5.23 hours · Performance 5.86 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 172 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · 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 | 3.7% |
2.6%
1.1 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.6% · Q3 3.4% · Q4 4.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
3.7%
2.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 2.1% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.9%
2.6 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.2% · Q3 6.1% · Q4 15.0% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
15.7%
8.1 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 8.2% · Q3 6.9% · Q4 6.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
9.8%
13.6 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 26.2% · Q3 21.0% · Q4 20.7% · 4Q avg 23.4% · 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 | 20.5% |
11.7%
8.8 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 24.9% · Q3 18.7% · Q4 19.5% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
9.8%
12.7 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 18.5% · Q3 22.1% · Q4 26.7% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
0.8%
4.5 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.4% · Q3 4.4% · Q4 7.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
12.5%
6.7 pts worse
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 31.1% · Q3 11.0% · Q4 16.2% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.1%
1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.1% · Q3 3.7% · Q4 3.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
94.3%
3.9 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 98.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-14 · Fire 2022-01-14
2 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-10-09 · Fire 2020-10-09
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-01-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-25
D · Potential for more than minimal harm
2020-10-09
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2020-11-08
D · Potential for more than minimal harm
2020-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-11-08
D · Potential for more than minimal harm
2020-10-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-11-08
D · Potential for more than minimal harm
2020-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-11-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-01-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-02-14
D · Potential for more than minimal harm
2022-01-14
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-02-14
D · Potential for more than minimal harm
2020-10-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-11-08
D · Potential for more than minimal harm
2020-10-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-11-08
D · Potential for more than minimal harm
2020-10-09
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2020-11-08
Penalties and ownership
What sits behind the stars
Ownership
Florida Department Of Veterans Affairs
5% Or Greater Direct Ownership Interest · Organization
Carter, Alfred
Corporate Director · Individual
Firebaugh, Joshua
Operational/Managerial Control · Individual
Sarrett, Marlies
Operational/Managerial Control · Individual
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