Cycle 1
Health 2025-07-31 · Fire 2025-07-31
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wesley Chapel, FL
Blue Heron Health And Rehabilitation
4-star overall rating with 3-star inspections with $10,709 in total fines with 3 recent health deficiencies
5085 Eagleston Blvd, Wesley Chapel, FL
(765) 664-5400
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
141
Certified beds
Average residents
131
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
2021-07-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
0.85
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.64
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
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,709
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.32% · Performance 23.34% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.67
Baseline 5.16% · Performance 7.63% · Measure score 0.67 · Achievement 0.67 · Improvement 0
Total nurse turnover
5.89
Performance 39.60% · Measure score 5.89 · Achievement 5.89 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.54
Baseline 4.79 hours · Performance 3.80 hours · Measure score 2.54 · Achievement 2.54 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.37% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 662 · Observed rate 10.27% · Lower 95% interval 8.32% |
| Discharge to community | 64.53% |
50.57%
14 pts better
|
Better than the National Rate · Eligible stays 647 · Observed rate 61.36% · Lower 95% interval 59.78% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 590 · Denominator 590 |
| Falls with major injury | 0.85% |
0.77%
0.1 pts worse
|
Numerator 5 · Denominator 590 |
| Discharge self-care score | 61.05% |
53.69%
7.4 pts better
|
Numerator 174 · Denominator 285 |
| Discharge mobility score | 47.37% |
50.94%
3.6 pts worse
|
Numerator 135 · Denominator 285 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 4 · Denominator 590 · Adjusted rate 0.75% |
| Healthcare-associated infections requiring hospitalization | 7.63% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 411 · Observed rate 8.03% · Lower 95% interval 5.83% |
| Staff COVID-19 vaccination coverage | 0.36% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 274 |
| Staff flu vaccination coverage | 7.33% |
42%
34.7 pts worse
|
Numerator 20 · Denominator 273 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 171 · Denominator 285 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 380 · Denominator 380 |
| Transfer of health information to patient | 99.23% |
96.28%
3 pts better
|
Numerator 129 · Denominator 130 |
| Resident COVID-19 vaccinations up to date | 9.79% |
25.2%
15.4 pts worse
|
Numerator 32 · Denominator 327 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.7 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
97.8%
2.1 pts worse
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 95.8% · Q3 94.7% · Q4 94.5% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
99.2%
3.1 pts worse
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
2.6%
3.8 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.9% · Q3 9.3% · Q4 5.5% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
3.7%
2.4 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.3% · Q3 7.2% · Q4 3.4% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
5.9%
5.5 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
15.7%
7.7 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 23.9% · Q3 20.9% · Q4 21.3% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.5% |
9.8%
8.3 pts better
|
16.7%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 2.2% · 4Q avg 1.5% · 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 | 13.2% |
11.7%
1.5 pts worse
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 23.3% · Q3 6.9% · Q4 8.1% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
9.8%
2.7 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 13.4% · Q3 4.8% · Q4 5.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · 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 | 28.5% |
12.5%
16 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 29.7% · Q3 19.1% · Q4 29.5% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.1%
1.3 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.0% · Q3 3.2% · Q4 3.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
94.3%
0.1 pts better
|
81.7%
12.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 92.0% · Q3 95.9% · Q4 97.3% · 4Q avg 94.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.3%
0.5 pts worse
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.9% · Q3 2.2% · Q4 0.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
94.7%
6.6 pts worse
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.6% |
26.2%
4.4 pts worse
|
23.9%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 29.4% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-27 · Fire 2023-04-27
13 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-07-12 · Fire 2021-07-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-04-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-31
F · Potential for more than minimal harm
2023-04-27
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 2023-05-26
F · Potential for more than minimal harm
2023-04-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-04-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-04-27
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 2023-05-26
E · Potential for more than minimal harm
2023-04-27
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-04-27
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-03-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-02
Penalties and ownership
What sits behind the stars
$10,709
2023-04-27
Fine
Fine · fine $10,709
Fine
Ownership
Ott, Gary
5% Or Greater Direct Ownership Interest · Individual
Ott Family Trust
5% Or Greater Direct Ownership Interest · Organization
Ott, Ryan
5% Or Greater Direct Ownership Interest · Individual
Ott, Dwight
5% Or Greater Direct Ownership Interest · Individual
Ott, Dwight
Corporate Officer · Individual
Ott, Gary
Corporate Officer · Individual
Ott, Ryan
Corporate Officer · Individual
Smith, Kimberly
Corporate Director · Individual
Smith, Kimberly
W-2 Managing Employee · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
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#3
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