Tampa, FL

Blue Palms Health And Rehabilitation Center At Fle

3-star overall rating with 2-star inspections with $16,801 in total fines with 12 recent health deficiencies

4100 E Fletcher Ave, Tampa, FL

(813) 632-2455

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 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

163

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Concordia Lutheran Ministries

Operator or chain grouping

Approved since

1979-05-17

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

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

0.59

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.93

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.18

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.71

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.52

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.31

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.35

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.60

CMS adjusted RN staffing hours

Adjusted total hours

3.77

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

73%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

37%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,080

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

41.37

Composite VBP score used to determine payment impact.

Payment multiplier

0.9943

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.48

Baseline 21.14% · Performance 19.35% · Measure score 4.48 · Achievement 4.48 · Improvement 3.85

Healthcare-associated infections

6.50

Baseline 6.36% · Performance 5.89% · Measure score 6.50 · Achievement 6.50 · Improvement 2.92

Total nurse turnover

3.84

Baseline 60.14% · Performance 48.00% · Measure score 3.84 · Achievement 3.84 · Improvement 2.94

Adjusted total nurse staffing

1.73

Baseline 4.02 hours · Performance 3.57 hours · Measure score 1.73 · Achievement 1.73 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.62%	10.72% 2.9 pts worse	No Different than the National Rate · Eligible stays 206 · Observed rate 17.48% · Lower 95% interval 10.57%
Discharge to community	60.21%	50.57% 9.6 pts better	Better than the National Rate · Eligible stays 195 · Observed rate 51.79% · Lower 95% interval 53.06%
Medicare spending per beneficiary	0.9	1.02 0.1 pts better
Drug regimen review with follow-up	63.72%	95.27% 31.5 pts worse	Numerator 72 · Denominator 113
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 113
Discharge self-care score	68.18%	53.69% 14.5 pts better	Numerator 60 · Denominator 88
Discharge mobility score	70.45%	50.94% 19.5 pts better	Numerator 62 · Denominator 88
Pressure ulcers or injuries, new or worsened	0.88%	2.29% 1.4 pts better	Numerator 1 · Denominator 113 · Adjusted rate 0.67%
Healthcare-associated infections requiring hospitalization	5.89%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 110 · Observed rate 4.55% · Lower 95% interval 3.72%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 123
Staff flu vaccination coverage	9.15%	42% 32.9 pts worse	Numerator 15 · Denominator 164
Discharge function score	68.18%	56.45% 11.7 pts better	Numerator 60 · Denominator 88
Transfer of health information to provider	97.06%	95.95% 1.1 pts better	Numerator 33 · Denominator 34
Transfer of health information to patient	98.18%	96.28% 1.9 pts better	Numerator 54 · Denominator 55
Resident COVID-19 vaccinations up to date	24%	25.2% 1.2 pts worse	Numerator 12 · Denominator 50

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.0	2.1 0.1 pts better	1.9 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.8 · Expected 2.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.2 0.4 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · 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	2.3%	2.6% 0.3 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.5% · Q3 2.0% · Q4 2.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.5%	3.7% 1.2 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 6.7% · Q4 0.0% · 4Q avg 2.5%
Percentage of long-stay residents who lose too much weight	10.4%	5.9% 4.5 pts worse	5.4% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 14.3% · Q3 13.6% · Q4 4.3% · 4Q avg 10.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.7%	15.7% 4 pts better	19.6% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.9% · Q3 14.9% · Q4 6.0% · 4Q avg 11.7%
Percentage of long-stay residents who received an antipsychotic medication	4.8%	9.8% 5 pts better	16.7% 11.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 6.2% · Q4 5.1% · 4Q avg 4.8% · 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	29.9%	11.7% 18.2 pts worse	16.3% 13.6 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 29.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.4%	9.8% 9.6 pts worse	14.9% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 16.0% · Q3 10.5% · Q4 24.4% · 4Q avg 19.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.4% 0.5 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 1.3% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	0.8% 0.4 pts worse	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.1% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	9.3%	12.5% 3.2 pts better	19.8% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 3.1% · Q3 6.9% · Q4 16.4% · 4Q avg 9.3%
Percentage of long-stay residents with pressure ulcers	2.8%	5.1% 2.3 pts better	5.1% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.4% · Q4 5.0% · 4Q avg 2.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.0%	94.3% 1.3 pts worse	81.7% 11.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 90.4% · Q3 99.5% · Q4 100.0% · 4Q avg 93.0%
Percentage of short-stay residents who had an outpatient emergency department visit	3.4%	9.3% 5.9 pts better	12.0% 8.6 pts better	Short Stay · 20240701-20250630 · Adjusted 3.4% · Observed 3.3% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.5% 0.7 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 2.9% · Q4 4.4% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.5%	94.7% 1.8 pts better	79.7% 16.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	35.8%	26.2% 9.6 pts worse	23.9% 11.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 35.8% · Observed 35.2% · Expected 23.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-04-10 · Fire 2024-04-10

12 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2021-11-05 · Fire 2021-11-05

8 health deficiencies

Top issue: Environmental (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2020-02-20 · Fire 2020-02-20

16 health deficiencies

Top issue: Pharmacy Service (5 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2020-02-20

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2020-03-21

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-06-19

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-07-12

G · Actual harm 2024-04-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-05-10

E · Potential for more than minimal harm 2024-04-10

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-05-10

E · Potential for more than minimal harm 2024-04-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F584 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

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 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

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 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-10

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-05-10

E · Potential for more than minimal harm 2021-11-05

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 2021-12-05

E · Potential for more than minimal harm 2021-11-05

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2021-12-05

D · Potential for more than minimal harm 2021-11-05

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2021-12-05

D · Potential for more than minimal harm 2021-11-05

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2021-12-05

D · Potential for more than minimal harm 2021-11-05

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2021-12-05

D · Potential for more than minimal harm 2021-11-05

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2021-12-05

F · Potential for more than minimal harm 2020-02-20

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 2020-03-21

E · Potential for more than minimal harm 2020-02-20

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 2020-03-21

E · Potential for more than minimal harm 2020-02-20

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2020-03-21

E · Potential for more than minimal harm 2020-02-20

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 2020-03-21

E · Potential for more than minimal harm 2020-02-20

F761 · Pharmacy Service Deficiencies

Health

Corrected 2020-03-21

E · Potential for more than minimal harm 2020-02-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-02-20

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-02-20

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-02-20

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-02-20

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 2020-03-21

D · Potential for more than minimal harm 2020-02-20

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-02-20

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 2020-03-21

D · Potential for more than minimal harm 2020-02-20

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 2020-03-21

D · Potential for more than minimal harm 2020-02-20

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-02-20

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-02-20

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 2020-03-21

Penalties and ownership