Cycle 1
Health 2024-09-06 · Fire 2024-09-06
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ocala, FL
Bridgewater Park Health & Rehabilitation Center
5-star overall rating with 4-star inspections with 6 recent health deficiencies
9280 South West 81st Ct, Ocala, FL
(765) 664-5400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
2017-11-30
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
0.45
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.68
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,288
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.44
Baseline 26.49% · Performance 20.87% · Measure score 5.44 · Achievement 1.22 · Improvement 5.44
Healthcare-associated infections
0
Baseline 6.72% · Performance 9.98% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.64
Baseline 46.71% · Performance 40.62% · Measure score 5.64 · Achievement 5.64 · Improvement 2.28
Adjusted total nurse staffing
2.27
Baseline 4.20 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 697 · Observed rate 8.03% · Lower 95% interval 7.39% |
| Discharge to community | 66.53% |
50.57%
16 pts better
|
Better than the National Rate · Eligible stays 687 · Observed rate 63.32% · Lower 95% interval 62.7% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 456 · Denominator 456 |
| Falls with major injury | 0.44% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 456 |
| Discharge self-care score | 70.99% |
53.69%
17.3 pts better
|
Numerator 93 · Denominator 131 |
| Discharge mobility score | 70.99% |
50.94%
20 pts better
|
Numerator 93 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 1.32% |
2.29%
1 pts better
|
Numerator 6 · Denominator 456 · Adjusted rate 1.38% |
| Healthcare-associated infections requiring hospitalization | 9.98% |
7.12%
2.9 pts worse
|
Worse than the National Rate · Eligible stays 428 · Observed rate 9.35% · Lower 95% interval 7.4% |
| Staff COVID-19 vaccination coverage | 0.39% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 255 |
| Staff flu vaccination coverage | 6.47% |
42%
35.5 pts worse
|
Numerator 22 · Denominator 340 |
| Discharge function score | 75.57% |
56.45%
19.1 pts better
|
Numerator 99 · Denominator 131 |
| Transfer of health information to provider | 99.23% |
95.95%
3.3 pts better
|
Numerator 388 · Denominator 391 |
| Transfer of health information to patient | 81.48% |
96.28%
14.8 pts worse
|
Numerator 22 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 19.77% |
25.2%
5.4 pts worse
|
Numerator 51 · Denominator 258 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.8%
1.8 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 2.2% |
2.6%
0.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 6.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
3.7%
3.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
5.9%
5.3 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
15.7%
8.6 pts worse
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 18.6% · Q3 31.8% · Q4 28.3% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
9.8%
2.4 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.6% · Q3 5.4% · Q4 9.8% · 4Q avg 7.4% · 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 | 7.4% |
11.7%
4.3 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 7.1% · Q4 11.1% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
9.8%
4.6 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 12.2% · Q3 2.3% · Q4 4.4% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.4%
1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 1.4% · 4Q avg 1.4% · 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 | 29.6% |
12.5%
17.1 pts worse
|
19.8%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.1% · Q2 35.1% · Q3 21.6% · Q4 19.2% · 4Q avg 29.6% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.1%
1.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.0% · Q3 6.2% · Q4 3.1% · 4Q avg 3.6% · 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 95.6% · Q2 94.2% · Q3 93.8% · Q4 94.1% · 4Q avg 94.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
9.3%
1.5 pts worse
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.3% · Q3 1.2% · Q4 1.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
94.7%
2.1 pts worse
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
26.2%
1.9 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 22.2% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-04 · Fire 2023-05-04
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-12-10 · Fire 2021-12-10
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-05-04
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 2023-06-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-09-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-06
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 2024-09-27
D · Potential for more than minimal harm
2024-09-06
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 2024-09-27
D · Potential for more than minimal harm
2024-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
E · Potential for more than minimal harm
2023-05-04
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 2023-06-08
D · Potential for more than minimal harm
2023-05-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-08
C · Minimal harm
2023-05-04
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-06-08
J · Immediate jeopardy
2021-12-10
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 2022-01-17
J · Immediate jeopardy
2021-12-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-01-17
F · Potential for more than minimal harm
2021-12-10
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 2022-01-17
E · Potential for more than minimal harm
2021-12-10
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 2022-01-17
E · Potential for more than minimal harm
2021-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-12-10
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 2022-01-17
D · Potential for more than minimal harm
2021-12-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-17
Penalties and ownership
What sits behind the stars
Ownership
Ott, Gary
5% Or Greater Direct Ownership Interest · Individual
Ott, Ryan
5% Or Greater Direct Ownership Interest · Individual
Ott, Dwight
5% Or Greater Direct Ownership Interest · Individual
Gibson, Cullen
5% Or Greater Direct Ownership Interest · Individual
Clevinger, Sidney
Operational/Managerial Control · Individual
Gibson, Cullen
Corporate Officer · Individual
Ott, Dwight
Corporate Officer · Individual
Ott, Gary
Corporate Officer · Individual
Ott, Ryan
Corporate Officer · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Wanczyk, Joseph
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Timberridge Nursing & Rehabilitation Center
Ocala, FL
3-star overall rating with 2-star inspections with $119,636 in total fines with 5 recent health deficiencies
#2
Hawthorne Center For Rehabilitation And Healing Of
Ocala, FL
2-star overall rating with 1-star inspections with $157,729 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Ocala
Ocala, FL
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out