Cycle 1
Health 2023-11-09 · Fire 2023-11-09
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Arcadia, FL
Desoto Health And Rehab
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
475 Nursing Home Dr, Arcadia, FL
(863) 494-5766
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
78
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-06-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.48
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,909
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.10
Composite VBP score used to determine payment impact.
Payment multiplier
1.0078
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.28
Baseline 20.86% · Performance 18.98% · Measure score 5.28 · Achievement 5.28 · Improvement 4.40
Healthcare-associated infections
8.27
Baseline 6.06% · Performance 5.36% · Measure score 8.27 · Achievement 8.27 · Improvement 6.05
Total nurse turnover
4.71
Performance 44.44% · Measure score 4.71 · Achievement 4.71 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.98
Baseline 4 hours · Performance 3.93 hours · Measure score 2.98 · Achievement 2.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.14% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 6.32% · Lower 95% interval 6.27% |
| Discharge to community | 58.34% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 52.94% · Lower 95% interval 48.84% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 77 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 28 · Denominator 48 |
| Discharge mobility score | 35.42% |
50.94%
15.5 pts worse
|
Numerator 17 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 11.69% |
2.29%
9.4 pts worse
|
Numerator 9 · Denominator 77 · Adjusted rate 7.82% |
| Healthcare-associated infections requiring hospitalization | 5.36% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 1.39% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 6.31% |
8.2%
1.9 pts worse
|
Numerator 7 · Denominator 111 |
| Staff flu vaccination coverage | 25.66% |
42%
16.3 pts worse
|
Numerator 29 · Denominator 113 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 24 · Denominator 48 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.06% |
96.28%
0.8 pts better
|
Numerator 33 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 26.32% |
25.2%
1.1 pts better
|
Numerator 10 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
1.2
2.6 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.6 · Expected 1.6 · 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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.8% |
3.7%
1.9 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 2.3% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.9%
2.8 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 4.4% · Q4 2.3% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.2% |
15.7%
12.5 pts worse
|
19.6%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 28.6% · Q3 25.5% · Q4 25.0% · 4Q avg 28.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.3% |
9.8%
3.5 pts better
|
16.7%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.6% · Q3 5.6% · Q4 2.7% · 4Q avg 6.3% · 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 | 19.7% |
11.7%
8 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
9.8%
3.3 pts worse
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 20.5% · Q3 15.9% · Q4 9.8% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.4%
1.4 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 1.1% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
0.8%
1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 2.2% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.2% |
12.5%
1.7 pts worse
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 9.4% · Q3 20.1% · Q4 15.5% · 4Q avg 14.2% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.1%
0.1 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 9.3% · Q3 3.4% · Q4 1.8% · 4Q avg 5.0% · 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 98.0% · Q2 90.7% · Q3 96.0% · Q4 93.2% · 4Q avg 94.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
9.3%
1.7 pts worse
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 10.1% · Expected 10.3% · 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 3.2% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.7%
3.4 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
26.2%
0.2 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 24.1% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-27 · Fire 2022-01-27
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-01-10 · Fire 2020-01-10
17 health deficiencies
Top issue: Administration (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-09
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-11-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-11-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-06
D · Potential for more than minimal harm
2022-01-27
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-02-27
F · Potential for more than minimal harm
2020-01-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-28
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 2025-05-28
F · Potential for more than minimal harm
2023-11-09
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 2023-12-07
D · Potential for more than minimal harm
2023-11-09
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 2023-12-06
D · Potential for more than minimal harm
2022-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-27
K · Immediate jeopardy
2020-01-10
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 2020-02-21
K · Immediate jeopardy
2020-01-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-02-21
F · Potential for more than minimal harm
2020-01-10
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 2020-02-21
F · Potential for more than minimal harm
2020-01-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-02-21
F · Potential for more than minimal harm
2020-01-10
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2020-02-21
F · Potential for more than minimal harm
2020-01-10
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2020-02-21
F · Potential for more than minimal harm
2020-01-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-02-21
E · Potential for more than minimal harm
2020-01-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-02-21
E · Potential for more than minimal harm
2020-01-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2020-02-21
E · Potential for more than minimal harm
2020-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-10
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 2020-02-21
D · Potential for more than minimal harm
2020-01-10
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 2020-02-21
D · Potential for more than minimal harm
2020-01-10
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 2020-02-21
D · Potential for more than minimal harm
2020-01-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-10
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 2020-02-21
Penalties and ownership
What sits behind the stars
Ownership
Badenhorst, Heloise
5% Or Greater Direct Ownership Interest · Individual
Badenhorst, Heloise
W-2 Managing Employee · Individual
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