Cycle 1
Health 2024-09-11 · Fire 2024-09-11
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tampa, FL
Fairway Oaks Center
1-star overall rating with 2-star inspections with 15 recent health deficiencies
13806 N 46th St, Tampa, FL
(813) 977-4214
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aston Health
Operator or chain grouping
Approved since
1977-07-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.60
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.07
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
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
74%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,841
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.74% · Performance 22.72% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.68
Baseline 6.82% · Performance 7.33% · Measure score 1.68 · Achievement 1.68 · Improvement 0
Total nurse turnover
3.12
Baseline 60.19% · Performance 50.93% · Measure score 3.12 · Achievement 3.12 · Improvement 2.12
Adjusted total nurse staffing
1.21
Baseline 3.62 hours · Performance 3.42 hours · Measure score 1.21 · Achievement 1.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.12% |
10.72%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 143 · Observed rate 20.28% · Lower 95% interval 10.41% |
| Discharge to community | 40.57% |
50.57%
10 pts worse
|
Worse than the National Rate · Eligible stays 111 · Observed rate 30.63% · Lower 95% interval 31.2% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 184 · Denominator 184 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 184 |
| Discharge self-care score | 29.67% |
53.69%
24 pts worse
|
Numerator 27 · Denominator 91 |
| Discharge mobility score | 23.08% |
50.94%
27.9 pts worse
|
Numerator 21 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 4.89% |
2.29%
2.6 pts worse
|
Numerator 9 · Denominator 184 · Adjusted rate 4.36% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 9.52% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 109 · Denominator 109 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 31.87% |
56.45%
24.6 pts worse
|
Numerator 29 · Denominator 91 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 71 · Denominator 71 |
| Transfer of health information to patient | 90.63% |
96.28%
5.7 pts worse
|
Numerator 58 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 17.46% |
25.2%
7.7 pts worse
|
Numerator 22 · Denominator 126 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.9 · 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 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.8%
1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 97.6% · Q4 98.9% · 4Q avg 98.8% |
| 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 | 2.4% |
2.6%
0.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.3% · Q3 2.4% · Q4 1.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 8.4% |
5.9%
2.5 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 17.9% · Q4 13.9% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
15.7%
6.9 pts worse
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 24.7% · Q3 21.2% · Q4 15.0% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
9.8%
11.4 pts worse
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 20.3% · Q3 23.8% · Q4 16.1% · 4Q avg 21.2% · 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 | 16.5% |
11.7%
4.8 pts worse
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
9.8%
0.6 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 2.8% · Q3 11.1% · Q4 4.3% · 4Q avg 9.2% · 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 | 19.0% |
12.5%
6.5 pts worse
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 26.3% · Q3 12.1% · Q4 22.1% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.1%
0.9 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.0% · Q3 7.8% · Q4 8.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
94.3%
1 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 93.4% · Q3 94.8% · Q4 98.4% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
9.3%
0.1 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 10.6% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.4% |
94.7%
2.7 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| 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 36.4% · Expected 28.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-01 · Fire 2022-09-01
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-04-15 · Fire 2021-04-15
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
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
2022-09-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-09-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-20
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 2025-12-20
D · Potential for more than minimal harm
2025-11-20
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 2025-12-20
D · Potential for more than minimal harm
2025-11-20
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 2025-12-20
E · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2022-09-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-09-01
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 2022-09-30
D · Potential for more than minimal harm
2022-09-01
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 2022-09-30
D · Potential for more than minimal harm
2022-09-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-09-01
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 2022-09-30
D · Potential for more than minimal harm
2022-09-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-09-01
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-09-30
D · Potential for more than minimal harm
2021-04-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-05-15
D · Potential for more than minimal harm
2021-04-15
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 2021-05-15
D · Potential for more than minimal harm
2021-04-15
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 2021-05-15
D · Potential for more than minimal harm
2021-04-15
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2021-05-15
D · Potential for more than minimal harm
2021-04-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-05-15
Penalties and ownership
What sits behind the stars
Ownership
Agbaneje Sterlin, Emmanuel
Operational/Managerial Control · Individual
Harris, Tomika
Operational/Managerial Control · Individual
Legendary, Zechariah
Operational/Managerial Control · Individual
Thacker, Tricia
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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#2
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3-star overall rating with 2-star inspections with 9 recent health deficiencies
#3
Excel Care Center
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4-star overall rating with 3-star inspections with 6 recent health deficiencies
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