Zephyrhills, FL

Hillside Health And Rehabilitation Center

3-star overall rating with 2-star inspections with $3,728 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

38220 Henry Dr, Zephyrhills, FL

(813) 788-7114

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

103

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1988-02-04

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.44

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.94

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.11

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.38

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.13

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.43

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.50

CMS adjusted total nurse staffing hours

Case-mix index

1.37

Higher values indicate more complex resident acuity

RN turnover

65%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

60%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,152

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

Performance score

7.90

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.40% · Performance 23.96% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 8.17% · Performance 9.39% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

1.83

Baseline 66.97% · Performance 57.14% · Measure score 1.83 · Achievement 1.60 · Improvement 1.83

Adjusted total nurse staffing

1.33

Baseline 3.61 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.65%	10.72% 1.9 pts worse	No Different than the National Rate · Eligible stays 125 · Observed rate 18.4% · Lower 95% interval 8.65%
Discharge to community	46.53%	50.57% 4 pts worse	No Different than the National Rate · Eligible stays 129 · Observed rate 39.53% · Lower 95% interval 38.95%
Medicare spending per beneficiary	1.16	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 124 · Denominator 124
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 124
Discharge self-care score	46.38%	53.69% 7.3 pts worse	Numerator 32 · Denominator 69
Discharge mobility score	55.07%	50.94% 4.1 pts better	Numerator 38 · Denominator 69
Pressure ulcers or injuries, new or worsened	1.61%	2.29% 0.7 pts better	Numerator 2 · Denominator 124 · Adjusted rate 1.34%
Healthcare-associated infections requiring hospitalization	9.39%	7.12% 2.3 pts worse	No Different than the National Rate · Eligible stays 91 · Observed rate 14.29% · Lower 95% interval 6.19%
Staff COVID-19 vaccination coverage	69.7%	8.2% 61.5 pts better	Numerator 115 · Denominator 165
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	57.97%	56.45% 1.5 pts better	Numerator 40 · Denominator 69
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 47 · Denominator 47
Transfer of health information to patient	93.88%	96.28% 2.4 pts worse	Numerator 46 · Denominator 49
Resident COVID-19 vaccinations up to date	46.88%	25.2% 21.7 pts better	Numerator 30 · Denominator 64

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 2.1 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.2 0.2 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · 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	0.3%	2.6% 2.3 pts better	3.3% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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	7.4%	5.9% 1.5 pts worse	5.4% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.2% · Q3 7.4% · Q4 12.5% · 4Q avg 7.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.0%	15.7% 0.3 pts worse	19.6% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 15.6% · Q3 13.0% · Q4 9.1% · 4Q avg 16.0%
Percentage of long-stay residents who received an antipsychotic medication	10.0%	9.8% 0.2 pts worse	16.7% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 8.2% · Q3 7.4% · Q4 7.1% · 4Q avg 10.0% · 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	15.4%	11.7% 3.7 pts worse	16.3% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 20.8% · Q3 8.0% · Q4 17.5% · 4Q avg 15.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.6%	9.8% 3.2 pts better	14.9% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 9.5% · Q3 1.5% · Q4 7.7% · 4Q avg 6.6% · 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	25.3%	12.5% 12.8 pts worse	19.8% 5.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 25.5% · Q3 24.4% · Q4 23.1% · 4Q avg 25.3%
Percentage of long-stay residents with pressure ulcers	8.2%	5.1% 3.1 pts worse	5.1% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.6% · Q3 4.8% · Q4 7.6% · 4Q avg 8.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	94.3% 5.3 pts better	81.7% 17.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 99.6% · Q4 99.6% · 4Q avg 99.6%
Percentage of short-stay residents who had an outpatient emergency department visit	6.8%	9.3% 2.5 pts better	12.0% 5.2 pts better	Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 7.6% · Expected 12.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.3%	1.5% 0.2 pts better	1.6% 0.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 2.4% · Q4 1.9% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.1%	94.7% 1.4 pts better	79.7% 16.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.2%	26.2% 5 pts worse	23.9% 7.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.2% · Observed 33.7% · Expected 25.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-21 · Fire 2025-08-21

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2023-08-16 · Fire 2023-08-16

7 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2021-08-25 · Fire 2021-08-25

15 health deficiencies

Top issue: Quality of Life and Care (6 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 2025-08-21

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-09-28

D · Potential for more than minimal harm 2023-08-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-11-10

D · Potential for more than minimal harm 2023-08-16

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-09-16

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-08-21

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 2025-09-21

E · Potential for more than minimal harm 2025-08-21

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-09-21

E · Potential for more than minimal harm 2025-08-21

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-09-21

E · Potential for more than minimal harm 2025-08-21

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-09-21

E · Potential for more than minimal harm 2025-08-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-21

D · Potential for more than minimal harm 2025-08-21

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 2025-09-21

D · Potential for more than minimal harm 2025-08-21

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 2025-09-21

D · Potential for more than minimal harm 2025-08-21

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-09-21

D · Potential for more than minimal harm 2025-08-21

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 2025-09-21

D · Potential for more than minimal harm 2025-01-23

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 2025-02-23

D · Potential for more than minimal harm 2025-01-23

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-23

E · Potential for more than minimal harm 2023-08-16

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-08-16

F554 · Resident Rights Deficiencies

Health

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

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-16

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-08-16

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 2023-09-11

D · Potential for more than minimal harm 2023-08-16

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-09-11

E · Potential for more than minimal harm 2023-05-03

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2023-05-31

D · Potential for more than minimal harm 2023-05-03

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 2023-05-31

D · Potential for more than minimal harm 2023-05-03

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-05-31

E · Potential for more than minimal harm 2021-08-25

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2021-11-27

E · Potential for more than minimal harm 2021-08-25

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 2021-11-27

E · Potential for more than minimal harm 2021-08-25

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 2021-09-24

E · Potential for more than minimal harm 2021-08-25

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 2021-09-24