Cycle 1
Health 2023-12-07 · Fire 2023-12-07
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dunedin, FL
Meadowpark Health And Rehabilitation Center
3-star overall rating with 2-star inspections with $72,858 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
870 Patricia Ave, Dunedin, FL
(727) 734-8861
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
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-06-01
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
0.81
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.49
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
3.41
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.59
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
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,646
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.79
Baseline 21.14% · Performance 19.67% · Measure score 3.79 · Achievement 3.79 · Improvement 3.07
Healthcare-associated infections
5.40
Baseline 6.89% · Performance 6.22% · Measure score 5.40 · Achievement 5.40 · Improvement 3.03
Total nurse turnover
2.84
Baseline 56.03% · Performance 52.08% · Measure score 2.84 · Achievement 2.84 · Improvement 0.77
Adjusted total nurse staffing
2.15
Baseline 4.17 hours · Performance 3.69 hours · Measure score 2.15 · Achievement 2.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 212 · Observed rate 8.96% · Lower 95% interval 6.87% |
| Discharge to community | 56.17% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 185 · Observed rate 50.81% · Lower 95% interval 49.72% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 125 · Denominator 130 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 1 · Denominator 130 |
| Discharge self-care score | 53.4% |
53.69%
0.3 pts worse
|
Numerator 55 · Denominator 103 |
| Discharge mobility score | 49.51% |
50.94%
1.4 pts worse
|
Numerator 51 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 6.15% |
2.29%
3.9 pts worse
|
Numerator 8 · Denominator 130 · Adjusted rate 5.72% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 4.41% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 76.47% |
8.2%
68.3 pts better
|
Numerator 130 · Denominator 170 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 165 |
| Discharge function score | 53.4% |
56.45%
3.1 pts worse
|
Numerator 55 · Denominator 103 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 98.04% |
96.28%
1.8 pts better
|
Numerator 50 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 2.86% |
25.2%
22.3 pts worse
|
Numerator 2 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.8 · Expected 2.8 · 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 1.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
97.8%
1 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 96.8% |
| 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 | 2.0% |
2.6%
0.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.4% · Q3 1.1% · Q4 2.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
3.7%
3.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.9%
1.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.6% · Q3 8.4% · Q4 5.1% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
15.7%
9.6 pts worse
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 23.5% · Q3 28.6% · Q4 21.0% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
9.8%
1 pts worse
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 13.0% · Q3 7.5% · Q4 12.5% · 4Q avg 10.8% · 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 | 26.6% |
11.7%
14.9 pts worse
|
16.3%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.6% · Q2 24.6% · Q3 14.1% · Q4 25.9% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.3% |
9.8%
5.5 pts worse
|
14.9%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 14.3% · Q3 10.0% · Q4 9.2% · 4Q avg 15.3% · 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 | 19.3% |
12.5%
6.8 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 15.7% · Q3 14.4% · Q4 19.7% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.1%
2.4 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 7.6% · Q3 6.5% · Q4 7.1% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
94.3%
4.2 pts worse
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.0% · Q2 91.9% · Q3 97.4% · Q4 94.1% · 4Q avg 90.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.3%
3.3 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 6.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.4% |
94.7%
6.3 pts worse
|
79.7%
8.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
26.2%
5.2 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 21.5% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-16 · Fire 2021-09-16
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-01-10 · Fire 2020-01-10
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-07
D · Potential for more than minimal harm
2021-09-16
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-09-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-10-16
D · Potential for more than minimal harm
2020-01-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-02-10
D · Potential for more than minimal harm
2020-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-21
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 2024-12-21
D · Potential for more than minimal harm
2024-11-21
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 2024-12-21
D · Potential for more than minimal harm
2024-11-21
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 2024-12-21
D · Potential for more than minimal harm
2024-11-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-21
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 2024-12-21
E · Potential for more than minimal harm
2023-12-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-07
E · Potential for more than minimal harm
2023-12-07
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 2024-01-07
E · Potential for more than minimal harm
2023-12-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-07
E · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-09-06
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 2023-10-06
J · Immediate jeopardy
2023-04-20
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 2023-04-21
J · Immediate jeopardy
2023-04-20
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 2023-04-21
E · Potential for more than minimal harm
2021-09-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-10-16
D · Potential for more than minimal harm
2021-09-16
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 2021-10-16
D · Potential for more than minimal harm
2021-09-16
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 2021-10-16
D · Potential for more than minimal harm
2021-09-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-10-16
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 2020-02-10
Penalties and ownership
What sits behind the stars
$72,858
2023-04-20
Fine
Fine · fine $72,858
Fine
Ownership
Meadowpark Rehab Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bp Meadowpark Trust
5% Or Greater Indirect Ownership Interest · Organization
Lf Meadowpark Trust
5% Or Greater Indirect Ownership Interest · Organization
Jackson, Marcia
Operational/Managerial Control · Individual
Knight, Sheila
Operational/Managerial Control · Individual
Lokmic, Ramoneth
Operational/Managerial Control · Individual
Palanca, Eduardo
Operational/Managerial Control · Individual
Wildes, Donna
Operational/Managerial Control · Individual
Wildes, Donna
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Cedar At Mease Life
Dunedin, FL
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#2
Aviata At Lakeside Oaks
Dunedin, FL
2-star overall rating with 2-star inspections with $13,520 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lake Haven Nursing And Rehab Center
Dunedin, FL
1-star overall rating with 1-star inspections with $281,689 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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