Cycle 1
Health 2024-07-18 · Fire 2024-07-18
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
North Port, FL
North Port Rehabilitation And Nursing Center
3-star overall rating with 2-star inspections with $20,056 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
6940 Outreach Way, North Port, FL
(941) 426-8411
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
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aston Health
Operator or chain grouping
Approved since
1986-01-01
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
0.46
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.25
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,201
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.23% · Performance 22.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.76% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.42
Performance 33.33% · Measure score 7.42 · Achievement 7.42 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.04
Baseline 3.48 hours · Performance 3.37 hours · Measure score 1.04 · Achievement 1.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.32% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 10.17% · Lower 95% interval 6.96% |
| Discharge to community | 24.98% |
50.57%
25.6 pts worse
|
Worse than the National Rate · Eligible stays 115 · Observed rate 16.52% · Lower 95% interval 18.25% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 101 |
| Discharge self-care score | 52.31% |
53.69%
1.4 pts worse
|
Numerator 34 · Denominator 65 |
| Discharge mobility score | 52.31% |
50.94%
1.4 pts better
|
Numerator 34 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 2.97% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 101 · Adjusted rate 2.66% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 7.87% · Lower 95% interval 4.79% |
| Staff COVID-19 vaccination coverage | 45.77% |
8.2%
37.6 pts better
|
Numerator 65 · Denominator 142 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 40 · Denominator 65 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 48 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 2% |
25.2%
23.2 pts worse
|
Numerator 1 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · 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 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 18.0% |
97.8%
79.8 pts worse
|
93.4%
75.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.5% · Q3 17.2% · Q4 26.4% · 4Q avg 18.0% |
| 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 | 1.7% |
2.6%
0.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 2.2% · Q4 4.2% · 4Q avg 1.7% · 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 | 8.6% |
5.9%
2.7 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 5.4% · Q3 6.4% · Q4 11.3% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
15.7%
0.2 pts worse
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 18.4% · Q3 17.9% · Q4 13.8% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
9.8%
1.1 pts worse
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.2% · Q3 11.5% · Q4 7.5% · 4Q avg 10.9% · 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 | 9.4% |
11.7%
2.3 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 15.2% · Q3 10.1% · Q4 2.9% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
9.8%
4.2 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.6% · Q3 4.1% · Q4 5.0% · 4Q avg 5.6% · 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 | 3.1% |
12.5%
9.4 pts better
|
19.8%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.7% · Q3 3.3% · Q4 4.1% · 4Q avg 3.1% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
5.1%
4.1 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 11.8% · Q3 7.9% · Q4 3.7% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 17.9% |
94.3%
76.4 pts worse
|
81.7%
63.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 8.1% · Q3 15.2% · Q4 34.1% · 4Q avg 17.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
9.3%
0.7 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 8.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.1% · Q3 2.0% · Q4 1.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.9% |
94.7%
43.8 pts worse
|
79.7%
28.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
26.2%
10.6 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 15.5% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-31 · Fire 2023-03-31
13 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-08-26 · Fire 2021-08-26
11 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
F · Potential for more than minimal harm
2024-07-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-18
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 2024-08-09
D · Potential for more than minimal harm
2024-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-09
F · Potential for more than minimal harm
2023-03-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-31
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-31
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-18
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 2024-08-09
E · Potential for more than minimal harm
2024-07-18
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 2024-08-09
E · Potential for more than minimal harm
2024-07-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-18
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 2024-08-09
E · Potential for more than minimal harm
2024-07-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-18
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 2024-08-09
D · Potential for more than minimal harm
2024-07-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-18
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-04-16
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 2024-05-13
D · Potential for more than minimal harm
2023-11-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-11-27
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 2023-12-27
E · Potential for more than minimal harm
2023-10-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-27
E · Potential for more than minimal harm
2023-10-18
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 2023-11-18
D · Potential for more than minimal harm
2023-10-18
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-11-18
E · Potential for more than minimal harm
2023-03-31
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 2023-04-24
E · Potential for more than minimal harm
2023-03-31
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 2023-06-02
E · Potential for more than minimal harm
2023-03-31
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 2023-06-02
E · Potential for more than minimal harm
2023-03-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-31
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-03-31
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-31
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 2023-04-24
D · Potential for more than minimal harm
2023-03-31
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-31
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-31
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 2023-04-24
D · Potential for more than minimal harm
2023-03-31
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-24
E · Potential for more than minimal harm
2021-08-26
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2021-09-26
D · Potential for more than minimal harm
2021-08-26
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 2021-09-26
D · Potential for more than minimal harm
2021-08-26
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 2021-09-26
D · Potential for more than minimal harm
2021-08-26
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 2021-09-26
D · Potential for more than minimal harm
2021-08-26
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 2021-09-26
Penalties and ownership
What sits behind the stars
$14,770
2023-10-18
Fine
Fine · fine $14,770
Fine
$5,286
2023-03-31
Fine
Fine · fine $5,286
Fine
Ownership
Np Rehab Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Friedman, Leopold
5% Or Greater Indirect Ownership Interest · Individual
Gleicher, Herman
Operational/Managerial Control · Individual
Gutman, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Koch, Rachel
Operational/Managerial Control · Individual
Np Rehab Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Thacker, Tricia
Corporate Officer · Individual
Villegas, Alexis
Operational/Managerial Control · Individual
Nearby options
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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3-star overall rating with 3-star inspections with $45,920 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Douglas Jacobson State Veterans Nursing Home
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3-star overall rating with 2-star inspections with abuse icon flag with $135,938 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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