Cycle 1
Health 2023-08-02 · Fire 2023-08-02
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Palm Harbor, FL
Oakpark Health And Rehabilitation Center
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2851 Tampa Rd, Palm Harbor, FL
(727) 787-4777
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
180
Certified beds
Average residents
174
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-12-01
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
0.59
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.22
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
0.44
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.24
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,417
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.31% · Performance 22.59% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.66
Baseline 5.66% · Performance 7.34% · Measure score 1.66 · Achievement 1.66 · Improvement 0
Total nurse turnover
4.41
Baseline 52.10% · Performance 45.64% · Measure score 4.41 · Achievement 4.41 · Improvement 1.87
Adjusted total nurse staffing
0.65
Baseline 3.59 hours · Performance 3.26 hours · Measure score 0.65 · Achievement 0.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.43% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 378 · Observed rate 13.76% · Lower 95% interval 10.32% |
| Discharge to community | 50% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 348 · Observed rate 43.1% · Lower 95% interval 44.35% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.36% |
95.27%
3.1 pts better
|
Numerator 360 · Denominator 366 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 366 |
| Discharge self-care score | 39.92% |
53.69%
13.8 pts worse
|
Numerator 97 · Denominator 243 |
| Discharge mobility score | 40.74% |
50.94%
10.2 pts worse
|
Numerator 99 · Denominator 243 |
| Pressure ulcers or injuries, new or worsened | 1.37% |
2.29%
0.9 pts better
|
Numerator 5 · Denominator 366 · Adjusted rate 1.11% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 206 · Observed rate 7.77% · Lower 95% interval 4.68% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 9.6% |
42%
32.4 pts worse
|
Numerator 31 · Denominator 323 |
| Discharge function score | 49.79% |
56.45%
6.7 pts worse
|
Numerator 121 · Denominator 243 |
| Transfer of health information to provider | 99.03% |
95.95%
3.1 pts better
|
Numerator 102 · Denominator 103 |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 160 · Denominator 164 |
| Resident COVID-19 vaccinations up to date | 1.42% |
25.2%
23.8 pts worse
|
Numerator 3 · Denominator 211 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.9 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 2.0 · 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 | 1.5% |
2.6%
1.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 2.3% · Q4 1.5% · 4Q avg 1.5% · 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 | 12.2% |
5.9%
6.3 pts worse
|
5.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 15.2% · Q3 12.8% · Q4 10.7% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
15.7%
3.9 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 7.1% · Q3 12.2% · Q4 14.3% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
9.8%
4.6 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 3.6% · Q3 3.8% · Q4 4.5% · 4Q avg 5.2% · 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 | 14.9% |
11.7%
3.2 pts worse
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 7.3% · Q3 11.2% · Q4 19.8% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
9.8%
4.3 pts worse
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 9.9% · Q3 17.7% · Q4 17.1% · 4Q avg 14.1% · 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 | 21.1% |
12.5%
8.6 pts worse
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 23.3% · Q3 22.5% · Q4 14.3% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
5.1%
2.1 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.9% · Q3 5.9% · Q4 6.1% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.3%
5.4 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
9.3%
1.8 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.8% · Expected 11.7% · 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 0.8% · Q2 2.0% · Q3 2.2% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
94.7%
0.4 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.7% |
26.2%
4.5 pts worse
|
23.9%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 31.4% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-13 · Fire 2021-08-13
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-11-22 · Fire 2019-11-22
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-02
D · Potential for more than minimal harm
2023-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-02
D · Potential for more than minimal harm
2023-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-02
D · Potential for more than minimal harm
2023-08-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-02
F · Potential for more than minimal harm
2021-08-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-10
F · Potential for more than minimal harm
2021-08-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2021-09-10
D · Potential for more than minimal harm
2019-11-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-12
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Not marked corrected
F · Potential for more than minimal harm
2025-12-11
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2026-01-11
E · Potential for more than minimal harm
2025-12-11
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 2026-01-11
E · Potential for more than minimal harm
2023-08-02
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 2023-09-02
D · Potential for more than minimal harm
2023-08-02
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 2023-09-02
D · Potential for more than minimal harm
2023-08-02
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 2023-09-02
D · Potential for more than minimal harm
2023-08-02
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 2023-09-02
D · Potential for more than minimal harm
2023-08-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-02
E · Potential for more than minimal harm
2021-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
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 2021-09-10
D · Potential for more than minimal harm
2021-08-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-13
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 2021-09-10
D · Potential for more than minimal harm
2021-08-13
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-09-10
D · Potential for more than minimal harm
2019-11-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-22
Penalties and ownership
What sits behind the stars
Ownership
Oakpark Rehab Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bp Oakpark Trust
5% Or Greater Indirect Ownership Interest · Organization
Lf Oakpark Trust
5% Or Greater Indirect Ownership Interest · Organization
Berard, Lori
Operational/Managerial Control · Individual
Dilella, Vincent
Operational/Managerial Control · Individual
Ferrone, Karen
Operational/Managerial Control · Individual
Reynard-Suriano, Su
Operational/Managerial Control · Individual
Wildes, Donna
Operational/Managerial Control · Individual
Wildes, Donna
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
St Mark Village
Palm Harbor, FL
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Aviata At Countryside
Palm Harbor, FL
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Aviata At The Palms
Palm Harbor, FL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $433,464 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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