4 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Tavernier, FL
2-star overall rating with 2-star inspections with $6,857 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
48 High Point Road, Tavernier, FL
(305) 853-0799
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-12-19
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
RN hours / resident day
0.80
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.33
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
3.02
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
3,611
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9965
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.74
Baseline 23.21% · Performance 18.74% · Measure score 6.74 · Achievement 5.81 · Improvement 6.74
Healthcare-associated infections
0
Baseline 7.75% · Performance 10.67% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.32
Baseline 4.67 hours · Performance 4.88 hours · Measure score 6.32 · Achievement 6.32 · Improvement 1.33
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.74% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 15.57% · Lower 95% interval 8.7% |
| Discharge to community | 46.13% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 40.63% · Lower 95% interval 38.72% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 91.47% |
95.27%
3.8 pts worse
|
Numerator 118 · Denominator 129 |
| Falls with major injury | 2.33% |
0.77%
1.6 pts worse
|
Numerator 3 · Denominator 129 |
| Discharge self-care score | 62.32% |
53.69%
8.6 pts better
|
Numerator 43 · Denominator 69 |
| Discharge mobility score | 71.01% |
50.94%
20.1 pts better
|
Numerator 49 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 1.55% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 129 · Adjusted rate 1.34% |
| Healthcare-associated infections requiring hospitalization | 10.67% |
7.12%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 84 · Observed rate 15.48% · Lower 95% interval 7.31% |
| Staff COVID-19 vaccination coverage | 1.72% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 116 |
| Staff flu vaccination coverage | 9.48% |
42%
32.5 pts worse
|
Numerator 11 · Denominator 116 |
| Discharge function score | 63.77% |
56.45%
7.3 pts better
|
Numerator 44 · Denominator 69 |
| Transfer of health information to provider | 57.45% |
95.95%
38.5 pts worse
|
Numerator 27 · Denominator 47 |
| Transfer of health information to patient | 63.41% |
96.28%
32.9 pts worse
|
Numerator 26 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 21.95% |
25.2%
3.2 pts worse
|
Numerator 18 · Denominator 82 |
Quality measures
| 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 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.2
1.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
97.8%
0.4 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 96.4% · Q4 97.9% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
99.2%
1.4 pts worse
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
2.6%
2.7 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 4.8% · Q3 2.4% · Q4 6.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
3.7%
2.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.9%
1.7 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.4% · Q3 2.6% · Q4 10.5% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
15.7%
11.6 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 33.3% · Q3 25.0% · Q4 24.1% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.0% |
9.8%
4.2 pts worse
|
16.7%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.0% · Q3 12.7% · Q4 14.0% · 4Q avg 14.0% · 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 | 21.6% |
11.7%
9.9 pts worse
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 32.4% · Q3 18.6% · Q4 11.0% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.0% |
9.8%
13.2 pts worse
|
14.9%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 25.7% · Q3 20.5% · Q4 27.1% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.4%
0.5 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
0.8%
2.4 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.7% · Q3 2.5% · Q4 4.9% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
12.5%
7.5 pts worse
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 25.5% · Q3 16.3% · Q4 16.7% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.1%
1.5 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 5.7% · Q3 5.0% · Q4 5.7% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
94.3%
2.5 pts worse
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.7% · Q2 96.2% · Q3 86.9% · Q4 90.8% · 4Q avg 91.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
9.3%
3.9 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 14.9% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.5%
2.3 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 4.8% · Q4 5.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
94.7%
11.4 pts worse
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
26.2%
1.5 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 31.7% · Expected 27.3% · Used in QM five-star |
Survey summary
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Infection Control (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-26
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-06-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-26
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-26
Fire Safety
Install proper backup exit lighting.
Corrected 2022-07-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-26
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-26
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-26
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-07-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-26
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-07-26
Fire Safety
Provide family notifications of emergency plan.
Corrected 2020-12-19
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-12-19
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-12-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-12-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-12-19
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-12-19
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-12-19
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2020-12-19
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-12-19
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-12-19
Inspection history
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 2025-02-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-26
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-05-26
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-26
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-01
Health
Dispose of garbage and refuse properly.
Corrected 2022-08-01
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 2022-08-01
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-01
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-08-01
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-08-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-08-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-01
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 2022-08-01
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-08-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-08-01
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2022-08-01
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-08-01
Health
Provide and implement an infection prevention and control program.
Corrected 2020-12-19
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-12-19
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2020-12-19
Health
Implement a program that monitors antibiotic use.
Corrected 2020-12-19
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2020-12-19
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-12-19
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2020-12-19
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2020-12-19
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2020-12-19
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2020-12-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-12-19
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 2020-12-19
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 2020-12-19
Penalties and ownership
Fine · fine $6,857
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
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