Cycle 1
Health 2025-01-09 · Fire 2025-01-09
5 health deficiencies
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Pensacola, FL
Pensacola Nursing & Rehabilitation Center
1-star overall rating with 1-star inspections with $47,013 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
235 West Airport Blvd, Pensacola, FL
(850) 857-5200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aston Health
Operator or chain grouping
Approved since
1997-01-08
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
0.60
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.56
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
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,421
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9975
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.88
Baseline 20.08% · Performance 20.10% · Measure score 2.88 · Achievement 2.88 · Improvement 0
Healthcare-associated infections
8.20
Baseline 11.13% · Performance 5.79% · Measure score 8.20 · Achievement 6.83 · Improvement 8.20
Total nurse turnover
3.08
Baseline 85.29% · Performance 63.64% · Measure score 3.08 · Achievement 0 · Improvement 3.08
Adjusted total nurse staffing
3.6
Baseline 3.69 hours · Performance 4.10 hours · Measure score 3.6 · Achievement 3.6 · Improvement 1.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.95% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 11.48% · Lower 95% interval 6.67% |
| Discharge to community | 48.21% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 39.47% · Lower 95% interval 32.13% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 61.82% |
95.27%
33.4 pts worse
|
Numerator 34 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 48.48% |
53.69%
5.2 pts worse
|
Numerator 16 · Denominator 33 |
| Discharge mobility score | 24.24% |
50.94%
26.7 pts worse
|
Numerator 8 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 3.69% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 1.85% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 17 · Denominator 33 |
| Transfer of health information to provider | 85% |
95.95%
11 pts worse
|
Numerator 17 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
1.2
2.4 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
97.8%
3.3 pts worse
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 94.1% · Q3 98.9% · Q4 98.8% · 4Q avg 94.5% |
| 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 | 5.5% |
2.6%
2.9 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.9% · Q3 5.6% · Q4 3.7% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
3.7%
0.9 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.4% · Q3 2.6% · Q4 1.4% · 4Q avg 2.8% |
| 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 9.6% · Q2 8.9% · Q3 4.9% · Q4 5.4% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
15.7%
0.5 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.5% · Q3 14.3% · Q4 18.2% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
9.8%
8.1 pts worse
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 16.7% · Q3 17.4% · Q4 16.7% · 4Q avg 17.9% · 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 | 11.0% |
11.7%
0.7 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 9.0% · Q3 2.6% · Q4 15.0% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
9.8%
0.3 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.7% · Q3 7.7% · Q4 12.5% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 | 20.5% |
12.5%
8 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 26.7% · Q3 22.6% · Q4 15.6% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.1%
2.8 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.4% · Q3 4.6% · Q4 7.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.7% |
94.3%
15.6 pts worse
|
81.7%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.2% · Q2 78.6% · Q3 77.6% · Q4 82.4% · 4Q avg 78.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.7% |
9.3%
8.4 pts worse
|
12.0%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 22.0% · Expected 13.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q4 2.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.7% |
94.7%
11 pts worse
|
79.7%
4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
26.2%
4.5 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 24.0% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-05-19 · Fire 2022-05-19
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-09
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-11
D · Potential for more than minimal harm
2023-09-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-11-08
D · Potential for more than minimal harm
2022-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
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 2022-06-30
D · Potential for more than minimal harm
2022-05-19
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-05
E · Potential for more than minimal harm
2025-01-09
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-02-05
D · Potential for more than minimal harm
2025-01-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-02-05
D · Potential for more than minimal harm
2025-01-09
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 2025-02-05
D · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-05
D · Potential for more than minimal harm
2023-09-21
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 2023-10-10
D · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-10
K · 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
K · Immediate jeopardy
2023-04-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-21
K · Immediate jeopardy
2023-04-20
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 2023-04-21
K · Immediate jeopardy
2023-04-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-21
K · Immediate jeopardy
2023-04-20
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-21
K · Immediate jeopardy
2023-04-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-21
K · Immediate jeopardy
2022-05-19
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 2022-06-30
K · Immediate jeopardy
2022-05-19
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 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-30
Penalties and ownership
What sits behind the stars
$47,013
2023-04-20
Fine
Fine · fine $47,013
Fine
Ownership
Pensacola Member LLC
5% Or Greater Direct Ownership Interest · Organization
Berkowitz, Cheskel
5% Or Greater Indirect Ownership Interest · Individual
Devarapalli, Hima
Operational/Managerial Control · Individual
Friedman, Leopold
5% Or Greater Indirect Ownership Interest · Individual
Friedman, Leopold
Corporate Officer · Individual
Hardy-Fauber, Tammy
Operational/Managerial Control · Individual
Huff, Tretta
Operational/Managerial Control · Individual
Leifer, Joel
5% Or Greater Indirect Ownership Interest · Individual
Orgel, Joseph
5% Or Greater Indirect Ownership Interest · Individual
Ornstein, Marton
5% Or Greater Indirect Ownership Interest · Individual
Salter, Sade
Operational/Managerial Control · Individual
Sh Indigo Citadel Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Thacker, Tricia
Corporate Officer · Individual
Zupnick, Joel
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Rosewood Healthcare And Rehabilitation Center
Pensacola, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Arabella Health & Wellness Of Pensacola
Pensacola, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Havens At Pensacola, The
Pensacola, FL
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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