Cycle 1
Health 2025-07-31 · Fire 2025-07-31
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Sun City Center, FL
Plaza West
3-star overall rating with 2-star inspections with 10 recent health deficiencies
912 American Eagle Blvd, Sun City Center, FL
(813) 633-3066
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
1994-06-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 4 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
0.97
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.00
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.93
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.37
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,461
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9973
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.49
Baseline 23.99% · Performance 22.61% · Measure score 1.49 · Achievement 0 · Improvement 1.49
Healthcare-associated infections
3.20
Baseline 8.09% · Performance 6.94% · Measure score 3.20 · Achievement 2.98 · Improvement 3.20
Total nurse turnover
7.36
Baseline 53.52% · Performance 33.61% · Measure score 7.36 · Achievement 7.36 · Improvement 6.45
Adjusted total nurse staffing
5.63
Baseline 4.68 hours · Performance 4.68 hours · Measure score 5.63 · Achievement 5.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.91% |
10.72%
2.2 pts worse
|
Worse than the National Rate · Eligible stays 460 · Observed rate 11.74% · Lower 95% interval 10.86% |
| Discharge to community | 67% |
50.57%
16.4 pts better
|
Better than the National Rate · Eligible stays 479 · Observed rate 64.72% · Lower 95% interval 62.76% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.87% |
95.27%
2.6 pts better
|
Numerator 322 · Denominator 329 |
| Falls with major injury | 0.3% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 328 |
| Discharge self-care score | 58.78% |
53.69%
5.1 pts better
|
Numerator 144 · Denominator 245 |
| Discharge mobility score | 60.82% |
50.94%
9.9 pts better
|
Numerator 149 · Denominator 245 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 326 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 287 · Observed rate 5.57% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 1.9% |
8.2%
6.3 pts worse
|
Numerator 4 · Denominator 211 |
| Staff flu vaccination coverage | 11.37% |
42%
30.6 pts worse
|
Numerator 24 · Denominator 211 |
| Discharge function score | 62.86% |
56.45%
6.4 pts better
|
Numerator 154 · Denominator 245 |
| Transfer of health information to provider | 95.73% |
95.95%
0.2 pts worse
|
Numerator 157 · Denominator 164 |
| Transfer of health information to patient | 96.9% |
96.28%
0.6 pts better
|
Numerator 125 · Denominator 129 |
| Resident COVID-19 vaccinations up to date | 25.44% |
25.2%
0.2 pts better
|
Numerator 43 · Denominator 169 |
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 3.0 · Expected 1.9 · 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 0.7 · Expected 1.6 · 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 | 3.3% |
2.6%
0.7 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 2.1% · Q4 2.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
3.7%
1.5 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 2.9% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.9%
0.6 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.4% · Q3 2.9% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
15.7%
11.1 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.8% · Q2 23.5% · Q3 18.4% · Q4 28.1% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.9% |
9.8%
7.9 pts better
|
16.7%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 4.3% · 4Q avg 1.9% · 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 | 30.9% |
11.7%
19.2 pts worse
|
16.3%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
9.8%
15.2 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 34.4% · Q3 27.8% · Q4 20.7% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
0.4%
2.5 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.4% · Q3 3.7% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
0.8%
3.9 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.8% · Q3 9.1% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
12.5%
18.4 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.8% · Q2 33.4% · Q3 27.8% · Q4 20.9% · 4Q avg 30.9% |
| 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 8.2% · Q2 7.2% · Q3 10.3% · Q4 4.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.3%
5.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.3%
0.5 pts worse
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 8.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
94.7%
0.5 pts worse
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
26.2%
1.3 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 21.7% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-12 · Fire 2023-05-12
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-07-23 · Fire 2021-07-23
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-05-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-12
D · Potential for more than minimal harm
2021-07-23
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 2021-08-23
D · Potential for more than minimal harm
2021-07-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-31
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 2025-08-31
E · Potential for more than minimal harm
2025-07-31
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 2025-08-31
E · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
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 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
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 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-31
E · Potential for more than minimal harm
2023-05-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-12
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 2023-06-12
E · Potential for more than minimal harm
2021-07-23
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 2021-08-23
D · Potential for more than minimal harm
2021-07-23
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 2021-08-23
D · Potential for more than minimal harm
2021-07-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-23
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 2021-08-23
Penalties and ownership
What sits behind the stars
Ownership
Ccrc Propco - Freedom Plaza, LLC
5% Or Greater Security Interest · Organization
Grella, Christopher
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Riazudeen, Shahul
Operational/Managerial Control · Individual
Roher, Angela
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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1-star overall rating with 1-star inspections with abuse icon flag with $85,965 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Sun Terrace Health Care Center
Sun City Center, FL
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Bayshore Pointe Nursing And Rehab Center
Tampa, FL
3-star overall rating with 2-star inspections with $23,560 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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