Cycle 1
Health 2024-12-11 · Fire 2024-12-11
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Clearwater, FL
Regency Oaks Health Center
2-star overall rating with 1-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2770 Regency Oaks Blvd, Clearwater, FL
(727) 791-1500
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
60
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
1991-10-07
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
0.90
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,308
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.78% · Performance 21.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.41
Baseline 5.70% · Performance 6.52% · Measure score 4.41 · Achievement 4.41 · Improvement 0
Total nurse turnover
7.30
Baseline 49.15% · Performance 33.85% · Measure score 7.30 · Achievement 7.30 · Improvement 5.80
Adjusted total nurse staffing
4.48
Baseline 4.72 hours · Performance 4.35 hours · Measure score 4.48 · Achievement 4.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 220 · Observed rate 8.64% · Lower 95% interval 7.72% |
| Discharge to community | 66.24% |
50.57%
15.7 pts better
|
Better than the National Rate · Eligible stays 230 · Observed rate 63.04% · Lower 95% interval 61.49% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.3% |
95.27%
1 pts better
|
Numerator 156 · Denominator 162 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 162 |
| Discharge self-care score | 47.41% |
53.69%
6.3 pts worse
|
Numerator 55 · Denominator 116 |
| Discharge mobility score | 44.83% |
50.94%
6.1 pts worse
|
Numerator 52 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 0.62% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 162 · Adjusted rate 0.78% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 4.67% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 129 |
| Staff flu vaccination coverage | 41.18% |
42%
0.8 pts worse
|
Numerator 42 · Denominator 102 |
| Discharge function score | 42.24% |
56.45%
14.2 pts worse
|
Numerator 49 · Denominator 116 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 98.96% |
96.28%
2.7 pts better
|
Numerator 95 · Denominator 96 |
| Resident COVID-19 vaccinations up to date | 11.83% |
25.2%
13.4 pts worse
|
Numerator 11 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · 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 | 4.2% |
2.6%
1.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.3% · Q3 3.3% · Q4 3.2% · 4Q avg 4.2% · 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 | 0.0% |
5.9%
5.9 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 25.2% |
15.7%
9.5 pts worse
|
19.6%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 30.8% · Q3 23.1% · Q4 14.8% · 4Q avg 25.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
9.8%
2.5 pts worse
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.0% · 4Q avg 12.3% · 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 | 14.5% |
11.7%
2.8 pts worse
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
9.8%
8.6 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 21.7% · Q3 4.3% · Q4 7.7% · 4Q avg 18.4% · 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 | 3.5% |
0.8%
2.7 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.1% · Q3 0.0% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.9% |
12.5%
1.4 pts worse
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 8.1% · Q3 10.0% · Q4 12.8% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.1%
1.7 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 4.0% · Q3 0.0% · Q4 4.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
94.3%
4.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 97.9% · Q3 98.2% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
9.3%
3.2 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
94.7%
3.8 pts worse
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
26.2%
3.1 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 26.4% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-02 · Fire 2022-12-02
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-06-04 · Fire 2021-06-04
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-12-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-11
D · Potential for more than minimal harm
2022-12-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-01
D · Potential for more than minimal harm
2021-06-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-04
D · Potential for more than minimal harm
2021-06-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-04
D · Potential for more than minimal harm
2021-06-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-12-11
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 2025-01-11
D · Potential for more than minimal harm
2024-12-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-11
J · Immediate jeopardy
2022-12-02
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 2023-01-01
J · Immediate jeopardy
2022-12-02
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 2023-01-01
J · Immediate jeopardy
2022-12-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-01
J · Immediate jeopardy
2022-12-02
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-01-01
J · Immediate jeopardy
2022-12-02
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-02
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 2023-01-01
D · Potential for more than minimal harm
2022-12-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-02
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 2023-01-01
E · Potential for more than minimal harm
2021-06-04
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 2021-07-04
D · Potential for more than minimal harm
2021-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-04
D · Potential for more than minimal harm
2021-06-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-04
D · Potential for more than minimal harm
2021-06-04
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-07-04
Penalties and ownership
What sits behind the stars
Ownership
Ccrc Opco Ventures LLC
5% Or Greater Direct Ownership Interest · Organization
Bolden, Kyle
Operational/Managerial Control · Individual
Hcp S-H 2014 Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Khalil, Moeen
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
S-H 2014 Opco Trs Inc
5% Or Greater Indirect Ownership Interest · Organization
Weaver, Lindsay
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Advanced Care Center
Clearwater, FL
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Aviata at Sand Key
Clearwater, FL
2-star overall rating with 1-star inspections with $175,634 in total fines with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Aviata At The Harbor
Safety Harbor, FL
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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