Cycle 1
Health 2025-05-08 · Fire 2025-05-08
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Port Saint Joe, FL
Shores Nursing And Rehab Center
1-star overall rating with 1-star inspections with Special Focus status with $137,446 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
220 Ninth Street, Port Saint Joe, FL
(850) 229-8244
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
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eliyahu Mirlis
Operator or chain grouping
Approved since
1983-06-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.61
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.13
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
1.23
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.22
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
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,938
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.27
Baseline 19.89% · Performance 19.45% · Measure score 4.27 · Achievement 4.27 · Improvement 1.04
Healthcare-associated infections
2.02
Baseline 6.63% · Performance 7.23% · Measure score 2.02 · Achievement 2.02 · Improvement 0
Total nurse turnover
2.84
Baseline 24.53% · Performance 52.05% · Measure score 2.84 · Achievement 2.84 · Improvement 0
Adjusted total nurse staffing
2.21
Baseline 4.19 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 9.59% · Lower 95% interval 6.43% |
| Discharge to community | 46.11% |
50.57%
4.5 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 40.38% · Lower 95% interval 33.36% |
| Medicare spending per beneficiary | 1.43 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 71 · Denominator 72 |
| Falls with major injury | 5.56% |
0.77%
4.8 pts worse
|
Numerator 4 · Denominator 72 |
| Discharge self-care score | 39.02% |
53.69%
14.7 pts worse
|
Numerator 16 · Denominator 41 |
| Discharge mobility score | 51.22% |
50.94%
0.3 pts better
|
Numerator 21 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 72 · Adjusted rate 2.55% |
| Healthcare-associated infections requiring hospitalization | 7.23% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 7.84% · Lower 95% interval 4.46% |
| Staff COVID-19 vaccination coverage | 67.42% |
8.2%
59.2 pts better
|
Numerator 60 · Denominator 89 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 60.98% |
56.45%
4.5 pts better
|
Numerator 25 · Denominator 41 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.33% |
25.2%
21.9 pts worse
|
Numerator 1 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.2
2.1 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.3 · Expected 1.7 · 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 | 4.3% |
2.6%
1.7 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.8% · Q3 3.5% · Q4 4.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
3.7%
3.5 pts worse
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.1% · Q3 11.7% · Q4 10.4% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.9%
2 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.2% · Q3 8.6% · Q4 10.3% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
15.7%
3.1 pts worse
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 20.9% · Q3 16.7% · Q4 16.9% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
9.8%
4.5 pts worse
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.3% · Q3 15.7% · Q4 14.6% · 4Q avg 14.3% · 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 | 6.9% |
11.7%
4.8 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 8.9% · Q3 4.7% · Q4 5.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
9.8%
2.1 pts worse
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 18.5% · Q3 10.0% · Q4 10.3% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.4%
1.2 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 3.1% · Q4 1.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
0.8%
2.3 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.8% · Q3 2.4% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.0% |
12.5%
1.5 pts worse
|
19.8%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 17.8% · Q3 18.9% · Q4 5.5% · 4Q avg 14.0% |
| 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 1.2% · Q3 1.1% · Q4 6.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.4% |
9.3%
16.1 pts worse
|
12.0%
13.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 27.3% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
94.7%
1.4 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.0% |
26.2%
13.8 pts worse
|
23.9%
16.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 40.0% · Observed 36.4% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-02 · Fire 2024-02-02
26 health deficiencies
Top issue: Resident Rights (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-08-31 · Fire 2022-08-31
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-05-08
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-05-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-05-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-05-08
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 2025-07-16
D · Potential for more than minimal harm
2025-05-08
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-05-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-16
D · Potential for more than minimal harm
2024-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-10
D · Potential for more than minimal harm
2022-08-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-31
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 2022-09-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
F584 · Resident Rights Deficiencies
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.
Not marked corrected
D · Potential for more than minimal harm
2025-05-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-08
F584 · Resident Rights Deficiencies
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 2025-06-23
D · Potential for more than minimal harm
2025-05-08
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 2025-06-23
D · Potential for more than minimal harm
2025-05-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-08
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-08
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 2025-06-23
D · Potential for more than minimal harm
2025-05-08
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-06-23
D · Potential for more than minimal harm
2024-10-31
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-08-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-12
F584 · Resident Rights Deficiencies
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 2024-09-17
E · Potential for more than minimal harm
2024-08-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-12
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 2024-09-17
D · Potential for more than minimal harm
2024-08-12
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 2024-09-17
D · Potential for more than minimal harm
2024-08-12
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2024-09-17
L · Immediate jeopardy
2024-02-02
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-03-24
L · Immediate jeopardy
2024-02-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-24
L · Immediate jeopardy
2024-02-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-24
L · Immediate jeopardy
2024-02-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-03-24
L · Immediate jeopardy
2024-02-02
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-03-24
G · Actual harm
2024-02-02
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 2024-03-24
G · Actual harm
2024-02-02
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 2024-03-24
F · Potential for more than minimal harm
2024-02-02
F584 · Resident Rights Deficiencies
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 2024-03-24
F · Potential for more than minimal harm
2024-02-02
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 2024-03-24
E · Potential for more than minimal harm
2024-02-02
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 2024-03-24
E · Potential for more than minimal harm
2024-02-02
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 2024-03-24
E · Potential for more than minimal harm
2024-02-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-02
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-02
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 2024-03-24
D · Potential for more than minimal harm
2024-02-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-02
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 2024-03-24
D · Potential for more than minimal harm
2024-02-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-03-24
Penalties and ownership
What sits behind the stars
$137,446
2024-02-02
Fine
Fine · fine $137,446
Fine
Ownership
220 Ninth St Port St Joe Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Becher, Sarah
5% Or Greater Indirect Ownership Interest · Individual
Harrison, Jack
Operational/Managerial Control · Individual
Mirlis, Eliyahu
5% Or Greater Indirect Ownership Interest · Individual
Mirlis, Eliyahu
Corporate Officer · Individual
New Horizon Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Thorngren, Daniel
Operational/Managerial Control · Individual
Vrd 10 Hldco LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Community Health And Rehabilitation Center
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4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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