Cycle 1
Health 2024-01-25 · Fire 2024-01-25
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Palm Harbor, FL
St Mark Village
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
2655 Nebraska Ave, Palm Harbor, FL
(727) 785-2577
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-11-24
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
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.08
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.29
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.22
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,315
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.44
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 20.73% · Performance 22.72% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.81
Baseline 5.90% · Performance 6.40% · Measure score 4.81 · Achievement 4.81 · Improvement 0
Total nurse turnover
2.74
Baseline 55.41% · Performance 52.50% · Measure score 2.74 · Achievement 2.74 · Improvement 0.45
Adjusted total nurse staffing
8.63
Baseline 4.23 hours · Performance 5.53 hours · Measure score 8.63 · Achievement 8.63 · Improvement 7.9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.51% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 350 · Observed rate 12.29% · Lower 95% interval 9.79% |
| Discharge to community | 69.58% |
50.57%
19 pts better
|
Better than the National Rate · Eligible stays 331 · Observed rate 66.16% · Lower 95% interval 63.94% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.35% |
95.27%
1.1 pts better
|
Numerator 264 · Denominator 274 |
| Falls with major injury | 0.37% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 273 |
| Discharge self-care score | 77.62% |
53.69%
23.9 pts better
|
Numerator 163 · Denominator 210 |
| Discharge mobility score | 56.67% |
50.94%
5.7 pts better
|
Numerator 119 · Denominator 210 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 3 · Denominator 274 · Adjusted rate 1.21% |
| Healthcare-associated infections requiring hospitalization | 6.4% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 227 · Observed rate 4.85% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 3.81% |
8.2%
4.4 pts worse
|
Numerator 8 · Denominator 210 |
| Staff flu vaccination coverage | 12.56% |
42%
29.4 pts worse
|
Numerator 26 · Denominator 207 |
| Discharge function score | 73.81% |
56.45%
17.4 pts better
|
Numerator 155 · Denominator 210 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 67 · Denominator 67 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 192 · Denominator 192 |
| Resident COVID-19 vaccinations up to date | 24.32% |
25.2%
0.9 pts worse
|
Numerator 36 · Denominator 148 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · 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 | 2.8% |
2.6%
0.2 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.8% · Q3 0.0% · Q4 3.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
3.7%
1.2 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 8.0% · Q3 4.2% · Q4 3.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.9%
1.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 12.5% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
15.7%
5.7 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 8.3% · Q3 12.0% · Q4 11.5% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
9.8%
1.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 8.5% · 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 | 10.7% |
11.7%
1 pts better
|
16.3%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
9.8%
6.2 pts worse
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · 4Q avg 16.0% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
0.8%
1.2 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.2% · Q4 4.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.5% |
12.5%
2 pts worse
|
19.8%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 4.8% · Q3 20.5% · 4Q avg 14.5% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.1%
3.6 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · 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 | 7.9% |
9.3%
1.4 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.4% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.7%
4.7 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
26.2%
0.5 pts better
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 22.6% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-29 · Fire 2021-12-29
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2020-11-25 · Fire 2020-11-25
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-01-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-25
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-02-23
D · Potential for more than minimal harm
2021-12-29
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 2022-01-29
D · Potential for more than minimal harm
2020-11-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-12-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2021-12-29
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 2022-01-29
D · Potential for more than minimal harm
2021-12-29
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 2022-01-29
E · Potential for more than minimal harm
2020-11-25
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2020-12-25
D · Potential for more than minimal harm
2020-11-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-12-25
Penalties and ownership
What sits behind the stars
Ownership
Cornell, Carol
Operational/Managerial Control · Individual
Cornell, Carol
Corporate Director · Individual
Dukas, Nicholas
Operational/Managerial Control · Individual
Dukas, Nicholas
Corporate Director · Individual
Gill, Archie
Operational/Managerial Control · Individual
Gorddard, Jeffrey
Operational/Managerial Control · Individual
Gorddard, Jeffrey
Corporate Officer · Individual
Greenawalt, Christine
Operational/Managerial Control · Individual
Henwood, Helen
Operational/Managerial Control · Individual
Henwood, Helen
Corporate Director · Individual
Isguzar, Huseyin
Operational/Managerial Control · Individual
Martin, Richard
Operational/Managerial Control · Individual
Martin, Richard
Corporate Director · Individual
Mason, Deena
Operational/Managerial Control · Individual
Mccord, Cary
Operational/Managerial Control · Individual
Mccord, Cary
Corporate Director · Individual
Miaoulis, Maria
Operational/Managerial Control · Individual
Miaoulis, Maria
Corporate Director · Individual
Quinton, Tara
Operational/Managerial Control · Individual
Rees, Randall
Operational/Managerial Control · Individual
Snare, Clayton
Operational/Managerial Control · Individual
Snare, Clayton
Corporate Director · Individual
Swenson, David
Operational/Managerial Control · Individual
Vincent, Patricia
Operational/Managerial Control · Individual
Vincent, Patricia
Corporate Director · Individual
Whitney Bank
5% Or Greater Security Interest · Organization
Woodard, Deborah
Operational/Managerial Control · Individual
Woodard, Deborah
Corporate Director · Individual
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#3
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3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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