Cycle 1
Health 2024-01-11 · Fire 2024-01-11
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tallahassee, FL
Tallahassee Memorial Hospital Extended Care
5-star overall rating with 5-star inspections with $8,018 in total fines
1609 Medical Dr, Tallahassee, FL
(850) 431-5440
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
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
1979-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
4.13
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.39
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
8.91
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
5.51
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
8.22
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
3.45
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.52
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
4.23
CMS adjusted RN staffing hours
Adjusted total hours
9.11
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
174
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
79.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0258
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.36
Baseline 19.34% · Performance 18.02% · Measure score 7.36 · Achievement 7.36 · Improvement 5.22
Healthcare-associated infections
6.79
Baseline 4.98% · Performance 5.81% · Measure score 6.79 · Achievement 6.79 · Improvement 0
Total nurse turnover
7.82
Performance 31.73% · Measure score 7.82 · Achievement 7.82 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
10
Baseline 8.08 hours · Performance 7.83 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 197 · Observed rate 10.15% · Lower 95% interval 8.65% |
| Discharge to community | 72.56% |
50.57%
22 pts better
|
Better than the National Rate · Eligible stays 191 · Observed rate 73.82% · Lower 95% interval 66.87% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.03% |
95.27%
0.8 pts better
|
Numerator 121 · Denominator 126 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 1 · Denominator 126 |
| Discharge self-care score | 60.19% |
53.69%
6.5 pts better
|
Numerator 62 · Denominator 103 |
| Discharge mobility score | 62.14% |
50.94%
11.2 pts better
|
Numerator 64 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 3.17% |
2.29%
0.9 pts worse
|
Numerator 4 · Denominator 126 · Adjusted rate 5.72% |
| Healthcare-associated infections requiring hospitalization | 5.81% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 2.56% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 10.32% |
8.2%
2.1 pts better
|
Numerator 13 · Denominator 126 |
| Staff flu vaccination coverage | 98.26% |
42%
56.3 pts better
|
Numerator 113 · Denominator 115 |
| Discharge function score | 56.31% |
56.45%
0.1 pts worse
|
Numerator 58 · Denominator 103 |
| Transfer of health information to provider | 93.69% |
95.95%
2.3 pts worse
|
Numerator 104 · Denominator 111 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 54.84% |
25.2%
29.6 pts better
|
Numerator 34 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
94.3%
13.3 pts worse
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 87.9% · Q3 69.3% · Q4 66.2% · 4Q avg 81.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.3%
3.3 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 1.8% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.8% |
94.7%
2.9 pts worse
|
79.7%
12.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
26.2%
8.9 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 14.5% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-18 · Fire 2022-08-18
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-06-10 · Fire 2021-06-10
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-08-18
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 2022-08-22
D · Potential for more than minimal harm
2021-06-10
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-06-22
Penalties and ownership
What sits behind the stars
$8,018
2024-02-27
Fine
Fine · fine $8,018
Fine
Ownership
Alford, Barbara
Corporate Officer · Individual
Alford, Barbara
W-2 Managing Employee · Individual
Barnett, Martha
Corporate Director · Individual
Blair, Cynthia
Corporate Officer · Individual
Blair, Cynthia
W-2 Managing Employee · Individual
Busch Transou, Susie
Corporate Director · Individual
Busch Transou, Susie
Corporate Officer · Individual
Camps, Joseph
Corporate Director · Individual
Dozier, Laurie
Corporate Director · Individual
Ennis, Erin
Corporate Director · Individual
Evans, Steven
Corporate Director · Individual
Fortunas, Paula
Corporate Officer · Individual
Fortunas, Paula
W-2 Managing Employee · Individual
Giudice, William
Corporate Officer · Individual
Giudice, William
W-2 Managing Employee · Individual
Gredler, Frank
Corporate Director · Individual
Gredler, Frank
Corporate Officer · Individual
Howell, Winston
Corporate Director · Individual
Jones, Warren
Corporate Officer · Individual
Jones, Warren
W-2 Managing Employee · Individual
Killius, James
Corporate Director · Individual
Lindsey, Donald
Corporate Officer · Individual
Lindsey, Donald
W-2 Managing Employee · Individual
Littles, Alma
Corporate Director · Individual
Littles, Alma
Corporate Officer · Individual
Mcknight, Avery
Corporate Director · Individual
Moore, Jason
Corporate Officer · Individual
Moore, Jason
W-2 Managing Employee · Individual
Moore, Rick
Corporate Director · Individual
Moore, Robert
Corporate Officer · Individual
Moore, Robert
W-2 Managing Employee · Individual
Moss, Robin
Corporate Officer · Individual
Moss, Robin
W-2 Managing Employee · Individual
Obryant, George
Corporate Officer · Individual
Obryant, George
W-2 Managing Employee · Individual
Rumana, Christopher
Corporate Director · Individual
Thornton, Glenda
Corporate Director · Individual
Thornton, Glenda
Corporate Officer · Individual
Watson, Dean
Corporate Officer · Individual
Watson, Dean
W-2 Managing Employee · Individual
Winchester, Gary
Corporate Director · Individual
Wong, Andrew
Corporate Director · Individual
Nearby options
Other facilities in reach
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Aviata At The Gardens - Tallahassee
Tallahassee, FL
3-star overall rating with 2-star inspections with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Centre Pointe Health And Rehab Center
Tallahassee, FL
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Aviata At Tallahassee
Tallahassee, FL
2-star overall rating with 2-star inspections with $3,728 in total fines with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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