Cycle 1
Health 2024-04-11 · Fire 2024-04-11
17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Tarpon Springs, FL
Tarpon Bayou Center
1-star overall rating with 1-star inspections with $10,170 in total fines with 17 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
515 Chesapeake Dr, Tarpon Springs, FL
(727) 934-4629
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
107
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Hearthstone Senior Communities
Operator or chain grouping
Approved since
1974-04-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 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
0.54
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,102
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.47
Baseline 23.07% · Performance 21.27% · Measure score 2.47 · Achievement 0 · Improvement 2.47
Healthcare-associated infections
2.01
Baseline 6.42% · Performance 7.23% · Measure score 2.01 · Achievement 2.01 · Improvement 0
Total nurse turnover
8.63
Baseline 54.76% · Performance 28.39% · Measure score 8.63 · Achievement 8.63 · Improvement 8.32
Adjusted total nurse staffing
1.84
Baseline 3.64 hours · Performance 3.60 hours · Measure score 1.84 · Achievement 1.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.23% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 11.34% · Lower 95% interval 7.82% |
| Discharge to community | 34.16% |
50.57%
16.4 pts worse
|
Worse than the National Rate · Eligible stays 69 · Observed rate 26.09% · Lower 95% interval 27.26% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.26% |
95.27%
2 pts better
|
Numerator 71 · Denominator 73 |
| Falls with major injury | 1.37% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 73 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 24 · Denominator 48 |
| Discharge mobility score | 54.17% |
50.94%
3.2 pts better
|
Numerator 26 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 2.74% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 73 · Adjusted rate 2.52% |
| Healthcare-associated infections requiring hospitalization | 7.23% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 6.9% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 84 |
| Staff flu vaccination coverage | 25.89% |
42%
16.1 pts worse
|
Numerator 29 · Denominator 112 |
| Discharge function score | 47.92% |
56.45%
8.5 pts worse
|
Numerator 23 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 18 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 37.14% |
25.2%
11.9 pts better
|
Numerator 13 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · 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 | 2.7% |
2.6%
0.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.9% · Q3 1.9% · Q4 3.9% · 4Q avg 2.7% · 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 | 13.0% |
5.9%
7.1 pts worse
|
5.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 20.2% · Q3 13.0% · Q4 5.5% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
15.7%
15.2 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 30.4% · Q3 28.9% · Q4 30.9% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
9.8%
12.6 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 25.8% · Q3 24.4% · Q4 24.4% · 4Q avg 22.4% · 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 | 10.3% |
11.7%
1.4 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 11.3% · Q3 12.6% · Q4 11.4% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
9.8%
4.8 pts worse
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 11.2% · Q3 16.0% · Q4 24.2% · 4Q avg 14.6% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 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 7.6% · Q2 7.8% · Q3 19.5% · Q4 22.0% · 4Q avg 14.5% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.1%
1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.9% · Q3 4.5% · Q4 2.8% · 4Q avg 4.1% · 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 | 6.6% |
9.3%
2.7 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 3.8% · Q4 4.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
26.2%
3.5 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 27.9% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-04 · Fire 2022-02-04
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2020-11-06 · Fire 2020-11-06
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-11
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-04-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-04-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-10
F · Potential for more than minimal harm
2022-02-04
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-02-23
F · Potential for more than minimal harm
2022-02-04
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-02-23
F · Potential for more than minimal harm
2022-02-04
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-02-23
D · Potential for more than minimal harm
2022-02-04
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 2022-02-23
D · Potential for more than minimal harm
2022-02-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-23
D · Potential for more than minimal harm
2020-11-06
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-11-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-11-06
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2020-12-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-04-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-04-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-11
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 2024-05-10
E · Potential for more than minimal harm
2024-04-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-11
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 2024-06-28
E · Potential for more than minimal harm
2024-04-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-11
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 2024-05-10
D · Potential for more than minimal harm
2024-04-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-04-11
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-11
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 2024-06-28
D · Potential for more than minimal harm
2024-04-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-04-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-04-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-04-11
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 2024-06-28
D · Potential for more than minimal harm
2024-04-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-05-10
D · Potential for more than minimal harm
2023-07-13
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 2023-08-01
D · Potential for more than minimal harm
2023-07-13
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 2023-08-01
D · Potential for more than minimal harm
2023-07-13
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-08-01
D · Potential for more than minimal harm
2022-02-04
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 2022-02-23
D · Potential for more than minimal harm
2020-11-06
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 2020-12-04
D · Potential for more than minimal harm
2020-11-06
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 2021-01-21
D · Potential for more than minimal harm
2020-11-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-01-21
Penalties and ownership
What sits behind the stars
$10,170
2024-04-11
Fine
Fine · fine $10,170
Fine
Ownership
Hearthstone Senior Communities, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Tarpon Rehabilitation Center, LLC
5% Or Greater Direct Ownership Interest · Organization
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Facility Support Company, LLC
Operational/Managerial Control · Organization
Garner, Alvin
Corporate Officer · Individual
Jaffe, Howard
Corporate Officer · Individual
Joseph, Patricia
Operational/Managerial Control · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Mattern, Andrea
Operational/Managerial Control · Individual
Rombold, Lori
Corporate Officer · Individual
Themis Health Management, LLC
Operational/Managerial Control · Organization
Wyatt, Brian
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Peninsula Health Center By Harborview
Tarpon Springs, FL
1-star overall rating with 1-star inspections with $169,096 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Aviata At The Palms
Palm Harbor, FL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $433,464 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
St Mark Village
Palm Harbor, FL
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
Jump out