Cycle 1
Health 2024-07-25 · Fire 2024-07-25
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dunedin, FL
The Cedar At Mease Life
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
910 New York Ave, Dunedin, FL
(727) 733-2113
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
100
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1991-06-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 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
0.80
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.14
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,304
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.49
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 19.35% · Performance 23.98% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.69
Baseline 5.31% · Performance 6.43% · Measure score 4.69 · Achievement 4.69 · Improvement 0
Total nurse turnover
6.92
Baseline 39.62% · Performance 35.38% · Measure score 6.92 · Achievement 6.92 · Improvement 2.37
Adjusted total nurse staffing
4.58
Baseline 4.79 hours · Performance 4.38 hours · Measure score 4.58 · Achievement 4.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.57% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 11.41% · Lower 95% interval 8.24% |
| Discharge to community | 57.69% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 54.48% · Lower 95% interval 49.31% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.54% |
95.27%
2.3 pts better
|
Numerator 119 · Denominator 122 |
| Falls with major injury | 0.82% |
0.77%
About the same
|
Numerator 1 · Denominator 122 |
| Discharge self-care score | 60.87% |
53.69%
7.2 pts better
|
Numerator 56 · Denominator 92 |
| Discharge mobility score | 41.3% |
50.94%
9.6 pts worse
|
Numerator 38 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 4.92% |
2.29%
2.6 pts worse
|
Numerator 6 · Denominator 122 · Adjusted rate 5.7% |
| Healthcare-associated infections requiring hospitalization | 6.43% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 4.35% · Lower 95% interval 2.95% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 91.67% |
42%
49.7 pts better
|
Numerator 121 · Denominator 132 |
| Discharge function score | 59.78% |
56.45%
3.3 pts better
|
Numerator 55 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 83 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 4.41% |
25.2%
20.8 pts worse
|
Numerator 3 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.5 · Expected 1.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
97.8%
5.2 pts worse
|
93.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 80.0% · Q4 90.0% · 4Q avg 92.6% |
| 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 | 3.3% |
2.6%
0.7 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.3% · Q3 3.3% · Q4 3.3% · 4Q avg 3.3% · 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 | 2.3% |
5.9%
3.6 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 5.0% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
15.7%
4.1 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 5.0% · Q4 9.5% · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.7% |
9.8%
26.9 pts worse
|
16.7%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 34.8% · Q3 40.0% · 4Q avg 36.7% · 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 need for help with daily activities has increased | 19.2% |
9.8%
9.4 pts worse
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 35.0% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.4% |
0.4%
5 pts worse
|
1.0%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 5.2% · Q3 2.7% · Q4 3.2% · 4Q avg 5.4% · 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 | 25.3% |
12.5%
12.8 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.7% · Q2 19.9% · Q3 29.4% · Q4 7.8% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.1%
1.9 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.7% · Q3 4.0% · Q4 2.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.6% · Q4 94.8% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
9.3%
2.3 pts worse
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.6% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.1% · Q3 3.0% · Q4 1.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
94.7%
4.6 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.3% |
26.2%
9.1 pts worse
|
23.9%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.3% · Observed 28.8% · Expected 19.5% · 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: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-02 · Fire 2021-04-02
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-23
D · Potential for more than minimal harm
2021-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-24
D · Potential for more than minimal harm
2021-04-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-04-01
D · Potential for more than minimal harm
2021-04-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-04-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-08-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-09-18
E · Potential for more than minimal harm
2021-04-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-04-22
D · Potential for more than minimal harm
2021-04-02
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-04-22
D · Potential for more than minimal harm
2021-04-02
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 2021-04-22
D · Potential for more than minimal harm
2021-04-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-04-23
Penalties and ownership
What sits behind the stars
Ownership
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Management, LLC
Operational/Managerial Control · Organization
Ahern, Susan
Operational/Managerial Control · Individual
Ahern, Susan
Corporate Officer · Individual
Bate, John
Corporate Director · Individual
Beck, Jeffrey
Corporate Officer · Individual
Chamberlain, Linda
Corporate Officer · Individual
Chambers Carroll, Mary Beth
Corporate Director · Individual
Chambers Carroll, Mary Beth
Corporate Officer · Individual
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Officer · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Glynn, James
Corporate Director · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Grant, Jonathan
Operational/Managerial Control · Individual
Grant, Jonathan
Corporate Officer · Individual
Kelly, Michael
Corporate Director · Individual
Kelly, Michael
Corporate Officer · Individual
Mease Life Inc
Operational/Managerial Control · Organization
Ora, Melvin
Corporate Director · Individual
Ora, Melvin
Corporate Officer · Individual
Pointer Kynes, Deborah
Corporate Director · Individual
Wolf, Daniel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Meadowpark Health And Rehabilitation Center
Dunedin, FL
3-star overall rating with 2-star inspections with $72,858 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Aviata At Lakeside Oaks
Dunedin, FL
2-star overall rating with 2-star inspections with $13,520 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lake Haven Nursing And Rehab Center
Dunedin, FL
1-star overall rating with 1-star inspections with $281,689 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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