Cycle 1
Health 2025-01-30 · Fire 2025-01-30
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Largo, FL
Tierra Pines Center
2-star overall rating with 3-star inspections with $4,147 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
7380 Ulmerton Rd, Largo, FL
(727) 535-9833
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aston Health
Operator or chain grouping
Approved since
1981-11-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.41
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
71%
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
4,954
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9911
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.01
Baseline 17.68% · Performance 18.64% · Measure score 6.01 · Achievement 6.01 · Improvement 0
Healthcare-associated infections
3.26
Baseline 8.41% · Performance 7.12% · Measure score 3.26 · Achievement 2.38 · Improvement 3.26
Total nurse turnover
3.8
Baseline 54.39% · Performance 48.15% · Measure score 3.8 · Achievement 3.8 · Improvement 1.61
Adjusted total nurse staffing
2.12
Baseline 4.17 hours · Performance 3.68 hours · Measure score 2.12 · Achievement 2.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.94% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 5% · Lower 95% interval 6.46% |
| Discharge to community | 29.73% |
50.57%
20.8 pts worse
|
Worse than the National Rate · Eligible stays 82 · Observed rate 20.73% · Lower 95% interval 21.64% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.18% |
95.27%
1.9 pts better
|
Numerator 138 · Denominator 142 |
| Falls with major injury | 2.11% |
0.77%
1.3 pts worse
|
Numerator 3 · Denominator 142 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 44 · Denominator 92 |
| Discharge mobility score | 51.09% |
50.94%
0.2 pts better
|
Numerator 47 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 4.23% |
2.29%
1.9 pts worse
|
Numerator 6 · Denominator 142 · Adjusted rate 3.91% |
| Healthcare-associated infections requiring hospitalization | 7.12% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 60 · Observed rate 6.67% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 77.88% |
8.2%
69.7 pts better
|
Numerator 81 · Denominator 104 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge function score | 48.91% |
56.45%
7.5 pts worse
|
Numerator 45 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 55 · Denominator 55 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 2.33% |
25.2%
22.9 pts worse
|
Numerator 2 · Denominator 86 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.4 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · 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 | 4.9% |
2.6%
2.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.1% · Q3 5.2% · Q4 6.4% · 4Q avg 4.9% · 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 | 7.2% |
5.9%
1.3 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 10.6% · Q3 2.4% · Q4 7.6% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
15.7%
9.7 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 26.4% · Q3 26.7% · Q4 23.8% · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
9.8%
12.9 pts worse
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 23.7% · Q3 18.9% · Q4 25.6% · 4Q avg 22.7% · 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 ability to walk independently worsened | 11.5% |
11.7%
0.2 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.1% · Q3 16.2% · Q4 19.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
9.8%
3.7 pts worse
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 12.7% · Q3 12.8% · Q4 19.5% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 | 16.5% |
12.5%
4 pts worse
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 17.7% · Q3 14.0% · Q4 12.5% · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
5.1%
3.7 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 9.8% · Q3 4.3% · Q4 6.8% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
94.3%
3.6 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 99.2% · Q3 98.5% · Q4 97.1% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
9.3%
0.2 pts worse
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 10.3% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.7% · Q3 2.6% · Q4 3.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
94.7%
0.9 pts worse
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
26.2%
2.8 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 23.7% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-08 · Fire 2022-12-08
9 health deficiencies
Top issue: Environmental (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-04-09 · Fire 2021-04-09
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-30
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-11
D · Potential for more than minimal harm
2022-12-08
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 2023-01-07
D · Potential for more than minimal harm
2022-12-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-02-06
D · Potential for more than minimal harm
2022-12-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-07
D · Potential for more than minimal harm
2022-12-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-07
D · Potential for more than minimal harm
2022-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-07
D · Potential for more than minimal harm
2022-12-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-07
D · Potential for more than minimal harm
2021-04-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-04-15
D · Potential for more than minimal harm
2021-04-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-30
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 2025-02-21
D · Potential for more than minimal harm
2025-01-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
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 2025-02-21
D · Potential for more than minimal harm
2025-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-21
E · Potential for more than minimal harm
2024-04-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-15
E · Potential for more than minimal harm
2023-10-31
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 2023-11-17
E · Potential for more than minimal harm
2022-12-08
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 2023-01-07
E · Potential for more than minimal harm
2022-12-08
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-01-07
E · Potential for more than minimal harm
2022-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-07
E · Potential for more than minimal harm
2022-12-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-01-07
D · Potential for more than minimal harm
2022-12-08
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 2023-01-07
D · Potential for more than minimal harm
2022-12-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-07
D · Potential for more than minimal harm
2022-12-08
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-01-07
D · Potential for more than minimal harm
2022-12-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-07
D · Potential for more than minimal harm
2021-04-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-05-09
D · Potential for more than minimal harm
2021-04-09
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 2021-05-09
D · Potential for more than minimal harm
2021-04-09
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 2021-05-09
Penalties and ownership
What sits behind the stars
$4,147
2025-01-30
Fine
Fine · fine $4,147
Fine
Ownership
Gabriel Living Center, LLC
5% Or Greater Direct Ownership Interest · Organization
Felicione, Theresa
W-2 Managing Employee · Individual
Gutman, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Klein, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Klein, Samuel
Corporate Officer · Individual
Lce Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
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#3
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