Cycle 1
Health 2024-11-21 · Fire 2024-11-21
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Trinity, FL
Trinity Regional Rehab Center
2-star overall rating with 2-star inspections with 9 recent health deficiencies
2144 Welbilt Blvd, Trinity, FL
(727) 859-4100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 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
No chain reported
Operator or chain grouping
Approved since
2008-11-25
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
0.41
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.24
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
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,294
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.34
Baseline 23.48% · Performance 20.36% · Measure score 4.34 · Achievement 2.31 · Improvement 4.34
Healthcare-associated infections
2.13
Baseline 7.98% · Performance 7.20% · Measure score 2.13 · Achievement 2.13 · Improvement 2.11
Total nurse turnover
3
Baseline 59.85% · Performance 51.40% · Measure score 3 · Achievement 3 · Improvement 1.91
Adjusted total nurse staffing
1.42
Baseline 3.79 hours · Performance 3.48 hours · Measure score 1.42 · Achievement 1.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.89% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 394 · Observed rate 13.71% · Lower 95% interval 10.37% |
| Discharge to community | 55.32% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 372 · Observed rate 50.54% · Lower 95% interval 50.49% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.44% |
95.27%
3.2 pts better
|
Numerator 315 · Denominator 320 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 4 · Denominator 320 |
| Discharge self-care score | 48.06% |
53.69%
5.6 pts worse
|
Numerator 99 · Denominator 206 |
| Discharge mobility score | 33.5% |
50.94%
17.4 pts worse
|
Numerator 69 · Denominator 206 |
| Pressure ulcers or injuries, new or worsened | 4.06% |
2.29%
1.8 pts worse
|
Numerator 13 · Denominator 320 · Adjusted rate 3.81% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 219 · Observed rate 6.85% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 7.53% |
8.2%
0.7 pts worse
|
Numerator 11 · Denominator 146 |
| Staff flu vaccination coverage | 16.56% |
42%
25.4 pts worse
|
Numerator 26 · Denominator 157 |
| Discharge function score | 37.86% |
56.45%
18.6 pts worse
|
Numerator 78 · Denominator 206 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 116 · Denominator 120 |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 120 · Denominator 123 |
| Resident COVID-19 vaccinations up to date | 18.39% |
25.2%
6.8 pts worse
|
Numerator 32 · Denominator 174 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · 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 | 98.8% |
99.2%
0.4 pts worse
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
2.6%
1.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 5.5% · Q3 2.9% · Q4 6.4% · 4Q avg 4.0% · 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 | 10.8% |
5.9%
4.9 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 15.4% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
15.7%
2.3 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q3 18.2% · Q4 10.7% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
9.8%
6.2 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 2.2% · Q4 8.0% · 4Q avg 3.6% · 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 | 22.0% |
11.7%
10.3 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · 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 · Q2 15.0% · Q3 9.1% · Q4 10.7% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
0.8%
1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.0% |
12.5%
4.5 pts worse
|
19.8%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 11.7% · Q3 22.9% · Q4 13.5% · 4Q avg 17.0% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.1%
2.2 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.0% · Q3 8.8% · Q4 8.0% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
94.3%
5.1 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.4% · Q3 99.7% · Q4 99.3% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
9.3%
1.5 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.4% · Q3 1.4% · Q4 0.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.7%
3 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
26.2%
0.2 pts better
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 24.1% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-21 · Fire 2022-09-21
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-04-22 · Fire 2021-04-22
11 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-09-21
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 2022-10-11
D · Potential for more than minimal harm
2021-04-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-05-22
D · Potential for more than minimal harm
2021-04-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-05-22
Inspection history
Recent health citations
G · Actual harm
2025-05-01
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-05-22
F · Potential for more than minimal harm
2024-11-21
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 2024-12-21
E · Potential for more than minimal harm
2024-11-21
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-12-21
E · Potential for more than minimal harm
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-21
E · Potential for more than minimal harm
2024-11-21
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 2024-12-21
D · Potential for more than minimal harm
2024-11-21
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 2024-12-21
D · Potential for more than minimal harm
2024-11-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-21
D · Potential for more than minimal harm
2023-05-04
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-04
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 2023-06-26
E · Potential for more than minimal harm
2021-04-22
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 2021-05-22
E · Potential for more than minimal harm
2021-04-22
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 2021-05-22
E · Potential for more than minimal harm
2021-04-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-05-22
D · Potential for more than minimal harm
2021-04-22
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 2021-05-22
D · Potential for more than minimal harm
2021-04-22
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 2021-05-22
D · Potential for more than minimal harm
2021-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-22
D · Potential for more than minimal harm
2021-04-22
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 2021-05-22
Penalties and ownership
What sits behind the stars
Ownership
Trinity Rehab Holding Group
5% Or Greater Direct Ownership Interest · Organization
Ark Post Acute Network LLC
Operational/Managerial Control · Organization
Bridges, Roy
Corporate Officer · Individual
Dulski, Ryan
W-2 Managing Employee · Individual
Justiniano, Kimberly
Corporate Officer · Individual
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#3
Nursing & Rehabilitation Center Of New Port Richey
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