Cycle 1
Health 2025-04-03 · Fire 2025-04-03
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Williston, FL
Williston Care Center And Rehab
2-star overall rating with 1-star inspections with $15,593 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
300 Nw 1st Ave, Williston, FL
(352) 528-3561
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 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
Gold Fl Trust Ii
Operator or chain grouping
Approved since
1984-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
46 facilities
Chain averages 3 overall / 3 health / 3 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
0.26
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,356
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.82
Baseline 22.41% · Performance 20.62% · Measure score 2.82 · Achievement 1.74 · Improvement 2.82
Healthcare-associated infections
0.73
Baseline 6.73% · Performance 7.62% · Measure score 0.73 · Achievement 0.73 · Improvement 0
Total nurse turnover
2.87
Baseline 54.62% · Performance 51.94% · Measure score 2.87 · Achievement 2.87 · Improvement 0.40
Adjusted total nurse staffing
1.85
Baseline 3.68 hours · Performance 3.60 hours · Measure score 1.85 · Achievement 1.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.21% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 4.79% · Lower 95% interval 6.2% |
| Discharge to community | 56.18% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 51.16% · Lower 95% interval 44.6% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.51% |
95.27%
4.2 pts better
|
Numerator 203 · Denominator 204 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 4 · Denominator 204 |
| Discharge self-care score | 79.65% |
53.69%
26 pts better
|
Numerator 90 · Denominator 113 |
| Discharge mobility score | 73.45% |
50.94%
22.5 pts better
|
Numerator 83 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 2.45% |
2.29%
0.2 pts worse
|
Numerator 5 · Denominator 204 · Adjusted rate 2.42% |
| Healthcare-associated infections requiring hospitalization | 7.62% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 8.64% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 10.91% |
8.2%
2.7 pts better
|
Numerator 6 · Denominator 55 |
| Staff flu vaccination coverage | 9.04% |
42%
33 pts worse
|
Numerator 17 · Denominator 188 |
| Discharge function score | 80.53% |
56.45%
24.1 pts better
|
Numerator 91 · Denominator 113 |
| Transfer of health information to provider | 88.68% |
95.95%
7.3 pts worse
|
Numerator 94 · Denominator 106 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.93% |
25.2%
18.3 pts worse
|
Numerator 7 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · 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 | 4.6% |
2.6%
2 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.0% · Q3 6.1% · Q4 4.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
3.7%
2.5 pts worse
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 6.7% · Q3 4.5% · Q4 4.5% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 9.8% |
5.9%
3.9 pts worse
|
5.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 9.9% · Q3 12.3% · Q4 10.5% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
15.7%
8.5 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.0% · Q3 8.3% · Q4 7.3% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
9.8%
0.2 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 11.3% · Q3 13.8% · Q4 6.2% · 4Q avg 9.6% · 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 | 3.9% |
11.7%
7.8 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.6% · Q3 6.5% · Q4 2.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
9.8%
4.7 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 3.6% · Q3 5.2% · Q4 5.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 2.3% |
12.5%
10.2 pts better
|
19.8%
17.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.0% · Q3 1.1% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.1%
About the same
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.1% · Q3 7.0% · Q4 4.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.3%
5.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
9.3%
3.3 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 14.1% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.7%
3.7 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.1% |
26.2%
7.9 pts worse
|
23.9%
10.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.1% · Observed 37.6% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-20 · Fire 2022-07-20
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-04-03
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 2025-05-12
D · Potential for more than minimal harm
2025-04-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-03
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 2025-05-12
D · Potential for more than minimal harm
2025-04-03
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 2025-05-12
D · Potential for more than minimal harm
2025-04-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-03
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 2025-05-12
D · Potential for more than minimal harm
2025-04-03
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 2025-05-12
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-12
E · Potential for more than minimal harm
2024-01-11
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 2024-02-15
D · Potential for more than minimal harm
2024-01-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
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 2024-02-15
D · Potential for more than minimal harm
2024-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
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 2024-02-15
D · Potential for more than minimal harm
2024-01-11
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 2024-02-15
D · Potential for more than minimal harm
2024-01-11
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 2024-02-15
D · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-15
K · Immediate jeopardy
2023-11-08
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-11-16
K · Immediate jeopardy
2023-11-08
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-11-08
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 2023-11-16
F · Potential for more than minimal harm
2023-03-06
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 2023-04-07
F · Potential for more than minimal harm
2022-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-29
F · Potential for more than minimal harm
2022-07-20
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 2022-08-29
E · Potential for more than minimal harm
2022-07-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-07-20
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 2022-08-29
E · Potential for more than minimal harm
2022-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-20
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-20
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 2022-08-29
Penalties and ownership
What sits behind the stars
$7,796
2023-11-08
Fine
Fine · fine $7,796
Fine
$7,797
2023-11-08
Fine
Fine · fine $7,797
Fine
Ownership
Williston Nursing Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Baijnath, Hemwattie
W-2 Managing Employee · Individual
Ellenbogen, Moss
Corporate Officer · Individual
Fl Master Opco Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Fl SNF Trust I
5% Or Greater Indirect Ownership Interest · Organization
Fl SNF Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
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#3
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