Tag 0689 · Severity G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-10At a glance
CMS data snapshot: 2026-08-01 · Sources and limitations
| Ownership | Non profit - Church related | Certified beds | 163 |
|---|---|---|---|
| Estimated occupancy | 76.7% | Latest inspection | 2024-04-10 |
County and Florida comparison
Navy: facility · Teal: county · Gray: Florida
Overall rating
Facility: 3 of 5
Health-inspection score
Facility: 67.0 points
Total nurse staffing
Facility: 3.49 hours/day
RN staffing
Facility: 0.49 hours/day
Staff turnover
Facility: 51.9%
Latest health deficiencies
Facility: 13 deficiencies
View data table
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 3 of 5 | 3 of 5 | 3 of 5 |
| Health-inspection score | 67.0 points | 56.5 points | 38.5 points |
| Total nurse staffing | 3.49 hours/day | 3.61 hours/day | 3.63 hours/day |
| RN staffing | 0.49 hours/day | 0.61 hours/day | 0.62 hours/day |
| Staff turnover | 51.9% | 43.7% | 41.8% |
| Latest health deficiencies | 13 deficiencies | 10 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Inspection history
2024-04-10
13 deficiencies
Highest severity: G
Immediate-jeopardy citations: 0
Tag 0725 · Severity E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0880 · Severity E
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0580 · Severity D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0584 · Severity D
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.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0609 · Severity D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0656 · Severity D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0677 · Severity D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0684 · Severity D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0695 · Severity D
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0761 · Severity D
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0847 · Severity D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0925 · Severity D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies · Deficient, Provider has date of correction 2024-05-102021-11-05
6 deficiencies
Highest severity: E
Immediate-jeopardy citations: 0
Tag 0656 · Severity E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2021-12-05Tag 0921 · Severity E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · Deficient, Provider has date of correction 2021-12-05Tag 0585 · Severity D
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.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2021-12-05Tag 0677 · Severity D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2021-12-05Tag 0757 · Severity D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2021-12-05Tag 0759 · Severity D
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2021-12-052020-02-20
18 deficiencies
Highest severity: F
Immediate-jeopardy citations: 0
Tag 0812 · Severity F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0550 · Severity E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0725 · Severity E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0758 · Severity E
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0761 · Severity E
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0880 · Severity E
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0554 · Severity D
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0578 · Severity D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0655 · Severity D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0656 · Severity D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0689 · Severity D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0690 · Severity D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0756 · Severity D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0759 · Severity D
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0760 · Severity D
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2020-03-21Tag 0842 · Severity D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2020-03-21Staffing composition
2.09 hours/dayNurse aide
0.92 hours/dayLPN
0.49 hours/dayRN
- Total staffing
- 3.49 hours/day
- County median
- 3.61 hours/day
- Florida median
- 3.63 hours/day
- Weekend total
- 3.22 hours/day
- Staff turnover
- 51.9%
- RN turnover
- 75.0%
Reported averages, not a real-time staffing schedule.
Resident outcomes
Lower is generally better
Hospitalizations
2.5 per 1,000 daysworseFlorida: 2.1 per 1,000 days · County: 2.1 per 1,000 days20250101-20251231
Emergency-department visits
0.9 per 1,000 daysbetterFlorida: 1.0 per 1,000 days · County: 0.7 per 1,000 days20250101-20251231
Falls with major injury
2.1%similarFlorida: 2.2% · County: 1.9%2025Q2-2026Q1
Pressure ulcers
4.3%similarFlorida: 4.2% · County: 4.3%2025Q2-2026Q1
Urinary tract infections
1.3%unavailableFlorida: 0.0% · County: 0.2%2025Q2-2026Q1
Antipsychotic medication use
1.8%betterFlorida: 7.0% · County: 7.7%2025Q2-2026Q1
These group measures do not predict an individual resident’s experience.
Questions to ask
Use these prompts during a tour or phone call
How many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingWhat is driving staff turnover, and what is being done to retain nurses and aides?
Suggested because of: staff turnoverWhat operational changes followed the facility's most recent penalty?
Suggested because of: penaltiesHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning
Facility Details
- County
- Hillsborough County
- Certified beds
- 163
- Average daily residents
- 125.1
- Ownership
- Non profit - Church related
- Provider type
- Medicare and Medicaid
- In hospital
- No
- Date certified
- 1979-05-17
- CCN
- 105351
Staffing Data
| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.08674 |
| Lpn hours | 0.91739 |
| Rn hours | 0.49054 |
| Reported total hours | 3.49467 |
| Weekend total hours | 3.2212 |
| Weekend rn hours | 0.40632 |
| Adjusted total hours | 3.66471 |
| Total turnover percent | 51.9 |
| Rn turnover percent | 75 |
| Administrators left | 0 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
Penalties & Enforcement
$16,801.00Total fines
2Number of fines
0Payment denials
| Date | Type | Amount |
|---|---|---|
| 2024-04-10 | Fine | $4,017.00 |
| 2024-04-10 | Fine | $12,784.00 |
Totals reflect the supplied CMS records, not a lifetime total.
Citations
13Health citations
1Fire safety citations
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
Serious Deficiencies
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
1
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ownership & Operators
| Name | Role | Share |
|---|---|---|
| Ownership Data Not Available | Not reported by CMS |
Helpful resources
Educational information, not medical or legal advice. Data & methodology