Tag 0867 · Severity F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Deficient, Provider has date of correction 2024-06-28Non-profit
Tarpon Bayou Center
515 Chesapeake Dr, Tarpon Springs, FL 34689
(727) 934-4629 · Hearthstone Senior Communities
At a glance
CMS data snapshot: 2026-08-01 · Sources and limitations
| Ownership | Non profit - Corporation | Certified beds | 114 |
|---|---|---|---|
| Estimated occupancy | 86.2% | Latest inspection | 2024-04-11 |
County and Florida comparison
Navy: facility · Teal: county · Gray: Florida
Overall rating
Facility: 1 of 5
Health-inspection score
Facility: 136.0 points
Total nurse staffing
Facility: 3.16 hours/day
RN staffing
Facility: 0.56 hours/day
Staff turnover
Facility: 23.1%
Latest health deficiencies
Facility: 17 deficiencies
View data table
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 1 of 5 | 2 of 5 | 3 of 5 |
| Health-inspection score | 136.0 points | 74.0 points | 38.5 points |
| Total nurse staffing | 3.16 hours/day | 3.51 hours/day | 3.63 hours/day |
| RN staffing | 0.56 hours/day | 0.56 hours/day | 0.62 hours/day |
| Staff turnover | 23.1% | 50.7% | 41.8% |
| Latest health deficiencies | 17 deficiencies | 11 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Inspection history
2024-04-11
17 deficiencies
Highest severity: F
Immediate-jeopardy citations: 0
Tag 0880 · Severity F
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2024-06-28Tag 0908 · Severity F
Keep all essential equipment working safely.
Environmental Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0584 · Severity E
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 0645 · Severity E
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0677 · Severity E
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 2024-06-28Tag 0679 · Severity E
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0550 · Severity D
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 2024-05-10Tag 0554 · Severity D
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-06-28Tag 0637 · Severity D
Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0641 · Severity D
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-10Tag 0657 · Severity D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-06-28Tag 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 2024-06-28Tag 0758 · Severity D
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 2024-06-28Tag 0759 · Severity D
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-06-28Tag 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 2024-06-28Tag 0881 · Severity D
Implement a program that monitors antibiotic use.
Infection Control Deficiencies · Deficient, Provider has date of correction 2024-05-102022-02-04
1 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 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 2022-02-232020-11-06
3 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 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 2020-12-04Tag 0688 · Severity D
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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2021-01-21Tag 0867 · Severity D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Deficient, Provider has date of correction 2021-01-21Staffing composition
2.00 hours/dayNurse aide
0.60 hours/dayLPN
0.56 hours/dayRN
- Total staffing
- 3.16 hours/day
- County median
- 3.51 hours/day
- Florida median
- 3.63 hours/day
- Weekend total
- 3.04 hours/day
- Staff turnover
- 23.1%
- RN turnover
- 28.6%
Reported averages, not a real-time staffing schedule.
Resident outcomes
Lower is generally better
Hospitalizations
2.2 per 1,000 daysworseFlorida: 2.1 per 1,000 days · County: 2.3 per 1,000 days20250101-20251231
Emergency-department visits
0.8 per 1,000 daysbetterFlorida: 1.0 per 1,000 days · County: 1.1 per 1,000 days20250101-20251231
Falls with major injury
3.3%worseFlorida: 2.2% · County: 2.3%2025Q2-2026Q1
Pressure ulcers
3.0%betterFlorida: 4.2% · County: 4.6%2025Q2-2026Q1
Urinary tract infections
0.0%unavailableFlorida: 0.0% · County: 0.2%2025Q2-2026Q1
Antipsychotic medication use
20.6%worseFlorida: 7.0% · County: 7.0%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 fall-prevention program is used, and how are families notified after a fall?
Suggested because of: falls major injuryHow are antipsychotic medications reviewed, reduced when appropriate, and discussed with families?
Suggested because of: antipsychotic useWhat 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
- Pinellas County
- Certified beds
- 114
- Average daily residents
- 98.3
- Ownership
- Non profit - Corporation
- Provider type
- Medicare and Medicaid
- In hospital
- No
- Date certified
- 1974-04-12
- CCN
- 105280
Staffing Data
| Reported measure | Value |
|---|---|
| Nurse aide hours | 1.99946 |
| Lpn hours | 0.59813 |
| Rn hours | 0.56239 |
| Reported total hours | 3.15998 |
| Weekend total hours | 3.03804 |
| Weekend rn hours | 0.24784 |
| Adjusted total hours | 3.27797 |
| Total turnover percent | 23.1 |
| Rn turnover percent | 28.6 |
| Administrators left | 0 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
Penalties & Enforcement
$10,170.00Total fines
1Number of fines
0Payment denials
| Date | Type | Amount |
|---|---|---|
| 2024-04-11 | Fine | $10,170.00 |
Totals reflect the supplied CMS records, not a lifetime total.
Citations
17Health citations
16Fire 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.
0
Ownership & Operators
| Name | Role | Share |
|---|---|---|
| TARPON REHABILITATION CENTER, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| HEARTHSTONE SENIOR COMMUNITIES, INC. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% |
| GARNER, ALVIN | CORPORATE OFFICER | NOT APPLICABLE |
| JAFFE, HOWARD | CORPORATE OFFICER | NOT APPLICABLE |
| ROMBOLD, LORI | CORPORATE OFFICER | NOT APPLICABLE |
| WYATT, BRIAN | CORPORATE OFFICER | NOT APPLICABLE |
| CONSULTING SUPPORT SERVICES, LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| FACILITY SUPPORT COMPANY, LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| KANE FINANCIAL SERVICES, LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| THEMIS HEALTH MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| JOSEPH, PATRICIA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MATTERN, ANDREA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| CONSULTING SUPPORT SERVICES, LLC | ADP OF THE SNF | NOT APPLICABLE |
| FACILITY SUPPORT COMPANY, LLC | ADP OF THE SNF | NOT APPLICABLE |
| KANE FINANCIAL SERVICES, LLC | ADP OF THE SNF | NOT APPLICABLE |
| SELECT REHABILITATION, LLC | ADP OF THE SNF | NOT APPLICABLE |
| THEMIS HEALTH MANAGEMENT, LLC | ADP OF THE SNF | NOT APPLICABLE |
| JOSEPH, PATRICIA | ADP OF THE SNF | NOT APPLICABLE |
| MATTERN, ANDREA | ADP OF THE SNF | NOT APPLICABLE |
Helpful resources
Educational information, not medical or legal advice. Data & methodology