01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-04-11 | 17 | 2024-04-11 | 7 |
| Cycle 2 | 2022-02-04 | 1 | 2022-02-04 | 5 |
| Cycle 3 | 2020-11-06 | 3 | 2020-11-06 | 4 |
CMS CCN 1052802026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Tarpon Bayou Center
515 Chesapeake Dr · Tarpon Springs, FL 34689 · Pinellas County
Certified beds114CMS provider file
Recent citation rows37current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-04-11 · FIREE0035Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0637Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0645Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0679Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0867Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-282024-04-11 · HEALTHF0881Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · HEALTHF0908Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Keep all essential equipment working safely.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-05-102024-04-11 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2024-05-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-04-11 | Fine | $10,170 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- TARPON REHABILITATION CENTER, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2009
- HEARTHSTONE SENIOR COMMUNITIES, INC.Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 04/01/2009
- GARNER, ALVINIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2009
- JAFFE, HOWARDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2009
- ROMBOLD, LORIIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2009
- WYATT, BRIANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2009
- CONSULTING SUPPORT SERVICES, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/28/2011
- FACILITY SUPPORT COMPANY, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/13/2010
- KANE FINANCIAL SERVICES, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/06/2012
- THEMIS HEALTH MANAGEMENT, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2009
- JOSEPH, PATRICIAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/20/2021
- MATTERN, ANDREAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/21/2021
- CONSULTING SUPPORT SERVICES, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/21/2025
- FACILITY SUPPORT COMPANY, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/21/2025
- KANE FINANCIAL SERVICES, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/21/2025
- SELECT REHABILITATION, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/19/2016
- THEMIS HEALTH MANAGEMENT, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/21/2025
- JOSEPH, PATRICIAIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/20/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.16per resident day
RN hours0.56per resident day
Weekend nurse hours3.04per resident day
Staff turnover23.1%CMS reported field
06 / LOCAL RECORDS
Open the Tarpon Springs ledger →