B+
84/100BLUE HERON HEALTH AND REHABILITATION Inspection Report, Violations & Safety Grade (WESLEY CHAPEL, Florida)
5085 EAGLESTON BLVD, WESLEY CHAPEL, Florida 33544
Phone: 7656645400
CMS Overall:4/5
Overview & Bed Count
Certified Beds
141
Avg Residents/Day
135.8
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Pasco
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health3/5
Staffing4/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Florida Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.85 | 0.73 | +0.12 |
| Total Nurse Hours per Resident per Day | 3.97 | 3.86 | +0.11 |
| CMS Staffing Rating | 4/5 | 3.3/5 | - |
| Nursing Staff Turnover | 44.5% | 41.5% | - |
Health Citation History
18 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-06-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-07-31 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | E – Moderate Harm Potential |
| 2025-07-31 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-07-31 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2023-04-27 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2023-04-27 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | F – Moderate Harm Potential |
| 2023-04-27 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | E – Moderate Harm Potential |
| 2023-04-27 | 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. | E – Moderate Harm Potential |
| 2023-04-27 | Administration Deficiencies | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | E – Moderate Harm Potential |
| 2023-04-27 | Administration Deficiencies | Provide a neutral and fair arbitration process and agree to arbitrator and venue. | E – Moderate Harm Potential |
| 2023-04-27 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2023-04-27 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-04-27 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2023-04-27 | 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. | D – Moderate Harm Potential |
| 2023-04-27 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-04-27 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2023-04-27 | Nutrition and Dietary Deficiencies | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | D – Moderate Harm Potential |
Fire Safety Citation History
2 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2023-04-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | D – Moderate Harm Potential |
| 2023-04-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
Need Help Finding Safe Care?
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WESLEY CHAPEL area at no cost.
Find Safe, Vetted Facilities Near WESLEY CHAPEL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.