Home › Florida › Pasco County › Blue Heron Health and Rehabilitation
Blue Heron Health and Rehabilitation
5085 Eagleston Blvd, Wesley Chapel, FL 33544 · CMS Certification Number (CCN) 106147
At a glance
- CMS overall rating
- ★★★★☆ 4 of 5
- Health inspection citations
- 18 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 2 from complaints)
- Fire safety citations
- 2
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- July 31, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Florida average | U.S. average |
|---|---|---|---|
| Overall | ★★★★☆ 4 of 5 | 3.3 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 3.3 | 2.9 |
| Quality measures | ★★★★★ 5 of 5 | 4.2 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | July 31, 2025 | 5 | 3 | 2 |
| Cycle 2 | April 27, 2023 | 13 | 13 | 0 |
CMS weighted health inspection score: 41 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
18 health citations across 3 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 13, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/13/2026 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/13/2026 |
July 31, 2025: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/31/2025 |
| D | F-0656 | 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 | Standard | Deficient, Provider has date of correction Corrected 08/31/2025 |
| E | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/31/2025 |
April 27, 2023: 13 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0848 | Provide a neutral and fair arbitration process and agree to arbitrator and venue. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| E | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| F | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| D | F-0801 | 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. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| E | F-0758 | 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 | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| D | F-0688 | 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 | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| D | F-0657 | 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 | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| D | F-0625 | 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. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| E | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/26/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
2 fire safety citations across 1 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 04/27/2023 | D | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/19/2023 |
| 04/27/2023 | D | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/19/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Florida average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.02 | 3.82 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.84 | 0.73 | 0.69 |
| LPN/LVN hours per resident per day | 0.89 | Not published | Not published |
| Nurse aide hours per resident per day | 2.28 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.56 | Not published | Not published |
| RN hours per resident per day, weekends | 0.64 | Not published | Not published |
| Total nursing staff turnover (%) | 43.2 | 41.4 | 45.8 |
| Registered nurse turnover (%) | 42.9 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Blue Heron Health and Rehabilitation LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Tlc Management (20 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 141
- Average residents per day
- 133.3
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- July 12, 2021
- County/parish
- Pasco
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
6 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| SMITH, KIMBERLY | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KIMBERLY | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| OTT, DWIGHT | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| OTT, GARY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| OTT, RYAN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TENDER LOVING CARE MANAGEMENT INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Blue Heron Health and Rehabilitation. Full inspection reports, quality measures and staffing.
- AHCA licensed health care facility complaint form. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.