Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Blue Heron Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that a fire-rated door leading to a hazardous dry storage room, protected by a one-hour fire barrier and equipped with a self-closing device, was held open by a bungee cord and obstructed by a storage rack, preventing it from self-closing and latching as required by NFPA 101. The Administrator confirmed the door should remain closed, and the deficiency was cited based on these observations.
Three gas-fed appliances on casters under the commercial cooking hood were found with restraint tethers attached but not secured to the wall attachments, as confirmed by the DOM during inspection. This failure to properly limit appliance movement resulted in non-compliance with NFPA 101, NFPA 96, and NFPA 54 standards.
The facility did not complete or update PASARR Level II assessments for three residents with significant mental health diagnoses, despite evidence in their medical records and medication orders. The DON confirmed that required diagnoses were missing from PASARR documentation and that the facility lacked a PASARR policy.
A resident who was totally dependent for eating and drinking due to multiple medical conditions was not provided with adequate hydration support. Observations showed fluids were not offered or consumed, and staff and family confirmed the resident could not access fluids independently. Despite being identified as high risk for dehydration, there was no care plan or physician order to address this need, and the facility lacked a dehydration policy.
A resident with quadriplegia, dementia, and total dependence for eating and drinking was not provided with a care plan or interventions addressing their high risk for dehydration. Observations showed fluids were not consistently available or offered, and staff interviews confirmed the resident could not request or obtain fluids independently. The medical record lacked orders or a care plan focus for hydration, and the facility did not provide a dehydration policy.
A resident who was totally dependent on staff for eating and drinking due to quadriplegia and other medical conditions was repeatedly observed without fluids accessible and was not offered hydration during activities or throughout the day. Despite being at high risk for dehydration, there was no care plan or physician order to ensure fluids were provided, and staff did not consistently offer fluids as required.
Fire-Rated Door in Hazardous Area Improperly Propped Open
Penalty
Summary
During a facility tour conducted with the Director of Maintenance (DOM) and the Administrator, surveyors observed that a fire-rated door in the kitchen exit passage leading into a hazardous dry storage room was not maintained in accordance with NFPA 101 standards. The door, which is protected by a one-hour fire barrier and equipped with a self-closing device, was found to be held open by a bungee cord wrapped around the door handle. Additionally, a storage rack was positioned in such a way that it further restricted the door from self-closing and latching as required. The Administrator, when interviewed at the time of the observation, confirmed the findings and acknowledged that the door should be kept closed. The report specifies that such doors are only permitted to be held open by an automatic release device that complies with NFPA 101 section 7.2.1.8.2, which ensures the door will close automatically upon activation of the fire alarm, sprinkler system, smoke detection system, or loss of power. In this instance, the door was not equipped with such a device and was instead manually propped open, which is not compliant with the cited regulations. No information was provided in the report regarding any residents or staff being directly affected at the time of the deficiency, nor was there mention of any medical history or specific conditions related to individuals in the facility. The deficiency was based solely on the physical observation of the door's condition and the facility's failure to maintain required fire safety standards for doors with self-closing devices in hazardous areas.
Plan Of Correction
1) No residents were identified. 2) No residents were identified. 3) Administrator immediately discarded bungee cord found to be propping fire door open on 08/04/2025. An in-service education was conducted by the Administrator, Director of Plant Operations, or designee on 08/21/2025 with staff addressing the maintaining doors with self-closing devices in accordance with NFPA 101 (2012 Edition). 4) The Director of Plant Operations, or designee, will audit at random five (5) Fire Rated Doors to observe if the door is free from devices that would prevent self-close and latch. Audits will be conducted once a week for four weeks, once a month for two months, or until substantial compliance is achieved. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, the frequency of further review and ongoing need for review will be determined by the QAPI committee. The same information is repeated in the original text, so it is presented here as a continuous paragraph for clarity.
Commercial Cooking Equipment Not Properly Secured
Penalty
Summary
During a facility tour conducted with the Director of Maintenance (DOM) and the Administrator, it was observed that three gas-fed appliances mounted on casters under the commercial cooking hood were not properly secured. Although each appliance had a restraint tether attached, none of the tethers were connected to the installed wall attachments located behind the appliances. The DOM confirmed these findings during the inspection by visually checking behind the appliances and acknowledging that the tethers were not attached to the wall as required. This lack of proper restraint for the gas-fed appliances constitutes a failure to maintain commercial cooking equipment in accordance with NFPA 101, NFPA 96, and NFPA 54 standards. The deficiency was identified in both buildings referenced in the report, with all three appliances in each building found in the same non-compliant condition. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
1) No residents were identified. 2) No residents were identified. 3) Restraint tethers immediately attached and secured to wall attachments located behind appliances on 08/04/2025 at 1:55 PM by Director of Plant Operations or designee. An in-service education was conducted by the Administrator, Director of Plant Operations, or designee on 08/21/2025 with dining staff addressing the commercial cooking equipment in accordance with NFPA 101 (2012 Edition). 4) The Director of Plant Operations, or designee will audit commercial cooking equipment in accordance with NFPA 101 (2012 Edition) to observe restraint tethers attached and secured to wall attachments located behind appliances. Audits will be conducted once a week for four weeks, once a month for two months, or until substantial compliance is achieved. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.
Failure to Complete and Coordinate PASARR Level II Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to properly complete the Pre-admission Screening and Resident Review (PASARR) Level II process for residents with qualifying mental health diagnoses. Specifically, three residents were admitted with diagnoses such as Alzheimer's disease, schizoaffective disorder, bipolar disorder, and other mental health conditions, but their PASARR Level I screens did not reflect these diagnoses, and recommendations for Level II PASARR were not acted upon. Medical records and medication orders indicated the presence of serious mental illness, yet the required PASARR documentation was incomplete or inaccurate, with qualifying diagnoses left unchecked and no follow-up assessments performed as required. Interviews with the Director of Nursing (DON) confirmed that it is the facility's responsibility to review and, if necessary, resubmit PASARR assessments to ensure accuracy. The DON acknowledged that the PASARRs for the affected residents were missing necessary diagnoses and should have been corrected and updated. Additionally, the facility was unable to provide a PASARR policy when requested, further indicating a lack of proper coordination and documentation in compliance with federal requirements.
Plan Of Correction
1) Resident #8 PASARR was updated on 08/20/2025. Resident #16 PASARR was updated on 08/20/2025. Resident #17 PASARR was updated on 08/20/2025. 2) An audit of all current residents was completed on 08/20/2025 by the Director of Nursing, or designee, to verify the PASARR Level II for residents with qualifying health diagnosis. 3) Admissions team in-serviced by the Executive Director on 08/20/2025 to verify the PASARR Level II for residents with qualifying health diagnosis. Interdisciplinary team in-serviced by the Executive Director and Director of Nursing, on 08/20/2025 to verify the PASARR Level II for residents with qualifying health diagnosis. 4) The Director of Nursing, or designee, will conduct a random audit of five (5) residents per week to verify the PASARR Level II for residents with qualifying health diagnosis for four (4) consecutive weeks, then once a week for four (4) weeks, then once a month for two months, or until substantial compliance is achieved. After substantial compliance, it will be reviewed at a minimum quarterly by Director of Social Services. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.
Failure to Implement Hydration Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was at high risk for dehydration. Multiple observations revealed that the resident, who was totally dependent for eating and drinking due to quadriplegia and other significant medical conditions, did not have fluids readily accessible or being offered by staff. The resident was observed on several occasions lying in bed or sitting in a wheelchair without hydration available, and a marked water cup showed no change in water level over time, indicating fluids were not being consumed or offered. Interviews with the resident's family member and staff confirmed that the resident required total assistance and could not independently access fluids. The family member expressed concern that staff were not offering fluids frequently enough, and the RN/Unit Manager acknowledged that the resident was unable to request or obtain fluids on their own. Despite the resident's high risk for dehydration, as documented in the quarterly risk assessment and MDS, there was no care plan focus or physician order in place to address this risk, such as encouraging or offering fluids every two hours. The review of the resident's medical record showed that while there were care plan interventions for assistance with ADLs and monitoring for urinary tract infections, there was no specific intervention or policy addressing the resident's hydration needs. The facility was unable to provide a dehydration policy when requested. These findings demonstrate that the facility did not meet the requirement to develop and implement a comprehensive care plan that addresses all identified needs, specifically the risk for dehydration in this resident.
Plan Of Correction
1) Resident #68's plan of care updated to reflect at risk for dehydration on 8/5/2025 with appropriate interventions. 2) An audit of current residents' quarterly hydration risk evaluation was conducted on 08/20/2025 by Director of Nursing, Nurse Management team, or designee to verify residents to be at risk for dehydration. Care plan reviews with intervention updated to include providing necessary assistance, encouragement and offering of fluids throughout shift, as clinically indicated. 3) An in-service education was conducted on 08/19/2025 by the Administrator, Director of Nursing, or designee with all licensed/registered nurses addressing the significance of hydration risk evaluation completed on admission, quarterly, and/or significant change, and the implementation of a plan of care for a resident at risk for dehydration. 4) The nursing management team, Registered Dietitian, and/or Dietary Manager will review each resident with risk factors for dehydration to ensure appropriate interventions are implemented and an updated plan of care is complete. The Director of Nursing (DON), or designee, will complete five (5) random weekly chart audits for six (6) consecutive weeks to review quarterly hydration risk evaluations and verify that appropriate interventions have been put in place to reduce the risk of dehydration. Audits will assure that care plans remain updated to reflect these interventions. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.
Failure to Implement Hydration Care Plan for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive care plan for a resident identified as being at high risk for dehydration. Multiple observations over several days revealed that the resident, who was non-verbal, totally dependent for eating and drinking, and unable to request or obtain fluids independently, did not have hydration or fluids readily available at the bedside during several checks. The resident was also observed attending activities without being offered fluids, and a marked water cup in the resident's room showed no change in water level, indicating fluids were not being consumed or offered as needed. The resident's medical record documented significant diagnoses, including quadriplegia, pneumonitis, moderate protein-calorie malnutrition, dementia, chronic kidney disease, and chronic urinary tract infections (UTIs). The care plan addressed the need for assistance with activities of daily living (ADLs) and feeding, as well as monitoring for changes related to UTIs, but did not include a specific focus or interventions for dehydration risk. A quarterly risk assessment and MDS confirmed the resident's total dependence and high risk for hydration issues, yet there was no care plan focus or physician order to encourage or offer fluids every two hours as would be expected for such a resident. Interviews with staff confirmed that the resident required total assistance and could not hold a cup or request fluids. Staff acknowledged the expectation to offer fluids to residents at risk for dehydration, especially those with recurrent UTIs, but there was no evidence in the medical record or care plan that these interventions were implemented. Additionally, the facility was unable to provide a dehydration policy when requested.
Plan Of Correction
1) Resident #58's plan of care updated to reflect at risk for dehydration on 8/5/2025 with appropriate interventions. 2) An audit of current residents' quarterly hydration risk evaluation was conducted on 08/20/2025 by the Director of Nursing, Nurse Management team, or designee to verify residents to be at risk for dehydration. Care plan reviews with intervention updated to include providing necessary assistance, encouragement, and offering of fluids throughout shift, as clinically indicated. 3) An in-service education was conducted on 08/19/2025 by the Administrator, Director of Nursing, or designee with all licensed/registered nurses addressing the significance of hydration risk evaluation completed on admission, quarterly, and/or significant change, and the implementation of a plan of care for a resident at risk for dehydration. 4) The nursing management team, Registered Dietitian, and/or Dietary Manager will review each resident with risk factors for dehydration to ensure appropriate interventions are implemented and an updated plan of care is complete. The Director of Nursing (DON), or designee, will complete five (5) random weekly chart audits for six (6) consecutive weeks to review quarterly hydration risk evaluations and verify that appropriate interventions have been put in place to reduce the risk of dehydration. Audits will assure that care plans remain updated to reflect these interventions. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.
Failure to Ensure Proper Hydration for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to ensure proper hydration for a resident who was totally dependent on staff for eating and drinking due to quadriplegia, dementia, and other significant medical conditions. Multiple observations over several days revealed that the resident was often found in bed or in a wheelchair without fluids accessible at the bedside, and there was no evidence that staff were offering fluids during activities or throughout the day. The resident's water cup was observed to remain at the same level for extended periods, indicating fluids were not being consumed or offered as needed. Interviews with the resident's family and staff confirmed that the resident was unable to request or obtain fluids independently and required total assistance. The family expressed concern that staff were not checking on the resident frequently enough or offering fluids as needed. Staff acknowledged that the resident was at high risk for dehydration and that the expectation was to offer fluids every two hours, especially for residents with recurring UTIs and other risk factors. However, there was no care plan focus or physician order in place to ensure fluids were encouraged or offered at the required frequency. A review of the resident's medical record and care plan showed the resident was assessed as high risk for dehydration, but interventions specific to hydration were not implemented. The facility was unable to provide a dehydration policy, and there was no documentation of a plan to address the resident's hydration needs, despite the resident's total dependence and high-risk status.
Plan Of Correction
1) Resident #58 was assessed on 08/05/2025 by Licensed Nurse, with no adverse effects noted. The Director of Nursing Services and Registered Dietitian reassessed the hydration status and fluid needs for resident #58 on 08/21/2025. All fluids provided on the resident tray at mealtime and at the resident's bedside were re-evaluated and preferences were readdressed. Appropriate revisions were made to the care plan(s) to reflect current hydration interventions. The revised care plans were reviewed with staff involved in the care of the resident. 2) An audit of current residents' hydration risk evaluations was conducted on 08/20/2025 by the Director of Clinical Services, and Nurse Management team to verify a resident to be at risk for dehydration. Care plan reviews with intervention updated to include providing necessary assistance, encouragement, and offering of fluids throughout shift, as clinically indicated. 3) An in-service education was conducted on 08/19/2025 by the Administrator, Director of Nursing, or designee with all direct care staff addressing the significance of accurate reporting of fluids consumed during meals, the need to encourage fluid intake, and the provision of sufficient intake between meals to maintain adequate hydration. The in-service also addressed the importance of reporting conditions that alter a resident's fluid needs. 4) The nursing management team, Registered Dietitian, and/or Dietary Manager will review each resident with risk factors for dehydration to ensure appropriate interventions are implemented and an updated plan of care is complete. The Director of Nursing (DON), or designee, will complete five (5) random resident observations or resident and staff interviews on varying shifts and varying days weekly for fluid consumption for six (6) consecutive weeks and review all fluid intake records to ensure that appropriate interventions have been put in place to reduce the risk of dehydration. Audits will assure that care plans remain updated to reflect these interventions. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, the frequency of further review and ongoing need for review will be determined by the QAPI committee.
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What surveyors actually found near you
We read the 186 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wesley Chapel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baldomero Lopez Memorial Veterans Nursing Home | 5.5 mi | ★★★★★ | 3 | 0 |
| Luxe At Lutz Rehabilitation Center (the) | 9.2 mi | ★★★★★ | 1 | 0 |
| Pruitthealth-north Tampa, Llc | 9.6 mi | ★★★★★ | 1 | 0 |
| Tampa Lakes Health And Rehabilitation Center | 10.5 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Lake Zephyr | 10.8 mi | ★★★★★ | 2 | 0 |
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