Cycle 1
Health 2024-03-26 · Fire 2024-03-26
10 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Winter Haven, FL
Astoria Health And Rehabilitation Center
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
701 Overlook Dr Se, Winter Haven, FL
(863) 318-5000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
124
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
2010-12-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,547
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.75
Baseline 24.67% · Performance 20.66% · Measure score 4.75 · Achievement 1.67 · Improvement 4.75
Healthcare-associated infections
5.02
Baseline 9.16% · Performance 6.86% · Measure score 5.02 · Achievement 3.25 · Improvement 5.02
Total nurse turnover
2.26
Performance 54.43% · Measure score 2.26 · Achievement 2.26 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.30
Baseline 3.70 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.11% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 439 · Observed rate 12.98% · Lower 95% interval 10.36% |
| Discharge to community | 67.13% |
50.57%
16.6 pts better
|
Better than the National Rate · Eligible stays 437 · Observed rate 62.24% · Lower 95% interval 61.52% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.47% |
95.27%
4.2 pts better
|
Numerator 373 · Denominator 375 |
| Falls with major injury | 0.53% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 375 |
| Discharge self-care score | 80.97% |
53.69%
27.3 pts better
|
Numerator 200 · Denominator 247 |
| Discharge mobility score | 83.81% |
50.94%
32.9 pts better
|
Numerator 207 · Denominator 247 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 5 · Denominator 375 · Adjusted rate 1.24% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 295 · Observed rate 6.44% · Lower 95% interval 4.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 197 |
| Staff flu vaccination coverage | 0.73% |
42%
41.3 pts worse
|
Numerator 2 · Denominator 274 |
| Discharge function score | 86.64% |
56.45%
30.2 pts better
|
Numerator 214 · Denominator 247 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 228 · Denominator 228 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 97 · Denominator 97 |
| Resident COVID-19 vaccinations up to date | 4.39% |
25.2%
20.8 pts worse
|
Numerator 9 · Denominator 205 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.8 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
97.8%
2.1 pts worse
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 90.9% · Q3 95.2% · Q4 97.7% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
99.2%
4.6 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.6%
0.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 3.6% · Q4 1.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
3.7%
1.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 0.0% · Q4 3.9% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.9%
1.4 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 0.0% · Q3 3.4% · Q4 5.1% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
15.7%
3.3 pts worse
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 16.1% · Q3 18.6% · Q4 21.0% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.1% |
9.8%
5.7 pts better
|
16.7%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.5% · Q3 5.8% · Q4 3.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.8% |
11.7%
2.1 pts worse
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 11.7% · Q4 10.3% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.8% |
9.8%
3 pts better
|
14.9%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.4% · Q3 5.3% · Q4 8.5% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
12.5%
10.1 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 27.4% · Q3 22.3% · Q4 13.4% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.1%
1.3 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.9% · Q3 3.3% · Q4 2.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
94.3%
3.7 pts worse
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 87.2% · Q3 89.6% · Q4 90.9% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
9.3%
2.2 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.9% · Q3 1.9% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.3% |
94.7%
23.4 pts worse
|
79.7%
8.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
26.2%
5.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 31.0% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-04 · Fire 2022-02-04
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2020-10-30 · Fire 2020-10-30
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-03-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-28
D · Potential for more than minimal harm
2022-02-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-03-03
D · Potential for more than minimal harm
2022-02-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-03-03
D · Potential for more than minimal harm
2022-02-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-03
D · Potential for more than minimal harm
2020-10-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-12-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-03-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-28
E · Potential for more than minimal harm
2024-03-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-28
E · Potential for more than minimal harm
2024-03-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-28
E · Potential for more than minimal harm
2024-03-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-28
E · Potential for more than minimal harm
2024-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-26
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-28
F · Potential for more than minimal harm
2022-02-04
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-04
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2022-03-04
F · Potential for more than minimal harm
2022-02-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-04
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-04
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-03-04
D · Potential for more than minimal harm
2020-10-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-12-03
D · Potential for more than minimal harm
2020-10-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-12-03
Penalties and ownership
What sits behind the stars
Ownership
Ott, Gary
5% Or Greater Direct Ownership Interest · Individual
Ott, Dwight
5% Or Greater Direct Ownership Interest · Individual
Lanham, Steven
5% Or Greater Direct Ownership Interest · Individual
Gibson, Cullen
5% Or Greater Direct Ownership Interest · Individual
Blackwell, Cory
Operational/Managerial Control · Individual
Gibson, Cullen
Corporate Officer · Individual
Ott, Dwight
Corporate Officer · Individual
Ott, Gary
Corporate Officer · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Viegas, Aleixo
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lake Mariam Health And Rehabilitation Center
Winter Haven, FL
1-star overall rating with 1-star inspections with Special Focus status with $353,123 in total fines with 36 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
Palm Garden Of Winter Haven
Winter Haven, FL
4-star overall rating with 3-star inspections with $24,395 in total fines with 8 recent health deficiencies
#3
Life Care Center Of Winter Haven
Winter Haven, FL
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out