Lakeland, FL

Breezy Hills Rehab And Care Center

2-star overall rating with 2-star inspections with $6,351 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

5245 N Socrum Loop Rd, Lakeland, FL

(863) 859-1446

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

113

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Excelsior Care Group

Operator or chain grouping

Approved since

1984-12-28

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

33 facilities

Chain averages 3 overall / 2 health / 3 staffing / 4 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

0.44

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.83

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.32

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.59

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.27

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.42

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.40

CMS adjusted total nurse staffing hours

Case-mix index

1.45

Higher values indicate more complex resident acuity

RN turnover

59%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,496

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

16.59

Composite VBP score used to determine payment impact.

Payment multiplier

0.9816

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.41

Performance 20.78% · Measure score 1.41 · Achievement 1.41 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

3.86

Performance 6.68% · Measure score 3.86 · Achievement 3.86 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

0

Performance 63.82% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.37

Baseline 3.18 hours · Performance 3.47 hours · Measure score 1.37 · Achievement 1.37 · Improvement 0.61

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.04%
10.72%
0.7 pts better
No Different than the National Rate · Eligible stays 68 · Observed rate 8.82% · Lower 95% interval 6.74%
Discharge to community 41.31%
50.57%
9.3 pts worse
No Different than the National Rate · Eligible stays 46 · Observed rate 30.43% · Lower 95% interval 30.77%
Medicare spending per beneficiary 1.01
1.02
About the same
Drug regimen review with follow-up 97.83%
95.27%
2.6 pts better
Numerator 135 · Denominator 138
Falls with major injury 0.72%
0.77%
0.1 pts better
Numerator 1 · Denominator 138
Discharge self-care score 31.91%
53.69%
21.8 pts worse
Numerator 30 · Denominator 94
Discharge mobility score 35.11%
50.94%
15.8 pts worse
Numerator 33 · Denominator 94
Pressure ulcers or injuries, new or worsened 2.17%
2.29%
0.1 pts better
Numerator 3 · Denominator 138 · Adjusted rate 2.18%
Healthcare-associated infections requiring hospitalization 6.68%
7.12%
0.4 pts better
No Different than the National Rate · Eligible stays 34 · Observed rate 5.88% · Lower 95% interval 3.25%
Staff COVID-19 vaccination coverage 29.85%
8.2%
21.7 pts better
Numerator 40 · Denominator 134
Staff flu vaccination coverage 14.19%
42%
27.8 pts worse
Numerator 22 · Denominator 155
Discharge function score 38.3%
56.45%
18.2 pts worse
Numerator 36 · Denominator 94
Transfer of health information to provider 97.5%
95.95%
1.5 pts better
Numerator 39 · Denominator 40
Transfer of health information to patient 94.87%
96.28%
1.4 pts worse
Numerator 37 · Denominator 39
Resident COVID-19 vaccinations up to date 0%
25.2%
25.2 pts worse
Numerator 0 · Denominator 92

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.3
2.1
1.2 pts worse
1.9
1.4 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.6 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.0
1.2
0.2 pts better
1.8
0.8 pts better
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.4%
97.8%
0.6 pts better
93.4%
5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
99.2%
0.8 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury 2.6%
2.6%
About the same
3.3%
0.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.3% · Q3 1.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 8.0%
3.7%
4.3 pts worse
11.4%
3.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.1% · Q3 3.6% · Q4 6.9% · 4Q avg 8.0%
Percentage of long-stay residents who lose too much weight 9.5%
5.9%
3.6 pts worse
5.4%
4.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 15.3% · Q3 8.3% · Q4 8.2% · 4Q avg 9.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 19.7%
15.7%
4 pts worse
19.6%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 19.5% · Q3 20.5% · Q4 17.2% · 4Q avg 19.7%
Percentage of long-stay residents who received an antipsychotic medication 8.5%
9.8%
1.3 pts better
16.7%
8.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.2% · Q3 7.5% · Q4 9.5% · 4Q avg 8.5% · 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 11.8%
11.7%
0.1 pts worse
16.3%
4.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 5.0% · Q3 12.9% · Q4 0.0% · 4Q avg 11.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 7.7%
9.8%
2.1 pts better
14.9%
7.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 10.7% · Q3 9.4% · Q4 4.8% · 4Q avg 7.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.4%
0.4 pts better
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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.3%
0.8%
0.5 pts better
1.7%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 8.3%
12.5%
4.2 pts better
19.8%
11.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.1% · Q3 4.7% · Q4 1.1% · 4Q avg 8.3%
Percentage of long-stay residents with pressure ulcers 5.1%
5.1%
About the same
5.1%
About the same
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.9% · Q3 4.6% · Q4 2.8% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 97.2%
94.3%
2.9 pts better
81.7%
15.5 pts better
Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 96.3% · Q3 98.0% · Q4 98.1% · 4Q avg 97.2%
Percentage of short-stay residents who had an outpatient emergency department visit 10.8%
9.3%
1.5 pts worse
12.0%
1.2 pts better
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 12.3% · Expected 12.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.8%
1.5%
0.3 pts worse
1.6%
0.2 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 2.5% · Q4 2.6% · 4Q avg 1.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 99.0%
94.7%
4.3 pts better
79.7%
19.3 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.3%
26.2%
5.9 pts better
23.9%
3.6 pts better
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 24.7% · Expected 29.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-08 · Fire 2025-05-08

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-02-08 · Fire 2023-02-08

14 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-05-27 · Fire 2021-05-27

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

10 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-05-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2025-06-08

D · Potential for more than minimal harm 2023-02-08

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2023-03-10

F · Potential for more than minimal harm 2021-05-27

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2021-06-25

F · Potential for more than minimal harm 2021-05-27

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2021-06-25

F · Potential for more than minimal harm 2021-05-27

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2021-06-25

F · Potential for more than minimal harm 2021-05-27

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2021-06-25

D · Potential for more than minimal harm 2021-05-27

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2021-06-25

D · Potential for more than minimal harm 2021-05-27

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2021-06-25

D · Potential for more than minimal harm 2021-05-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-06-25

D · Potential for more than minimal harm 2021-05-27

K373 · Smoke Deficiencies

Fire Safety

Have enough space near smoke barriers to protect residents.

Corrected 2021-06-25

D · Potential for more than minimal harm 2021-05-27

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-06-25

D · Potential for more than minimal harm 2021-05-27

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-06-25

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-08

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 2025-06-08

E · Potential for more than minimal harm 2025-05-08

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-06-08

E · Potential for more than minimal harm 2025-05-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

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 2025-06-08

D · Potential for more than minimal harm 2025-05-08

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-05-08

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-06-08

D · Potential for more than minimal harm 2025-03-27

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2025-04-11

D · Potential for more than minimal harm 2024-07-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-07-02

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-07-02

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-07-17

F · Potential for more than minimal harm 2023-02-08

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 2023-03-10

F · Potential for more than minimal harm 2023-02-08

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2023-03-10

F · Potential for more than minimal harm 2023-02-08

F848 · Administration Deficiencies

Health

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected 2023-03-10

E · Potential for more than minimal harm 2023-02-08

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 2023-03-10

E · Potential for more than minimal harm 2023-02-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-03-10

D · Potential for more than minimal harm 2023-02-08

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 2023-03-10

E · Potential for more than minimal harm 2021-05-27

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 2021-08-26

E · Potential for more than minimal harm 2021-05-27

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2021-08-26

D · Potential for more than minimal harm 2021-05-27

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2021-06-27

D · Potential for more than minimal harm 2021-05-27

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 2021-06-27

D · Potential for more than minimal harm 2021-05-27

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2021-06-27

D · Potential for more than minimal harm 2021-05-27

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2021-08-26

D · Potential for more than minimal harm 2021-05-27

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2021-08-26

D · Potential for more than minimal harm 2021-05-27

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 2021-06-27

Penalties and ownership

What sits behind the stars

$6,351 2023-07-17

Fine

Fine · fine $6,351

Fine

Ownership

Lakeview SNF Operations Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2021-09-03
Berkowitz, Cheskel

5% Or Greater Indirect Ownership Interest · Individual

0% 28 facilities 2021-09-30
Joseph, Edeline

W-2 Managing Employee · Individual

0% 1 facilities 2021-10-01
Landa, Benjamin

5% Or Greater Indirect Ownership Interest · Individual

0% 103 facilities 2021-09-30
Leifer, Joel

5% Or Greater Indirect Ownership Interest · Individual

0% 43 facilities 2021-09-30
Leifer, Joel

Corporate Officer · Individual

0% 43 facilities 2022-04-01
Sunshine SNF Group LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 4 facilities 2021-09-30
Zupnick, Joel

5% Or Greater Indirect Ownership Interest · Individual

0% 37 facilities 2021-09-30

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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

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#2

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3-star overall rating with 2-star inspections with abuse icon flag with $24,252 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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#3

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2-star overall rating with 3-star inspections with 2 recent health deficiencies

Overall
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Health
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Staffing
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