Cycle 1
Health 2024-02-26 · Fire 2024-02-26
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lakeland, FL
Florida Presbyterian Homes Inc
5-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
909 Lakeside Ave, Lakeland, FL
(863) 688-5521
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Westminster Communities Of Florida
Operator or chain grouping
Approved since
1997-04-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 5 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
1.05
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,209
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.29% · Performance 22.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.36
Baseline 5.95% · Performance 6.83% · Measure score 3.36 · Achievement 3.36 · Improvement 0
Total nurse turnover
4.90
Baseline 85.71% · Performance 52.86% · Measure score 4.90 · Achievement 2.65 · Improvement 4.90
Adjusted total nurse staffing
5.19
Baseline 6.04 hours · Performance 4.56 hours · Measure score 5.19 · Achievement 5.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.35% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 221 · Observed rate 12.22% · Lower 95% interval 9.18% |
| Discharge to community | 63% |
50.57%
12.4 pts better
|
Better than the National Rate · Eligible stays 220 · Observed rate 60.45% · Lower 95% interval 56.39% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.69% |
95.27%
1.4 pts better
|
Numerator 175 · Denominator 181 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 181 |
| Discharge self-care score | 76.07% |
53.69%
22.4 pts better
|
Numerator 89 · Denominator 117 |
| Discharge mobility score | 67.52% |
50.94%
16.6 pts better
|
Numerator 79 · Denominator 117 |
| Pressure ulcers or injuries, new or worsened | 1.1% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 181 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 5.07% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 69.02% |
8.2%
60.8 pts better
|
Numerator 127 · Denominator 184 |
| Staff flu vaccination coverage | 90.71% |
42%
48.7 pts better
|
Numerator 166 · Denominator 183 |
| Discharge function score | 75.21% |
56.45%
18.8 pts better
|
Numerator 88 · Denominator 117 |
| Transfer of health information to provider | 96.91% |
95.95%
1 pts better
|
Numerator 94 · Denominator 97 |
| Transfer of health information to patient | 96.92% |
96.28%
0.6 pts better
|
Numerator 63 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 20.18% |
25.2%
5 pts worse
|
Numerator 22 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · 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 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.2% |
2.6%
0.6 pts worse
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 1.1% |
5.9%
4.8 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.8% |
15.7%
14.1 pts worse
|
19.6%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 30.8% · Q3 29.2% · Q4 26.1% · 4Q avg 29.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.6% |
9.8%
7.2 pts better
|
16.7%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · 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 | 11.0% |
11.7%
0.7 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
9.8%
9.6 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 19.2% · Q3 13.0% · Q4 4.3% · 4Q avg 19.4% · 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 | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.8% |
12.5%
2.3 pts worse
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 12.3% · Q3 8.5% · Q4 8.2% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
5.1%
4.4 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.3%
4.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.2% · Q4 98.2% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
9.3%
0.8 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 7.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.7%
3.9 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
26.2%
5.6 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.8% · Observed 27.8% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-03 · Fire 2022-03-03
5 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-01-08 · Fire 2021-01-08
3 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-02-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-15
D · Potential for more than minimal harm
2021-01-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-02-28
D · Potential for more than minimal harm
2021-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-02-28
D · Potential for more than minimal harm
2021-01-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-02-28
D · Potential for more than minimal harm
2021-01-08
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-02-28
D · Potential for more than minimal harm
2021-01-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-02-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-02-26
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 2024-03-15
E · Potential for more than minimal harm
2024-02-26
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 2024-03-15
E · Potential for more than minimal harm
2024-02-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-26
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 2024-03-18
D · Potential for more than minimal harm
2024-02-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-26
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 2024-03-15
D · Potential for more than minimal harm
2024-02-26
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 2024-03-15
F · Potential for more than minimal harm
2022-03-03
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-04-02
E · Potential for more than minimal harm
2022-03-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-04-02
E · Potential for more than minimal harm
2022-03-03
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-04-02
D · Potential for more than minimal harm
2022-03-03
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 2022-04-02
D · Potential for more than minimal harm
2022-03-03
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 2022-04-02
D · Potential for more than minimal harm
2021-01-08
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 2021-02-04
D · Potential for more than minimal harm
2021-01-08
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 2021-02-04
D · Potential for more than minimal harm
2021-01-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-02-04
Penalties and ownership
What sits behind the stars
Ownership
Abuaita, Ala
Operational/Managerial Control · Individual
Doddridge, Donald
Corporate Director · Individual
Doddridge, Donald
Corporate Officer · Individual
Durrant, Ellisa
Operational/Managerial Control · Individual
Faubel, Megan
Corporate Officer · Individual
Hennis, Garry
Corporate Director · Individual
Hennis, Garry
Corporate Officer · Individual
Keith, Henry
Corporate Director · Individual
Keith, Henry
Corporate Officer · Individual
Tamney, Michael
Corporate Officer · Individual
Nearby options
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#3
Vivo Healthcare Lakeland
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