Cycle 1
Health 2025-04-10 · Fire 2025-04-10
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lake City, FL
Lake City Healthcare And Rehabilitation Center
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
298 Sw Prosperity Place, Lake City, FL
(386) 269-3900
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
113
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
2019-08-20
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
0.35
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,218
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.51
Baseline 21.84% · Performance 19.91% · Measure score 3.51 · Achievement 3.29 · Improvement 3.51
Healthcare-associated infections
2.84
Baseline 5.29% · Performance 6.99% · Measure score 2.84 · Achievement 2.84 · Improvement 0
Total nurse turnover
0
Performance 62.33% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.41
Baseline 3.94 hours · Performance 4.05 hours · Measure score 3.41 · Achievement 3.41 · Improvement 0.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 263 · Observed rate 11.79% · Lower 95% interval 8.45% |
| Discharge to community | 57.49% |
50.57%
6.9 pts better
|
Better than the National Rate · Eligible stays 246 · Observed rate 49.59% · Lower 95% interval 50.75% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 240 · Denominator 240 |
| Falls with major injury | 0.42% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 240 |
| Discharge self-care score | 59.15% |
53.69%
5.5 pts better
|
Numerator 97 · Denominator 164 |
| Discharge mobility score | 43.9% |
50.94%
7 pts worse
|
Numerator 72 · Denominator 164 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 8 · Denominator 240 · Adjusted rate 3.47% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 6.71% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 0.43% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 233 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 54.27% |
56.45%
2.2 pts worse
|
Numerator 89 · Denominator 164 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 163 · Denominator 163 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 129 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.2
1.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
97.8%
1 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 97.4% · Q3 95.9% · Q4 96.2% · 4Q avg 96.8% |
| 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 | 1.9% |
2.6%
0.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 5.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
3.7%
1.3 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 0.0% · Q4 4.1% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
5.9%
1.5 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.9% · Q3 7.9% · Q4 6.6% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
15.7%
0.4 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 11.4% · Q3 14.1% · Q4 29.2% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
9.8%
6.6 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.8% · Q3 3.9% · Q4 3.4% · 4Q avg 3.2% · 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 | 13.7% |
11.7%
2 pts worse
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 7.5% · Q3 26.0% · Q4 13.5% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.1% |
9.8%
3.7 pts better
|
14.9%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.7% · Q3 6.5% · Q4 3.2% · 4Q avg 6.1% · 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 1.2% · 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 | 8.8% |
12.5%
3.7 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.2% · Q3 9.9% · Q4 11.0% · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.1%
3.4 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 7.4% · Q3 9.8% · Q4 5.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
94.3%
4.9 pts worse
|
81.7%
7.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 87.5% · Q3 90.1% · Q4 87.5% · 4Q avg 89.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
9.3%
2.1 pts worse
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.9% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
94.7%
2.4 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
26.2%
1.9 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 26.2% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-19 · Fire 2024-01-19
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-07-27 · Fire 2022-07-27
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-22
E · Potential for more than minimal harm
2024-01-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-19
E · Potential for more than minimal harm
2022-07-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-22
E · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
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 2025-05-22
D · Potential for more than minimal harm
2025-04-10
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 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
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 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
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 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
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 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-22
E · Potential for more than minimal harm
2024-01-19
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 2024-02-20
D · Potential for more than minimal harm
2024-01-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-19
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 2024-02-19
D · Potential for more than minimal harm
2024-01-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-19
F · Potential for more than minimal harm
2022-07-27
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 2022-08-24
E · Potential for more than minimal harm
2022-07-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-27
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 2022-08-24
D · Potential for more than minimal harm
2022-07-27
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 2022-08-24
D · Potential for more than minimal harm
2022-07-27
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-27
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 2022-08-24
D · Potential for more than minimal harm
2022-07-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-27
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 2022-08-24
D · Potential for more than minimal harm
2022-07-27
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 2022-08-24
Penalties and ownership
What sits behind the stars
Ownership
Lake City Operating Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bdcc Consutking Group LLC
5% Or Greater Indirect Ownership Interest · Organization
David, Rochel
5% Or Greater Indirect Ownership Interest · Individual
Fdz Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Friedman, Leah
5% Or Greater Indirect Ownership Interest · Individual
Jz Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Powers, Brian
5% Or Greater Indirect Ownership Interest · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Rubiweb Florida Services Group Usa LLC
5% Or Greater Indirect Ownership Interest · Organization
Weber, Aron
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Charles
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
Operational/Managerial Control · Individual
Zahler, Jacob
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Lake Montgomery Health And Rehabilitation Center
Lake City, FL
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Solaris Healthcare Lake City
Lake City, FL
4-star overall rating with 3-star inspections with $24,850 in total fines with 6 recent health deficiencies
#3
Baya Pointe Nursing And Rehabilitation Center
Lake City, FL
1-star overall rating with 1-star inspections with $157,180 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out