Winter Haven, FL

Lake Mariam Health And Rehabilitation Center

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

1801 N Lake Mariam Dr, Winter Haven, FL

(863) 293-1989

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

93

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Robert Schoenfeld

Operator or chain grouping

Approved since

1983-02-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.55

Registered nurse staffing

LPN hours / resident day

0.94

Licensed practical nurse staffing

Aide hours / resident day

3.10

Nurse aide staffing

Weekend hours

4.13

Weekend nurse staffing

RN turnover

47%

Annual RN turnover

Total nurse turnover

52%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.1
2.1
1 pts worse
1.9
1.2 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 2.2
1.2
1 pts worse
1.8
0.4 pts worse
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 94.9%
97.8%
2.9 pts worse
93.4%
1.5 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents experiencing one or more falls with major injury 2.1%
2.6%
0.5 pts better
3.3%
1.2 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents who lose too much weight 4.4%
5.9%
1.5 pts better
5.4%
1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 11.0%
15.7%
4.7 pts better
19.6%
8.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 14.2%
9.8%
4.4 pts worse
16.7%
2.5 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 15.7%
11.7%
4 pts worse
16.3%
0.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 13.1%
9.8%
3.3 pts worse
14.9%
1.8 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with a urinary tract infection 0.9%
0.8%
0.1 pts worse
1.7%
0.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 23.7%
12.5%
11.2 pts worse
19.8%
3.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 3.0%
5.1%
2.1 pts better
5.1%
2.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 69.2%
94.3%
25.1 pts worse
81.7%
12.5 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.5%
1.5 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 82.5%
94.7%
12.2 pts worse
79.7%
2.8 pts better
Short Stay · 2024Q3-2025Q2

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-01-25 · Fire 2024-01-25

36 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2021-10-08 · Fire 2021-10-08

11 health deficiencies

Top issue: Resident Rights (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-11-15 · Fire 2019-11-15

14 health deficiencies

Top issue: Resident Rights (4 deficiencies)

3 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-01-25

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-25

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-02-05

D · Potential for more than minimal harm 2019-11-15

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2019-12-15

D · Potential for more than minimal harm 2019-11-15

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2019-12-15

D · Potential for more than minimal harm 2019-11-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-12-15

Inspection history

Recent health citations

G · Actual harm 2024-10-17

F624 · Resident Rights Deficiencies

Health

Prepare residents for a safe transfer or discharge from the nursing home.

Corrected 2024-11-15

E · Potential for more than minimal harm 2024-10-17

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 2024-11-15

D · Potential for more than minimal harm 2024-10-17

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 2024-11-15

K · Immediate jeopardy 2024-05-17

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-06-06

K · Immediate jeopardy 2024-01-25

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 2024-06-06

E · Potential for more than minimal harm 2024-01-25

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 2024-06-06

E · Potential for more than minimal harm 2024-01-25

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 2024-06-06

E · Potential for more than minimal harm 2024-01-25

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-02-25

E · Potential for more than minimal harm 2024-01-25

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2024-04-25

E · Potential for more than minimal harm 2024-01-25

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-02-25

E · Potential for more than minimal harm 2024-01-25

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 2024-06-06

E · Potential for more than minimal harm 2024-01-25

F867 · Administration Deficiencies

Health

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

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-01-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-02-25

E · Potential for more than minimal harm 2024-01-25

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-02-25

E · Potential for more than minimal harm 2024-01-25

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

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 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F559 · Resident Rights Deficiencies

Health

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

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 2024-02-25

D · Potential for more than minimal harm 2024-01-25

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 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

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 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

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 2024-04-25

D · Potential for more than minimal harm 2024-01-25

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

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 2024-04-25

D · Potential for more than minimal harm 2024-01-25

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

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 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F837 · Administration Deficiencies

Health

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F918 · Environmental Deficiencies

Health

Provide a bathroom in or located near each resident’s room.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F920 · Environmental Deficiencies

Health

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F924 · Environmental Deficiencies

Health

Put firmly secured handrails on each side of hallways.

Corrected 2024-02-25

D · Potential for more than minimal harm 2024-01-25

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2024-02-25

J · Immediate jeopardy 2023-08-18

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-09-15

J · Immediate jeopardy 2023-08-18

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 2023-09-15

E · Potential for more than minimal harm 2023-08-18

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 2023-09-15

E · Potential for more than minimal harm 2023-08-18

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2023-09-15

E · Potential for more than minimal harm 2021-10-08

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2021-11-08

D · Potential for more than minimal harm 2021-10-08

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2021-11-08

D · Potential for more than minimal harm 2021-10-08

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 2021-11-08

D · Potential for more than minimal harm 2021-10-08

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 2021-11-08

D · Potential for more than minimal harm 2021-10-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2021-12-30

D · Potential for more than minimal harm 2021-10-08

F867 · Administration Deficiencies

Health

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

Corrected 2021-12-30

D · Potential for more than minimal harm 2021-10-08

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2021-11-08

E · Potential for more than minimal harm 2019-11-15

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2019-12-15

E · Potential for more than minimal harm 2019-11-15

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 2019-12-15

E · Potential for more than minimal harm 2019-11-15

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 2019-12-15

E · Potential for more than minimal harm 2019-11-15

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2019-12-15

D · Potential for more than minimal harm 2019-11-15

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2019-12-15

D · Potential for more than minimal harm 2019-11-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-12-15

D · Potential for more than minimal harm 2019-11-15

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 2019-12-15

D · Potential for more than minimal harm 2019-11-15

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 2019-12-15

D · Potential for more than minimal harm 2019-11-15

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 2019-12-15

D · Potential for more than minimal harm 2019-11-15

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 2019-12-15

Penalties and ownership

What sits behind the stars

$12,529 2024-10-17

Fine

Fine · fine $12,529

Fine

$12,542 2024-01-25

Fine

Fine · fine $12,542

Fine

$296,449 2024-01-25

Fine

Fine · fine $296,449

Fine

$31,603 2023-08-18

Fine

Fine · fine $31,603

Fine

Ownership

Lake Mariam Fl Holdco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2023-08-11
Schoenfeld, Robert

5% Or Greater Indirect Ownership Interest · Individual

75% 12 facilities 2023-08-11
Fl Hc Opco LLC

Operational/Managerial Control · Organization

0% 5 facilities 2023-04-01
Schoenfeld, Robert

Operational/Managerial Control · Individual

0% 12 facilities 2023-04-01
Schoenfeld, Robert

Corporate Officer · Individual

0% 12 facilities 2023-08-11

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