Cycle 1
Health 2024-10-31 · Fire 2024-10-31
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Madison, FL
Lake Park Of Madison Nursing And Rehabilitation Ce
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
259 Sw Captain Brown Rd, Madison, FL
(850) 973-8277
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Maximus Healthcare Group
Operator or chain grouping
Approved since
1995-08-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 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
0.54
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.27
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
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,031
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.89
Baseline 23.04% · Performance 21.00% · Measure score 2.89 · Achievement 0.94 · Improvement 2.89
Healthcare-associated infections
0
Baseline 7.75% · Performance 7.84% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.02
Baseline 47.75% · Performance 35.00% · Measure score 7.02 · Achievement 7.02 · Improvement 5.07
Adjusted total nurse staffing
3.79
Baseline 4.88 hours · Performance 4.16 hours · Measure score 3.79 · Achievement 3.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.16% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 14.93% · Lower 95% interval 8.78% |
| Discharge to community | 50.25% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 39.53% · Lower 95% interval 34.53% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 15.07% |
95.27%
80.2 pts worse
|
Numerator 11 · Denominator 73 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 73 |
| Discharge self-care score | 34.88% |
53.69%
18.8 pts worse
|
Numerator 15 · Denominator 43 |
| Discharge mobility score | 46.51% |
50.94%
4.4 pts worse
|
Numerator 20 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 12.33% |
2.29%
10 pts worse
|
Numerator 9 · Denominator 73 · Adjusted rate 10.69% |
| Healthcare-associated infections requiring hospitalization | 7.84% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 10.64% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 9.09% |
42%
32.9 pts worse
|
Numerator 17 · Denominator 187 |
| Discharge function score | 48.84% |
56.45%
7.6 pts worse
|
Numerator 21 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 15% |
25.2%
10.2 pts worse
|
Numerator 6 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · 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 | 2.6% |
2.6%
About the same
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.2% · Q3 2.4% · Q4 2.6% · 4Q avg 2.6% · 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 | 6.5% |
5.9%
0.6 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.4% · Q3 6.6% · Q4 5.9% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
15.7%
4.6 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 10.8% · Q3 11.2% · Q4 12.5% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
9.8%
4.2 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.6% · Q3 5.1% · Q4 7.7% · 4Q avg 5.6% · 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 | 5.5% |
11.7%
6.2 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.4% · Q3 3.7% · Q4 0.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
9.8%
4.1 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.4% · Q3 5.4% · Q4 7.5% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 4.5% |
12.5%
8 pts better
|
19.8%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.9% · Q3 3.6% · Q4 5.4% · 4Q avg 4.5% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.1%
0.2 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.5% · Q3 4.5% · Q4 5.6% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
94.3%
5.1 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
9.3%
1 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 9.1% · Expected 12.3% · 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 0.0% · Q2 2.0% · Q3 2.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
94.7%
0.7 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.6% |
26.2%
6.4 pts worse
|
23.9%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.6% · Observed 36.4% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-03-23 · Fire 2022-03-23
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-16
D · Potential for more than minimal harm
2023-07-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-31
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 2024-12-12
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-20
D · Potential for more than minimal harm
2022-03-23
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 2022-04-23
Penalties and ownership
What sits behind the stars
Ownership
Lake Park Max Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bornstein, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Hirsch, Nisson
5% Or Greater Indirect Ownership Interest · Individual
Lbs Capital Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Maximus Rrs LLC
5% Or Greater Indirect Ownership Interest · Organization
Royal Rehab South
5% Or Greater Indirect Ownership Interest · Organization
Sevor, Ashley
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Madison Health And Rehabilitation Center
Madison, FL
5-star overall rating with 5-star inspections
#2
Greenville Nursing And Rehab Center
Greenville, FL
1-star overall rating with 1-star inspections with $222,253 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Center
Live Oak, FL
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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