Lake Wales, FL

Lake Wales Wellness And Rehabilitation Center

1-star overall rating with 1-star inspections with abuse icon flag with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

730 N Scenic Hwy, Lake Wales, FL

(863) 676-1512

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

100

Certified beds

Average residents

78

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ahava Healthcare

Operator or chain grouping

Approved since

2006-03-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

15 facilities

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

1.05

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.47

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.95

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.48

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.48

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.42

CMS adjusted RN staffing hours

Adjusted total hours

3.85

CMS adjusted total nurse staffing hours

Case-mix index

1.40

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,741

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

Performance score

15.48

Composite VBP score used to determine payment impact.

Payment multiplier

0.9815

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

1.70

Baseline 8.80% · Performance 7.96% · Measure score 1.70 · Achievement 0 · Improvement 1.70

Total nurse turnover

1.19

Baseline 62.77% · Performance 58.82% · Measure score 1.19 · Achievement 1.19 · Improvement 0.54

Adjusted total nurse staffing

1.75

Baseline 4.13 hours · Performance 3.58 hours · Measure score 1.75 · Achievement 1.75 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.45%
10.72%
1.3 pts better
No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 6.43%
Discharge to community 53.12%
50.57%
2.5 pts better
No Different than the National Rate · Eligible stays 36 · Observed rate 50% · Lower 95% interval 40.49%
Medicare spending per beneficiary 1.04
1.02
About the same
Drug regimen review with follow-up 85.71%
95.27%
9.6 pts worse
Numerator 54 · Denominator 63
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 63
Discharge self-care score 39.02%
53.69%
14.7 pts worse
Numerator 16 · Denominator 41
Discharge mobility score 24.39%
50.94%
26.5 pts worse
Numerator 10 · Denominator 41
Pressure ulcers or injuries, new or worsened 1.59%
2.29%
0.7 pts better
Numerator 1 · Denominator 63 · Adjusted rate 1.48%
Healthcare-associated infections requiring hospitalization 7.96%
7.12%
0.8 pts worse
No Different than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 3.89%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 25
Staff flu vaccination coverage 37.72%
42%
4.3 pts worse
Numerator 43 · Denominator 114
Discharge function score 43.9%
56.45%
12.6 pts worse
Numerator 18 · Denominator 41
Transfer of health information to provider 96.67%
95.95%
0.7 pts better
Numerator 29 · Denominator 30
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 14 · 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 33

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.8
2.1
0.3 pts better
1.9
0.1 pts better
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star
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 · Adjusted 2.2 · Observed 1.7 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 99.3%
97.8%
1.5 pts better
93.4%
5.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3%
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 2.2%
2.6%
0.4 pts better
3.3%
1.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 2.9% · Q4 2.9% · 4Q avg 2.2% · 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 9.7%
5.9%
3.8 pts worse
5.4%
4.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 6.8% · Q3 8.2% · Q4 10.5% · 4Q avg 9.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 26.2%
15.7%
10.5 pts worse
19.6%
6.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 29.0% · Q3 24.6% · Q4 20.3% · 4Q avg 26.2%
Percentage of long-stay residents who received an antipsychotic medication 7.1%
9.8%
2.7 pts better
16.7%
9.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 12.2% · Q3 4.8% · Q4 4.8% · 4Q avg 7.1% · 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 16.4%
11.7%
4.7 pts worse
16.3%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 13.3%
9.8%
3.5 pts worse
14.9%
1.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 15.5% · Q3 8.6% · Q4 15.7% · 4Q avg 13.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.3%
0.4%
0.1 pts better
1.0%
0.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · 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 15.2%
12.5%
2.7 pts worse
19.8%
4.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 15.3% · Q3 18.5% · Q4 11.5% · 4Q avg 15.2%
Percentage of long-stay residents with pressure ulcers 4.4%
5.1%
0.7 pts better
5.1%
0.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.9% · Q3 5.8% · Q4 5.2% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 87.0%
94.3%
7.3 pts worse
81.7%
5.3 pts better
Short Stay · 2024Q4-2025Q3 · Q1 63.4% · Q2 87.4% · Q3 100.0% · Q4 99.0% · 4Q avg 87.0%
Percentage of short-stay residents who had an outpatient emergency department visit 21.5%
9.3%
12.2 pts worse
12.0%
9.5 pts worse
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 20.0% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 2.1%
1.5%
0.6 pts worse
1.6%
0.5 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.4% · Q3 1.4% · Q4 1.8% · 4Q avg 2.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88.2%
94.7%
6.5 pts worse
79.7%
8.5 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.7%
26.2%
3.5 pts better
23.9%
1.2 pts better
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 20.0% · Expected 21.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-06-24 · Fire 2024-06-24

18 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2022-08-11 · Fire 2022-08-11

11 health deficiencies

Top issue: Resident Rights (4 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2021-03-26 · Fire 2021-03-26

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

7 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 2024-06-24

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-24

K521 · Services Deficiencies

Fire Safety

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

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-24

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-02-06

K521 · Services Deficiencies

Fire Safety

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

Corrected 2024-03-18

D · Potential for more than minimal harm 2022-08-11

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2022-09-11

D · Potential for more than minimal harm 2022-08-11

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2022-09-11

D · Potential for more than minimal harm 2022-08-11

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 2022-09-11

D · Potential for more than minimal harm 2021-03-26

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2021-04-23

D · Potential for more than minimal harm 2021-03-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-04-23

D · Potential for more than minimal harm 2021-03-26

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2021-04-23

D · Potential for more than minimal harm 2021-03-26

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 2021-04-23

D · Potential for more than minimal harm 2021-03-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2021-04-23

D · Potential for more than minimal harm 2021-03-26

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2021-04-23

Inspection history

Recent health citations

G · Actual harm 2025-06-24

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 2025-07-11

G · Actual harm 2025-04-30

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 2025-05-30

F · Potential for more than minimal harm 2025-04-30

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-30

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-30

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-30

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-30

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 2025-05-30

D · Potential for more than minimal harm 2025-04-30

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-05-30

F · Potential for more than minimal harm 2024-06-24

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 2024-07-24

F · Potential for more than minimal harm 2024-06-24

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 2024-07-24

F · Potential for more than minimal harm 2024-06-24

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-24

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-24

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 2024-07-24

D · Potential for more than minimal harm 2024-06-24

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-24

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 2024-07-24

D · Potential for more than minimal harm 2024-06-24

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 2024-07-24

D · Potential for more than minimal harm 2024-06-24

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-24

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 2024-07-24

D · Potential for more than minimal harm 2023-06-19

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 2023-07-07

D · Potential for more than minimal harm 2023-06-19

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 2023-07-10

G · Actual harm 2022-08-11

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-11

D · Potential for more than minimal harm 2022-08-11

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 2022-09-11

D · Potential for more than minimal harm 2022-08-11

F582 · Resident Rights Deficiencies

Health

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

Corrected 2022-09-11

D · Potential for more than minimal harm 2022-08-11

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 2022-09-11

D · Potential for more than minimal harm 2022-08-11

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2022-09-11

D · Potential for more than minimal harm 2022-08-11

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 2022-09-11

D · Potential for more than minimal harm 2022-08-11

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 2022-09-11

D · Potential for more than minimal harm 2022-08-11

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-09-11

D · Potential for more than minimal harm 2022-08-11

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 2022-09-11

D · Potential for more than minimal harm 2022-08-11

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 2022-09-11

D · Potential for more than minimal harm 2022-08-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-09-11

E · Potential for more than minimal harm 2021-03-26

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-04-23

D · Potential for more than minimal harm 2021-03-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-04-23

D · Potential for more than minimal harm 2021-03-26

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 2021-04-23

D · Potential for more than minimal harm 2021-03-26

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2021-04-23

D · Potential for more than minimal harm 2021-03-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-04-23

Penalties and ownership

What sits behind the stars

Ownership

Mfi Healthcare Fl LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2019-06-01
Niederman, Anshel

5% Or Greater Indirect Ownership Interest · Individual

50% 18 facilities 2019-06-01
Philipson Family Limited Liability Company, LLC

5% Or Greater Indirect Ownership Interest · Organization

20% 26 facilities 2019-06-01
Ecm Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

10% 6 facilities 2019-06-01
Labin, Shiya

5% Or Greater Indirect Ownership Interest · Individual

10% 14 facilities 2019-06-01
Neuman, Benjamin

5% Or Greater Indirect Ownership Interest · Individual

10% 14 facilities 2019-06-01
Dean, Byron

Operational/Managerial Control · Individual

0% 1 facilities 2024-07-10
Niederman, Anshel

Corporate Officer · Individual

0% 18 facilities 2019-06-01
Spadola, Cara

Operational/Managerial Control · Individual

0% 2 facilities 2024-07-10

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