Cycle 1
Health 2023-09-28 · Fire 2023-09-28
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Lakeland, FL
Lakeland Hills Center
2-star overall rating with 1-star inspections with abuse icon flag with $214,420 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
610 E Bella Vista Dr, Lakeland, FL
(863) 688-8591
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Hearthstone Senior Communities
Operator or chain grouping
Approved since
1974-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 2 health / 3 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
0.49
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
79%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,370
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.53
Baseline 21.65% · Performance 19.79% · Measure score 3.53 · Achievement 3.53 · Improvement 3.51
Healthcare-associated infections
4.50
Baseline 7.38% · Performance 6.49% · Measure score 4.50 · Achievement 4.50 · Improvement 3.22
Total nurse turnover
5.96
Baseline 60.47% · Performance 39.33% · Measure score 5.96 · Achievement 5.96 · Improvement 5.44
Adjusted total nurse staffing
0.58
Baseline 3.32 hours · Performance 3.24 hours · Measure score 0.58 · Achievement 0.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 9.38% · Lower 95% interval 6.88% |
| Discharge to community | 39.86% |
50.57%
10.7 pts worse
|
Worse than the National Rate · Eligible stays 70 · Observed rate 30% · Lower 95% interval 29.77% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 79 · Denominator 79 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 79 |
| Discharge self-care score | 38.89% |
53.69%
14.8 pts worse
|
Numerator 21 · Denominator 54 |
| Discharge mobility score | 31.48% |
50.94%
19.5 pts worse
|
Numerator 17 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 2.53% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 79 · Adjusted rate 1.86% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 97 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 123 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 28 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.33% |
25.2%
22.9 pts worse
|
Numerator 1 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · 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 1.6 · 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 | 3.9% |
2.6%
1.3 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.4% · Q3 4.0% · Q4 3.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.9% |
3.7%
4.2 pts worse
|
11.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.3% · Q3 6.0% · Q4 13.1% · 4Q avg 7.9% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.9%
0.2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 3.5% · Q3 6.9% · Q4 5.6% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
15.7%
1.1 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 12.8% · Q3 9.9% · Q4 15.4% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
9.8%
5 pts worse
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 14.5% · Q3 15.8% · Q4 14.7% · 4Q avg 14.8% · 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 | 4.5% |
11.7%
7.2 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 8.5% · Q3 4.4% · Q4 0.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
9.8%
5.9 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.9% · Q3 2.4% · Q4 3.5% · 4Q avg 3.9% · 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 | 0.0% |
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 | 3.7% |
12.5%
8.8 pts better
|
19.8%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 6.9% · Q4 5.6% · 4Q avg 3.7% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.1%
0.4 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.8% · Q3 3.5% · Q4 2.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.9% |
9.3%
6.4 pts better
|
12.0%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.9% · Observed 3.7% · Expected 14.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.9% · Q3 1.4% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
26.2%
5.7 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 25.9% · Expected 30.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-19 · Fire 2021-08-19
5 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-11-22 · Fire 2019-11-22
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 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
2023-09-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-28
D · Potential for more than minimal harm
2021-08-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-09-19
D · Potential for more than minimal harm
2021-08-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-09-19
D · Potential for more than minimal harm
2021-08-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-19
D · Potential for more than minimal harm
2019-11-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-22
Inspection history
Recent health citations
K · Immediate jeopardy
2025-04-11
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 2025-06-29
K · Immediate jeopardy
2025-04-11
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 2025-05-29
K · Immediate jeopardy
2025-04-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-29
E · Potential for more than minimal harm
2025-01-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-14
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 2025-02-14
D · Potential for more than minimal harm
2025-01-14
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 2025-02-14
F · Potential for more than minimal harm
2024-08-12
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 2024-09-11
F · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-28
E · Potential for more than minimal harm
2023-09-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-28
E · Potential for more than minimal harm
2023-09-28
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-28
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 2023-10-28
D · Potential for more than minimal harm
2023-09-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-28
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 2023-10-28
D · Potential for more than minimal harm
2023-09-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-07-18
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 2023-08-18
D · Potential for more than minimal harm
2021-08-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-09-19
D · Potential for more than minimal harm
2019-11-22
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 2019-12-22
D · Potential for more than minimal harm
2019-11-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
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 2019-12-22
D · Potential for more than minimal harm
2019-11-22
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 2019-12-22
Penalties and ownership
What sits behind the stars
$214,420
2025-04-11
Fine
Fine · fine $214,420
Fine
$0
2025-04-11
Payment Denial
Payment Denial · denial start 2025-06-12 · 17 days
17 day denial
Ownership
Hearthstone Senior Communities, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Lakeland Hills Rehabilitation Center, LLC
5% Or Greater Direct Ownership Interest · Organization
Bowden, Destiny
Operational/Managerial Control · Individual
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Facility Support Company, LLC
Operational/Managerial Control · Organization
Garner, Alvin
Corporate Officer · Individual
Jaffe, Howard
Corporate Officer · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Kuhlmeyer, Richard
Operational/Managerial Control · Individual
Rombold, Lori
Corporate Officer · Individual
Themis Health Management, LLC
Operational/Managerial Control · Organization
Wyatt, Brian
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Vivo Healthcare Lakeland
Lakeland, FL
1-star overall rating with 1-star inspections with abuse icon flag with $181,077 in total fines with 13 recent health deficiencies
#2
Charming Lakes Rehab
Lakeland, FL
1-star overall rating with 1-star inspections with $136,136 in total fines with 12 recent health deficiencies
#3
Valencia Hills Health And Rehabilitation Center
Lakeland, FL
1-star overall rating with 1-star inspections with $24,236 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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