Cycle 1
Health 2025-10-02 · Fire 2025-10-02
7 health deficiencies
Top issue: Administration (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Altoona, FL
Lakeview Terrace Rehab And Health Care Center
3-star overall rating with 2-star inspections with 7 recent health deficiencies
110 Lodge Terrace Dr, Altoona, FL
(352) 669-2133
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-06-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.75
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.94
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
4.65
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
7.35
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.69
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
6.26
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
7.69
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,330
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.51
Composite VBP score used to determine payment impact.
Payment multiplier
1.0127
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.44
Baseline 18.72% · Performance 20.77% · Measure score 1.44 · Achievement 1.44 · Improvement 0
Healthcare-associated infections
5.77
Baseline 5.97% · Performance 6.11% · Measure score 5.77 · Achievement 5.77 · Improvement 0
Total nurse turnover
5.79
Baseline 51.85% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 3.89
Adjusted total nurse staffing
10
Baseline 5.90 hours · Performance 6.17 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.91% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 7.63% · Lower 95% interval 6.45% |
| Discharge to community | 71.52% |
50.57%
20.9 pts better
|
Better than the National Rate · Eligible stays 109 · Observed rate 71.56% · Lower 95% interval 64.11% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.43% |
95.27%
3.8 pts worse
|
Numerator 64 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 56.36% |
53.69%
2.7 pts better
|
Numerator 31 · Denominator 55 |
| Discharge mobility score | 23.64% |
50.94%
27.3 pts worse
|
Numerator 13 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 70 · Adjusted rate 3.8% |
| Healthcare-associated infections requiring hospitalization | 6.11% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 3.53% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 109 |
| Staff flu vaccination coverage | 14.81% |
42%
27.2 pts worse
|
Numerator 20 · Denominator 135 |
| Discharge function score | 41.82% |
56.45%
14.6 pts worse
|
Numerator 23 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 25.81% |
25.2%
0.6 pts better
|
Numerator 8 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.6% |
97.8%
17.2 pts worse
|
93.4%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 88.0% · Q3 47.6% · Q4 80.0% · 4Q avg 80.6% |
| 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 | 1.1% |
2.6%
1.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
5.9%
5 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
15.7%
0.3 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.0% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
9.8%
0.9 pts worse
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · 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 | 38.8% |
11.7%
27.1 pts worse
|
16.3%
22.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.2% |
9.8%
21.4 pts worse
|
14.9%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 45.0% · 4Q avg 31.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
0.4%
2.2 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.2% · Q3 4.4% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.5% |
12.5%
22 pts worse
|
19.8%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.3% · Q2 45.7% · Q3 21.0% · Q4 18.4% · 4Q avg 34.5% |
| 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 · Q1 4.3% · Q2 3.8% · Q3 3.3% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
94.3%
0.2 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 88.2% · Q4 90.9% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.4% |
9.3%
5.9 pts better
|
12.0%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.4% · Observed 3.2% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
94.7%
3.2 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
26.2%
1 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 22.2% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-10 · Fire 2024-07-10
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-19
F · Potential for more than minimal harm
2023-03-16
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-16
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-10-02
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2026-01-09
F · Potential for more than minimal harm
2025-10-02
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2026-01-09
E · Potential for more than minimal harm
2025-10-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-09
E · Potential for more than minimal harm
2025-10-02
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 2026-01-09
D · Potential for more than minimal harm
2025-10-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-10-02
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 2026-01-09
D · Potential for more than minimal harm
2025-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-09
E · Potential for more than minimal harm
2024-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-10
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 2024-08-19
D · Potential for more than minimal harm
2024-07-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-19
D · Potential for more than minimal harm
2023-03-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
Ownership
Dsi Management LLC
Operational/Managerial Control · Organization
Folk, Amber
Corporate Director · Individual
Frisbie, Tammi
Operational/Managerial Control · Individual
Hamrick, Jonathan
Corporate Director · Individual
Koromilas, Shannon
Corporate Director · Individual
Payton, Donald
Corporate Director · Individual
Schultz, Gregory
Operational/Managerial Control · Individual
Schultz, Kenneth
Corporate Officer · Individual
Seay, Raleigh
Corporate Director · Individual
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#2
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2-star overall rating with 1-star inspections with $26,685 in total fines with 10 recent health deficiencies
#3
Ruleme Center
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2-star overall rating with 3-star inspections with $24,889 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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