Cycle 1
Health 2024-05-09 · Fire 2024-05-09
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Avon Park, FL
Royal Care Of Avon Park
1-star overall rating with 1-star inspections with $17,342 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1213 W Stratford Rd, Avon Park, FL
(863) 453-6674
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
90
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-07-01
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
0.94
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.63
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
0.92
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,872
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.79% · Performance 23.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.42% · Performance 10.73% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.55
Baseline 54.00% · Performance 41.00% · Measure score 5.55 · Achievement 5.55 · Improvement 3.96
Adjusted total nurse staffing
1.97
Baseline 3.90 hours · Performance 3.64 hours · Measure score 1.97 · Achievement 1.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.14% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 227 · Observed rate 9.25% · Lower 95% interval 6.98% |
| Discharge to community | 53.48% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 204 · Observed rate 45.59% · Lower 95% interval 47.12% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.27% |
95.27%
2 pts better
|
Numerator 214 · Denominator 220 |
| Falls with major injury | 0.91% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 220 |
| Discharge self-care score | 42.06% |
53.69%
11.6 pts worse
|
Numerator 53 · Denominator 126 |
| Discharge mobility score | 30.16% |
50.94%
20.8 pts worse
|
Numerator 38 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 11 · Denominator 220 · Adjusted rate 4.09% |
| Healthcare-associated infections requiring hospitalization | 10.73% |
7.12%
3.6 pts worse
|
Worse than the National Rate · Eligible stays 147 · Observed rate 15.65% · Lower 95% interval 7.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 144 |
| Staff flu vaccination coverage | 31.58% |
42%
10.4 pts worse
|
Numerator 48 · Denominator 152 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 54 · Denominator 126 |
| Transfer of health information to provider | 96.34% |
95.95%
0.4 pts better
|
Numerator 158 · Denominator 164 |
| Transfer of health information to patient | 70% |
96.28%
26.3 pts worse
|
Numerator 14 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 24.35% |
25.2%
0.8 pts worse
|
Numerator 28 · Denominator 115 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · 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 | 1.5% |
2.6%
1.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.9% · Q4 1.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
3.7%
3.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.9%
2.8 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 2.4% · Q4 5.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
15.7%
3.5 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 23.9% · Q3 15.9% · Q4 11.6% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
9.8%
6 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 6.2% · Q4 6.1% · 4Q avg 3.8% · 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 | 17.5% |
11.7%
5.8 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 4.6% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
9.8%
2.1 pts worse
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 13.6% · Q3 5.0% · Q4 7.3% · 4Q avg 11.9% · 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 1.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
0.8%
4 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 0.0% · Q3 6.1% · Q4 4.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.6% |
12.5%
1.9 pts better
|
19.8%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 12.2% · Q3 6.3% · Q4 8.1% · 4Q avg 10.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.1%
2 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.0% · Q3 5.5% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
94.3%
4.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.3% · Q3 99.0% · Q4 99.5% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
9.3%
1.5 pts worse
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.9% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.5% · Q3 1.4% · Q4 0.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.7%
2 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
26.2%
8.3 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.8% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-22 · Fire 2021-12-22
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-03-13 · Fire 2020-03-13
6 health deficiencies
Top issue: Quality of Life and Care (3 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
2024-05-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-31
D · Potential for more than minimal harm
2020-03-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-04-17
D · Potential for more than minimal harm
2020-03-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-04-17
D · Potential for more than minimal harm
2020-03-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-17
Inspection history
Recent health citations
G · Actual harm
2024-05-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-05-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-05-09
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 2024-05-31
E · Potential for more than minimal harm
2024-05-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-09
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 2024-05-31
E · Potential for more than minimal harm
2024-05-09
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 2024-05-31
E · Potential for more than minimal harm
2024-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-09
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
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 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-05-31
D · Potential for more than minimal harm
2021-12-22
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 2022-01-14
D · Potential for more than minimal harm
2021-12-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-14
E · Potential for more than minimal harm
2020-03-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-04-06
D · Potential for more than minimal harm
2020-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-06
D · Potential for more than minimal harm
2020-03-13
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 2020-04-06
D · Potential for more than minimal harm
2020-03-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-04-06
D · Potential for more than minimal harm
2020-03-13
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 2020-04-06
D · Potential for more than minimal harm
2020-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-06
Penalties and ownership
What sits behind the stars
$4,017
2024-05-09
Fine
Fine · fine $4,017
Fine
$13,325
2024-05-09
Fine
Fine · fine $13,325
Fine
Ownership
Strohli, Eli
5% Or Greater Direct Ownership Interest · Individual
Geldart, Donald
Operational/Managerial Control · Individual
Matheis, Pamela
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Oaks At Avon
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2-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
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Sebring, FL
2-star overall rating with 1-star inspections with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Vivo Healthcare Sebring
Sebring, FL
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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