Cycle 1
Health 2024-01-24 · Fire 2024-01-24
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Winter Haven, FL
Winter Haven Health And Rehabilitation Center
2-star overall rating with 2-star inspections with $4,190 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
202 Ave O Ne, Winter Haven, FL
(863) 293-3103
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
132
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Senior Health South
Operator or chain grouping
Approved since
1982-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 2 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
0.44
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,503
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.34% · Performance 21.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.72% · Performance 9.75% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.91
Baseline 48.57% · Performance 31.36% · Measure score 7.91 · Achievement 7.91 · Improvement 6.76
Adjusted total nurse staffing
1.48
Baseline 3.47 hours · Performance 3.50 hours · Measure score 1.48 · Achievement 1.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.08% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 13.54% · Lower 95% interval 8.3% |
| Discharge to community | 39.27% |
50.57%
11.3 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 28.21% · Lower 95% interval 24.34% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.2% |
95.27%
2.1 pts worse
|
Numerator 96 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 50.75% |
53.69%
2.9 pts worse
|
Numerator 34 · Denominator 67 |
| Discharge mobility score | 35.82% |
50.94%
15.1 pts worse
|
Numerator 24 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 103 · Adjusted rate 0.76% |
| Healthcare-associated infections requiring hospitalization | 9.75% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 18.18% · Lower 95% interval 5.79% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 158 |
| Staff flu vaccination coverage | 12.78% |
42%
29.2 pts worse
|
Numerator 23 · Denominator 180 |
| Discharge function score | 56.72% |
56.45%
0.3 pts better
|
Numerator 38 · Denominator 67 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| 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 | 6.06% |
25.2%
19.1 pts worse
|
Numerator 4 · Denominator 66 |
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 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.8%
1.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 2.5% · Q4 1.7% · 4Q avg 2.3% · 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 | 4.5% |
5.9%
1.4 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.1% · Q3 5.0% · Q4 4.0% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
15.7%
8.6 pts worse
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 25.7% · Q3 22.5% · Q4 27.2% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.4% |
9.8%
14.6 pts worse
|
16.7%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 27.3% · Q3 22.2% · Q4 25.3% · 4Q avg 24.4% · 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 | 9.6% |
11.7%
2.1 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 12.1% · Q3 12.4% · Q4 6.8% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
9.8%
0.2 pts worse
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.0% · Q3 13.5% · Q4 11.2% · 4Q avg 10.0% · 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 | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.7% |
12.5%
6.8 pts better
|
19.8%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 3.7% · Q3 6.3% · Q4 2.8% · 4Q avg 5.7% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.1%
0.6 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.0% · Q3 5.4% · Q4 6.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
94.3%
2.7 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 98.3% · Q3 99.2% · Q4 92.9% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
9.3%
2.5 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 12.7% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.4% · Q3 5.3% · Q4 3.5% · 4Q avg 3.0% · 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 | 28.4% |
26.2%
2.2 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 26.6% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-22 · Fire 2021-10-22
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-02-07 · Fire 2020-02-07
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-03
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 2024-10-03
D · Potential for more than minimal harm
2024-09-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-01-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-01-24
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-02-24
D · Potential for more than minimal harm
2020-02-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-07
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 2020-03-07
D · Potential for more than minimal harm
2020-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-07
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2020-03-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-01-24
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 2024-02-24
E · Potential for more than minimal harm
2024-01-24
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 2024-02-24
E · Potential for more than minimal harm
2024-01-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-24
E · Potential for more than minimal harm
2024-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-24
E · Potential for more than minimal harm
2024-01-24
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 2024-02-24
D · Potential for more than minimal harm
2024-01-24
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 2024-02-24
D · Potential for more than minimal harm
2024-01-24
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 2024-02-24
D · Potential for more than minimal harm
2024-01-24
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 2024-02-24
D · Potential for more than minimal harm
2024-01-24
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 2024-02-24
D · Potential for more than minimal harm
2024-01-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-24
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 2024-02-24
D · Potential for more than minimal harm
2024-01-24
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-02-24
E · Potential for more than minimal harm
2021-10-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-11-21
E · Potential for more than minimal harm
2021-10-22
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 2021-11-21
E · Potential for more than minimal harm
2021-10-22
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-11-21
D · Potential for more than minimal harm
2021-10-22
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 2021-11-21
D · Potential for more than minimal harm
2021-10-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-11-21
D · Potential for more than minimal harm
2021-10-22
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 2021-11-21
D · Potential for more than minimal harm
2021-10-22
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-11-21
D · Potential for more than minimal harm
2020-02-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-07
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 2020-03-07
D · Potential for more than minimal harm
2020-02-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-07
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-03-07
Penalties and ownership
What sits behind the stars
$4,190
2024-01-24
Fine
Fine · fine $4,190
Fine
Ownership
Senior Health South Ex LLC
5% Or Greater Direct Ownership Interest · Organization
Brown, Jennifer
Operational/Managerial Control · Individual
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Depiano, Rich
Corporate Officer · Individual
Eleus Health Management LLC
Operational/Managerial Control · Organization
Facility Support Company, LLC
Operational/Managerial Control · Organization
Jaffe, Howard
Corporate Officer · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Mullen, Ann
Corporate Officer · Individual
Omega Healthcare Investors, Inc
5% Or Greater Security Interest · Organization
Richmond, Penny
Corporate Officer · Individual
Robinson-Brady, Alexia
Operational/Managerial Control · Individual
Senior Health Properties South, Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Life Care Center Of Winter Haven
Winter Haven, FL
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Palm Garden Of Winter Haven
Winter Haven, FL
4-star overall rating with 3-star inspections with $24,395 in total fines with 8 recent health deficiencies
#3
Lake Mariam Health And Rehabilitation Center
Winter Haven, FL
1-star overall rating with 1-star inspections with Special Focus status with $353,123 in total fines with 36 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
Jump out