5245 N Socrum Loop Rd, Lakeland, FL 33809
(863) 859-1446 · Excelsior Care Group
| Ownership | For profit - Limited Liability company | Certified beds | 120 |
|---|---|---|---|
| Estimated occupancy | 97.9% | Latest inspection | 2025-05-08 |
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 2 of 5 | 2 of 5 | 3 of 5 |
| Health-inspection score | 74.0 points | 74.0 points | 38.5 points |
| Total nurse staffing | 3.47 hours/day | 3.52 hours/day | 3.63 hours/day |
| RN staffing | 0.40 hours/day | 0.52 hours/day | 0.62 hours/day |
| Staff turnover | 48.4% | 45.5% | 41.8% |
| Latest health deficiencies | 11 deficiencies | 10 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Immediate-jeopardy citations: 0
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2025-06-08PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2025-06-08Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-06-08Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2025-06-08Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-06-08Ensure 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-06-08Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-06-08Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-06-08Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-06-08Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-06-08Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2025-06-08Immediate-jeopardy citations: 0
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2023-03-10Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · Deficient, Provider has date of correction 2023-03-10Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Administration Deficiencies · Deficient, Provider has date of correction 2023-03-10Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-03-10Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2023-03-10Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2023-03-10Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-03-10Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-03-10Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-03-10Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2023-03-10Ensure 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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2023-03-10Immediate-jeopardy citations: 0
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2021-08-26Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Deficient, Provider has date of correction 2021-08-26Honor 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.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2021-06-27Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2021-06-27Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2021-06-27Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2021-08-26Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2021-08-26Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2021-06-27Reported averages, not a real-time staffing schedule.
These group measures do not predict an individual resident’s experience.
How many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingWhat is driving staff turnover, and what is being done to retain nurses and aides?
Suggested because of: staff turnoverHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.13546 |
| Lpn hours | 0.93867 |
| Rn hours | 0.39647 |
| Reported total hours | 3.47059 |
| Weekend total hours | 3.30694 |
| Weekend rn hours | 0.34586 |
| Adjusted total hours | 3.45719 |
| Total turnover percent | 48.4 |
| Rn turnover percent | 58.8 |
| Administrators left | 1 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
0
| Name | Role | Share |
|---|---|---|
| LAKEVIEW SNF OPERATIONS HOLDINGS LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| SUNSHINE SNF GROUP LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% |
| LEIFER, JOEL | CORPORATE OFFICER | NOT APPLICABLE |
| BRADLEY, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| BRADLEY, MICHAEL | ADP OF THE SNF | NOT APPLICABLE |
Educational information, not medical or legal advice. Data & methodology