Tag 0554 · Severity D
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2026-02-04701 Victoria St, Brandon, FL 33510
(813) 681-4220 · Excelsior Care Group
| Ownership | For profit - Corporation | Certified beds | 120 |
|---|---|---|---|
| Estimated occupancy | 95.4% | Latest inspection | 2026-01-08 |
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 4 of 5 | 3 of 5 | 3 of 5 |
| Health-inspection score | 38.0 points | 56.5 points | 38.5 points |
| Total nurse staffing | 3.48 hours/day | 3.61 hours/day | 3.63 hours/day |
| RN staffing | 0.63 hours/day | 0.61 hours/day | 0.62 hours/day |
| Staff turnover | 67.4% | 43.7% | 41.8% |
| Latest health deficiencies | 11 deficiencies | 10 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Immediate-jeopardy citations: 0
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2026-02-04Honor 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 2026-02-04Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2026-02-04Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2026-02-04PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2026-02-04Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2026-02-04Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2026-02-04Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2026-02-04Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2026-02-04Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2026-02-04Procure 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 2026-02-04Immediate-jeopardy citations: 0
No matching citation detail was published.
Reported averages, not a real-time staffing schedule.
These group measures do not predict an individual resident’s experience.
What is driving staff turnover, and what is being done to retain nurses and aides?
Suggested because of: staff turnoverHow does the care team prevent and treat pressure injuries?
Suggested because of: pressure ulcersHow are antipsychotic medications reviewed, reduced when appropriate, and discussed with families?
Suggested because of: antipsychotic useHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.15314 |
| Lpn hours | 0.6935 |
| Rn hours | 0.63308 |
| Reported total hours | 3.47973 |
| Weekend total hours | 3.18943 |
| Weekend rn hours | 0.39997 |
| Adjusted total hours | 3.34398 |
| Total turnover percent | 67.4 |
| Rn turnover percent | 77.8 |
| Administrators left | 0 |
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 |
|---|---|---|
| BRANDON HEALTH MEMBER LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| FLNHO CAPITAL GROUP LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 33% |
| ORNSTEIN, MARTON | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% |
| LUCADANO, KIMBERLY | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
Educational information, not medical or legal advice. Data & methodology