LAKE MARIAM HEALTH AND REHABILITATION CENTER
Open-data reference.
LAKE MARIAM HEALTH AND REHABILITATION CENTER is a for profit - limited liability company facility in WINTER HAVEN, FL with 120 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $353K.
1801 N LAKE MARIAM DR, WINTER HAVEN, FL 33884
Phone: 8632931989
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 105428
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 93
- In Hospital
- No
- County
- Polk
- Last Inspection
- Jan 25, 2024
- Special Focus
- SFF Candidate
Staffing Data
- RN Hours
- 0.55 (nat'l avg: 0.68)
- LPN Hours
- 0.94
- CNA Hours
- 3.10
- Total Nursing Hours
- 4.60 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 52.0%
- RN Turnover
- 47.1%
What the CMS Record Reveals About LAKE MARIAM HEALTH AND REHABILITATION CENTER
LAKE MARIAM HEALTH AND REHABILITATION CENTER operates 120 certified beds in WINTER HAVEN, FL with approximately 93 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (4★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 5 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 4 penalties totaling $353K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.60 total nursing hours per resident day (national average 3.89), with RN coverage at 0.55 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, LAKE MARIAM HEALTH AND REHABILITATION CENTER falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 52.0%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Prepare residents for a safe transfer or discharge from the nursing home.
Category: Resident Rights Deficiencies
Corrected: Nov 15, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Nov 15, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Nov 15, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 6, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Feb 25, 2024
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Category: Administration Deficiencies
Corrected: Feb 25, 2024
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 25, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jun 6, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Feb 25, 2024
Have policies on smoking.
Category: Environmental Deficiencies
Corrected: Feb 25, 2024
Put firmly secured handrails on each side of hallways.
Category: Environmental Deficiencies
Corrected: Feb 25, 2024
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Category: Environmental Deficiencies
Corrected: Feb 25, 2024
Provide a bathroom in or located near each resident’s room.
Category: Environmental Deficiencies
Corrected: Feb 25, 2024
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Category: Environmental Deficiencies
Corrected: Feb 25, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Feb 25, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 25, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Jun 6, 2024
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category: Administration Deficiencies
Corrected: Feb 25, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 6, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Feb 25, 2024
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 25, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 25, 2024
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 25, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 25, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Apr 25, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Apr 25, 2024
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Feb 25, 2024
Try 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.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 25, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 25, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 25, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 25, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 6, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 25, 2024
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 25, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 25, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 25, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 6, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 25, 2024
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category: Resident Rights Deficiencies
Corrected: Feb 25, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Feb 25, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Sep 15, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 15, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 15, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Sep 15, 2023
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Nov 8, 2021
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Nov 8, 2021
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Dec 30, 2021
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Dec 30, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 8, 2021
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 8, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.4% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.1% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 94.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 69.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 15.7% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 11.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 82.5% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 23.7% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 14.2% | Yes |
Penalty History 4 penalties totaling $353K
| Date | Type | Amount |
|---|---|---|
| Oct 17, 2024 | Fine | $13K |
| Jan 25, 2024 | Fine | $13K |
| Jan 25, 2024 | Fine | $296K |
| Aug 18, 2023 | Fine | $32K |
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for LAKE MARIAM HEALTH AND REHABILITATION CENTER?
What are the staffing levels at LAKE MARIAM HEALTH AND REHABILITATION CENTER?
How many beds does LAKE MARIAM HEALTH AND REHABILITATION CENTER have?
Does LAKE MARIAM HEALTH AND REHABILITATION CENTER have any deficiencies on record?
Has LAKE MARIAM HEALTH AND REHABILITATION CENTER received any fines or penalties?
Who owns LAKE MARIAM HEALTH AND REHABILITATION CENTER?
When was LAKE MARIAM HEALTH AND REHABILITATION CENTER last inspected?
What quality measures are tracked for LAKE MARIAM HEALTH AND REHABILITATION CENTER?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.