Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B
Grade
50
Score
CMS Ratings
9.5/22
Staffing Quality
8.8/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
2.0/10

Current Availability Estimate

Occupancy Rate97.9%
120
Total Beds
118
Occupied
2
Available

Basic Information

Address:

5245 N SOCRUM LOOP RD

LAKELAND, FL 33809

Number of Beds:

120

Estimated Occupancy:

98% (~3 available)

Chain:

EXCELSIOR CARE GROUP

Quality Ratings

Overall Rating:2/5 Stars
Health Inspection:2/5 Stars
Staffing Rating:2/5 Stars
Quality Measures:3/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

105482

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Below Average

This Facility

0.40

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Below Average

This Facility

3.47

hours

National Avg

3.89

hours

Breakdown:

RN: 0.40hLPN: 0.94hAide: 2.14h

Staff Turnover Rate

Annual nursing staff turnover

Average

This Facility

48.4%

National Avg

46.6%

RN Turnover: 58.8%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

48

Inspections

5

Mar 27, 2025 - Health Survey

2 deficiencies cited

Medium - PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: Apr 11, 2025From Complaint
Medium - PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: Apr 11, 2025From Complaint

Jul 2, 2024 - Health Survey

6 deficiencies cited

Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Jul 17, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 17, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 17, 2024From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Jul 17, 2024From Complaint
Medium - PatternTag F0699

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Corrected: Jul 17, 2024From Complaint
Medium - PatternTag F0699

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Corrected: Jul 17, 2024From Complaint

Feb 8, 2023 - Health Survey

22 deficiencies cited

Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Mar 10, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Mar 10, 2023
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Mar 10, 2023From Complaint
Medium - PatternTag F0848

Administration Deficiencies

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected: Mar 10, 2023
Medium - PatternTag F0582

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected: Mar 10, 2023
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Mar 10, 2023
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Mar 10, 2023
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Mar 10, 2023
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Mar 10, 2023
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Mar 10, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Mar 10, 2023
Medium - PatternTag F0582

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected: Mar 10, 2023
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Mar 10, 2023
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Mar 10, 2023
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Mar 10, 2023
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Mar 10, 2023
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Mar 10, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Mar 10, 2023
Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Mar 10, 2023
Medium - PatternTag F0848

Administration Deficiencies

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected: Mar 10, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Mar 10, 2023
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Mar 10, 2023From Complaint

May 27, 2021 - Health Survey

16 deficiencies cited

Medium - PatternTag F0584

Resident Rights Deficiencies

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: Jun 27, 2021
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Jun 27, 2021
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jun 27, 2021
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Aug 26, 2021
Medium - PatternTag F0700

Quality of Life and Care Deficiencies

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.

Corrected: Aug 26, 2021
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Jun 27, 2021
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Aug 26, 2021
Medium - PatternTag F0700

Quality of Life and Care Deficiencies

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.

Corrected: Aug 26, 2021
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Jun 27, 2021
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Aug 26, 2021
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Aug 26, 2021
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Jun 27, 2021
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Aug 26, 2021
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Aug 26, 2021
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jun 27, 2021
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Jun 27, 2021

Aug 9, 2019 - Health Survey

2 deficiencies cited

Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Sep 9, 2019
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Sep 9, 2019

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

No penalties or payment denials in the past 3 years

Key Highlights

🏆
Clean Safety Record
No recent penalties or high-severity deficiencies
🏢
Part of Healthcare Chain
EXCELSIOR CARE GROUP

Frequently Asked Questions

What is the quality rating for BREEZY HILLS REHAB AND CARE CENTER?

BREEZY HILLS REHAB AND CARE CENTER has an overall CMS rating of 2 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

BREEZY HILLS REHAB AND CARE CENTER has 120 certified beds. The facility averages 118 residents per day, with an occupancy rate of approximately 98%.

What type of ownership does this facility have?

This facility is for profit - limited liability company owned. It is part of the EXCELSIOR CARE GROUP network.

How can I contact BREEZY HILLS REHAB AND CARE CENTER?

You can call BREEZY HILLS REHAB AND CARE CENTER at (863)859-1446. The facility is located at 5245 N SOCRUM LOOP RD, LAKELAND, FL 33809.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

Important Considerations for This Facility

Based on this facility's data, we recommend reading these guides to understand what to look for:

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