Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BREEZY HILLS REHAB AND CARE CENTER
LAKELAND, FL · 120 certified beds · Last Life Safety survey May 8, 2025
CMS Certification Number 105482 · first certified December 1984
Ownership
Operated by EXCELSIOR CARE GROUP · For profit - Limited Liability company
- Ownership changed April 1, 2022 (change of ownership)from LAKELAND FACILITY OPERATIONS LLC
Position within FL
18 citations — more than 95% of the 694 certified nursing homes in FL. Compared within FL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to March 2027. This facility’s last Life Safety survey was May 2025. Facilities in FL are typically surveyed 15–23 months after the last one (median 17), measured over 729 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 18 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
How that compares
Compared with the median facility in FL, and nationally. Surveyors differ markedly between states, so the FL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 18 |
| Median facility in FL | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 27, 2021 | 10 |
| February 8, 2023 | 5 |
| May 8, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2023-02-08 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2023-02-08 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-05-08 |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | 1 | 2023-02-08 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2021-05-27 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2021-05-27 |
| E-0029 | Develop a communication plan. | 1 | 2021-05-27 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2021-05-27 |
What the citations cover
- Smoke Deficiencies 5
- Emergency Preparedness Deficiencies 4
- Egress Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 8, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 8, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 8, 2025) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (June 8, 2025) |
February 8, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 10, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 10, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 10, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 10, 2023) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (March 10, 2023) |
May 27, 2021 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 25, 2021) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (June 25, 2021) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (June 25, 2021) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 25, 2021) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 25, 2021) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 25, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 25, 2021) |
| K-0373 | Have enough space near smoke barriers to protect residents. | Deficient, Provider has date of correction (June 25, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 25, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 25, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.