Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Winter Haven during CMS and state inspections, most recent first.
The facility failed to provide dignified care and dining services to residents, including improper meal assistance positioning, unauthorized use of clothing protectors, and staff speaking in different languages during care, causing discomfort to residents.
The facility failed to provide adequate foot care for three diabetic residents, leading to deficiencies in care. One resident experienced pain due to untrimmed toenails, despite having an active podiatry consult. Another resident had long, thickened toenails and a fungal infection, with delayed podiatry intervention. A third resident had long, thick, yellow toenails, with staff acknowledging the need for podiatry care but failing to provide timely intervention. The facility's policy on nail care for diabetic residents was not followed, contributing to the deficiencies.
A long-term care facility experienced a medication error rate of 42.42%, significantly exceeding the acceptable threshold of 5%. Errors included incorrect medication administration, failure to notify physicians of late medications, and improper documentation. Staff failed to follow facility policies, such as crushing enteric-coated tablets, not priming insulin pens, and administering medications without physician parameters. The Director of Nursing acknowledged these deficiencies, highlighting a need for adherence to established protocols.
The facility failed to assess two residents for self-administration of medications and did not obtain physician orders for medications observed in one resident's room. A resident was seen using a nebulizer without a physician order, and another had throat spray and ointment without orders. The facility's policy required assessments and documentation for self-administration, which were not followed.
A resident reported missing clothes to the facility, but no grievance was filed, violating the resident's right to voice grievances. The resident, with intact cognition, was not informed about the grievance process. The Director of Housekeeping was aware of the complaint but did not assist in filing a grievance, contrary to the facility's policy.
A facility failed to provide timely written notification to a resident and their representative before an emergency hospital transfer due to a medical condition. The required notice was not documented until after the transfer, contrary to facility policy, as confirmed by staff interviews.
The facility failed to accurately complete PASRR documentation for multiple residents, omitting diagnoses such as dementia and Alzheimer's disease. This resulted in incomplete Level I screenings and the absence of required Level II evaluations, contrary to facility policy and regulatory requirements.
A facility failed to provide wound care as ordered for a resident with diabetes and skin disorders. During an observation, a nurse found the resident's foot wounds uncovered, contrary to physician orders. The care plan required prompt treatment of skin breaks, and orders specified dressing procedures. Despite the resident's tendency to remove dressings, the facility did not adhere to its policy on treatment orders, resulting in a deficiency.
A facility failed to obtain timely physician-ordered lab tests for a resident with hypothyroidism. The resident was on Levothyroxine and had orders for TSH, Free T4, and PTH tests, which were not completed as required. Documentation showed partial administration and order clarification issues, with thyroid panel results only obtained 30 days after the order was discontinued. The DON stated labs should be done promptly, with the lab vendor visiting daily except Sundays.
An LPN failed to clean a blood pressure cuff between uses on two residents during medication administration, leading to a breach in infection control protocols.
Failure to Provide Dignified Care and Dining Services
Penalty
Summary
The facility failed to ensure residents were provided dining services and care with dignity, affecting four residents. Resident #63, who had hemiplegia and feeding difficulties, was observed being assisted with meals by a CNA who stood over her instead of sitting at eye level, as per facility policy. The CNA admitted to standing due to the need to assist multiple residents simultaneously, and there was a lack of clear communication among staff regarding the proper positioning during meal assistance. Resident #2 was observed being given a clothing protector without consent, and a napkin was tucked into the neckline without prior discussion or inclusion in the care plan. The resident had severe cognitive impairment, and the care plan did not reflect any choice regarding the use of clothing protectors. The facility's policy required staff to sit while assisting residents with meals, but this was not consistently followed. Residents #26 and #72 reported feeling uncomfortable when staff spoke in languages other than English during care. Resident #26, who had intact cognition, felt abused when staff switched languages upon realizing she understood French. Resident #72, also with intact cognition, reported similar incidents. The facility's mission statement emphasized dignity and resident-centered care, but these incidents contradicted those values, as residents felt their preferences and comfort were not prioritized.
Deficiency in Foot Care for Diabetic Residents
Penalty
Summary
The facility failed to provide proper foot care and treatment to maintain good foot health for three residents, leading to deficiencies in care. Resident #134, who has Type 2 Diabetes Mellitus and difficulty walking, repeatedly requested assistance with toenail care due to pain but was not attended to. Despite having an active podiatry consult, staff failed to ensure the resident received the necessary care. Observations revealed that the resident's toenails were protruding through his socks, and staff interviews indicated a lack of communication and follow-up regarding the resident's requests and needs. Resident #141, also with Type 2 Diabetes Mellitus, was observed with long, thickened toenails and a fungal infection on her fingernails. The resident expressed dissatisfaction with the lack of nail care since admission. Although a podiatry consult was eventually made, the staff failed to address the resident's nail care needs promptly. The resident's care records did not reflect the condition of her nails, and there was no documentation of appropriate interventions or assessments. Resident #140, another diabetic resident, was found with long, thick, and yellow toenails. The staff acknowledged the need for podiatry care but did not provide timely intervention. The facility's policy on nail care for residents with diabetes was not followed, as staff did not ensure the resident's toenails were maintained according to professional standards. The lack of proper foot care and communication among staff contributed to the deficiencies observed in the care of these residents.
High Medication Error Rate in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 42.42% based on observations of medication administration. During the survey, multiple instances of medication errors were identified involving six residents. These errors included incorrect medication administration, failure to administer medications as per physician orders, and improper documentation of medication administration. For instance, a Licensed Practical Nurse (LPN) crushed an enteric-coated aspirin instead of administering a chewable tablet as ordered for a resident with coronary artery disease. Additionally, the same LPN documented the administration of medications that were not given, such as Docusate Sodium and Hydralazine, without proper physician parameters for holding the medication. Another incident involved a Registered Nurse (RN) administering medications late without notifying the physician, as required by facility policy. The RN dispensed medications for a resident, including psychotropic and anticoagulant medications, which were scheduled for earlier administration. The facility's policy mandates that the physician be notified of late medication administration, but this was not done. Furthermore, the RN failed to administer a prescribed medication, Sertraline, after it was accidentally discarded, and did not document the incident appropriately. Additional errors were observed with other residents, including the improper disposal of medications, failure to prime insulin pens before administration, and incorrect medication administration based on blood pressure readings without physician orders. The Director of Nursing acknowledged these errors, stating that the facility's policy requires accurate documentation and adherence to physician orders. The facility's policies on medication administration and blood glucose monitoring were not followed, contributing to the high medication error rate.
Failure to Assess and Obtain Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were assessed for self-administration of medications and did not obtain physician orders for medications observed in one resident's room. Resident #49 was observed using a nebulizer without a physician order for self-administration. The resident's medical history included unspecified dementia and chronic obstructive pulmonary disease (COPD). The care plan for Resident #49 did not include any focus or intervention for self-administration of medication, and the facility did not provide a self-administration assessment for this resident. Resident #141 was observed with a bottle of throat spray and mentholated topical ointment on the over-bed table within reach, without a physician order for their use. The resident confirmed using the throat spray and ointment when feeling unwell. Staff were unaware of these items at the resident's bedside, and no physician order was found for self-administration of these medications. The facility reported that no residents were self-administering medications at the time. The facility's policy on self-administration of medications required an assessment by the interdisciplinary care team to determine if self-administration was safe and clinically appropriate. The policy also required documentation in the resident's care plan and medication administration record. However, these procedures were not followed for the residents involved, leading to the deficiency.
Failure to File Grievance for Missing Clothes
Penalty
Summary
The facility failed to file a grievance related to missing clothes for a resident, which was a violation of the resident's right to voice grievances without discrimination or reprisal. During observations, the resident was seen sitting on her bed and reported that she had complained about her missing clothes, but no action had been taken. The resident also stated that she was not informed about the grievance process. The resident had intact cognition, as indicated by a BIMS score of 15, and had been readmitted to the facility with diagnoses including fractures and hip pain. Interviews with staff revealed that the Director of Housekeeping was aware of the resident's complaint about missing clothes but did not assist in filing a grievance. The Nursing Home Administrator expected grievances to be filed when complaints were brought to staff attention, but this did not occur in this case. The facility's grievance policy, which was supposed to be provided to residents upon request, outlined the right to file grievances and the procedure for handling them, including follow-up with residents to ensure satisfaction. However, this policy was not followed, leading to the deficiency.
Failure to Provide Timely Transfer Notification
Penalty
Summary
The facility failed to provide written notification to a resident and their representative prior to an emergency transfer to a hospital. The resident, who was their own responsible party, was transferred due to a large abscess on the neck and swallowing issues. The transfer occurred without the required written notice being given to the resident or their representative, as confirmed by the Executive Director and the Social Service Director. The facility's policy requires that notice be provided as soon as practicable before a transfer, but in this case, the notice was not documented until after the transfer had already taken place. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the written notice was not provided to the resident prior to the transfer. The notice was signed by staff after the resident had left the facility, and the facility's policy was not followed. The Social Service Director later provided a transfer notice dated the day of the transfer, but it was signed the following day, indicating a failure to adhere to the policy of providing timely notification.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was completed accurately for eleven residents. These residents had various diagnoses, including dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder, which were not accurately reflected in their PASRR documentation. For instance, Resident #112 was admitted with diagnoses including major depressive disorder and dementia, but the PASRR did not reflect the dementia diagnosis. Similarly, Resident #144's PASRR did not include the diagnosis of Cognitive Communication Deficit, and questions related to dementia were incorrectly answered. The report highlights that several residents, such as Resident #21, had diagnoses of epilepsy and dementia that were not included in their PASRR documentation. Despite having active diagnoses of these conditions, the PASRR screenings were incomplete, and necessary Level II evaluations were not conducted. Staff Q, a social worker, was unaware of these omissions and acknowledged that the facility did not conduct dementia testing. This lack of awareness and incomplete documentation was a recurring issue for multiple residents, including Residents #12, #126, #140, #130, #23, #54, #18, and #49. The facility's policy on PASRR was not adhered to, as evidenced by the incomplete Level I screenings and the absence of required Level II evaluations for residents with qualifying diagnoses. The policy mandates that potential admissions be screened for serious mental disorders or intellectual disabilities, and any positive Level I screen should lead to a Level II evaluation by the state-designated authority. However, the facility failed to update PASRR documentation when new diagnoses were made, and there was a lack of communication with state authorities regarding significant changes in residents' conditions. This oversight resulted in the facility not meeting the regulatory requirements for PASRR screenings and evaluations.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care in accordance with professional standards of practice and as ordered by the physician for a resident. During an observation, a registered nurse found that the resident's left foot wounds were not covered with dressings as required. The nurse checked the resident's footwear for bandages but found none and stated that the dressings would be replaced immediately. The resident had been admitted with diagnoses including diabetes mellitus and a disorder of the skin and subcutaneous tissue, which required careful monitoring and treatment of skin integrity. The resident's care plan included interventions to check for skin breaks and treat them promptly as ordered by the doctor. Physician orders specified the cleansing and dressing of the resident's foot wounds, with instructions to verify the placement of wound dressings during specific shifts. However, it was noted that the resident often removed the dressings, and rolled gauze was used to help secure them. Despite these measures, the facility's policy on treatment orders, which required adherence to physician orders and product instructions, was not followed, leading to the deficiency.
Failure to Obtain Timely Laboratory Testing for Resident
Penalty
Summary
The facility failed to obtain physician-ordered laboratory testing for a resident diagnosed with unspecified hypothyroidism. The resident was receiving Levothyroxine sodium daily, and there was an order for Thyroid-Stimulating Hormone (TSH), Free T4, and Parathyroid Hormone (PTH) to be drawn every night shift from January 6 to January 21. However, the laboratory testing was not completed as ordered, with documentation indicating that the tests were only partially administered and that there were issues requiring clarification of the order. Despite staff documentation indicating the tests were completed, the facility could not provide any thyroid panel results for the specified period. The resident's progress notes revealed multiple entries indicating the need for order clarification, and a provider's note from January 6 confirmed the plan to check PTH. The laboratory results for the thyroid panel were only obtained on February 19, approximately 30 days after the order was discontinued. During an interview, the Director of Nursing stated that the expectation was to get labs as soon as possible and described the process for ordering tests through the lab portal, noting that the laboratory vendor visited the facility daily except Sundays.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of medications to two residents. On the morning of February 19, 2025, a Licensed Practical Nurse (LPN) was observed administering medications to Resident #149. The LPN used a blood pressure wrist cuff from the medication cart to measure the resident's blood pressure, which initially registered an error. A second attempt yielded a reading of 101/48, leading the LPN to withhold the resident's Lisinopril. After administering other medications, the LPN returned the blood pressure cuff to the medication cart without cleaning it. Subsequently, the same LPN was observed administering medications to Resident #218. The LPN retrieved the same blood pressure cuff from the medication cart and used it to measure the resident's blood pressure, obtaining a reading of 120/57. The LPN then administered the resident's medications, withholding Losartan, and returned the cuff to the cart. During an interview, the LPN confirmed using the same cuff for both residents without cleaning it between uses, acknowledging that the cuff should have been cleaned between residents to prevent cross-contamination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Winter Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Winter Haven | 0.2 mi | — | 0 | 0 |
| Lake Mariam Health And Rehabilitation Center | 0.7 mi | — | 4 | 2 |
| Winter Haven Health And Rehabilitation Center | 1.2 mi | — | 0 | 0 |
| Astoria Health And Rehabilitation Center | 1.6 mi | — | 0 | 0 |
| Spring Lake Rehabilitation Center | 2.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.