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Nursing HomeMedicaid Investigative

Royal Care of Avon Park

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1213 W Stratford Rd, Avon Park, FL 3382590 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.7/5

based on 55 Google reviews

5
4
3
2
1
Royal Care of Avon Park Nursing Home in Avon Park, FL — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (17 vs median 6.0)

Bottom 25% in FL · Meets national RN staffing standard · Above average staffing · $17,342 in fines

Source: Medicare data

What this means for your family

While many families report excellent results from the rehabilitation therapy team, the facility has a history of serious, recurring complaints regarding medical oversight and communication. If you choose this facility, ensure you have a clear, direct line of communication with the administration and monitor your loved one's medical care and hydration levels closely.

Google Reviews

Google Reviews

55 reviews on Google
Royal Care of Avon Park receives highly polarized feedback, with many families praising the rehabilitation therapy team and staff attentiveness, while others report severe neglect and communication failures. Critical concerns include reports of residents suffering from dehydration, unaddressed medical needs, and difficulty reaching staff by phone. Families should be aware that experiences appear inconsistent, ranging from excellent recovery support to traumatic neglect.

Quality Themes

Tap a score for details
Food3.0Staff6.0Clean5.0ActivitiesN/AMeds2.0MemoryN/AComms3.0Value2.0

Strengths

  • Effective rehabilitation therapy
  • Attentive and caring nursing staff
  • Clean and well-maintained facility
  • Helpful administrative communication (for some)

Concerns

  • Severe neglect and lack of medical oversight (mentioned by 6 reviewers)
  • Poor communication and difficulty reaching staff by phone (mentioned by 5 reviewers)
  • Inadequate staffing levels leading to delayed care (mentioned by 3 reviewers)
  • Unsanitary conditions or unpleasant odors (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'16(2)'19(7)'21(1)'24(4)'26(9)

Distribution · 60 analyzed

5
39
4
3
3
1
2
0
1
17

How They Respond to Reviews

100%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed you have a high response rate to online feedback; how do you use that family input to improve the daily experience for residents?
  • 2Given the recent focus on health inspection outcomes, what specific changes or quality improvement plans have been implemented to ensure better medical oversight for residents?
  • 3Some families have expressed difficulty with phone communication; what is the best way for us to stay updated on our loved one's status, and who is our primary point of contact?
  • 4Since rehabilitation therapy is a noted strength here, how do you coordinate that care with the nursing staff to ensure consistency throughout the day?
  • 5I understand there have been concerns regarding medication management; could you walk me through your current process for ensuring residents receive the right medications at the right time?
  • 6How do you ensure that common areas and resident rooms maintain a consistently clean and fresh environment throughout the day?

Personalized based on this facility's data


Key Review Excerpts

My friend who was rehabbing from total hip replacement was at the Palms of Sebring and treated so badly she checked herself out, a no no. Couldn’t handle the abuse there! She’s at Royal Care now and getting the rehab she hoped for!

Friend of rehab patient · 2026★★★★★

My father went there for rehab. do not take yr family there please. my father lost 20 lbs and was severely dehydrated in just a couple weeks and ended up in the hosp with double pneumonia and severe dehydration.

Daughter of rehab patient · 2024☆☆☆☆

2nd visit Feb 2025, Much better now, areas that had been low show great improvement 2nd stay went very good, the improvements show that they have listened to concerns voice!

Repeat rehab patient · 2025★★★★★
Source: 55 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.82hrs
OK
Registered nurses for medical care
Total Nursing
4.00hrs
97%
All nurses + aides combined
Staff Turnover
48%
Lower is better (< 30% = good)
RN Turnover
25%
Lower is better (< 30% = good)

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

11

measures

Worse Than Avg

1

measures

Mixed Results

5

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.5%
Better than Avg
Here
0.5%
US
12.1%
FL
4.1%
Highlands
21.0%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility9.6%
Better than Avg
Here
9.6%
US
19.4%
FL
11.5%
Highlands
12.5%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility6.2%
Better than Avg
Here
6.2%
US
15.4%
FL
8.7%
Highlands
9.8%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.8%
Better than Avg
Here
7.8%
US
14.4%
FL
9.1%
Highlands
9.4%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
FL
98.1%
Highlands
98.9%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
FL
99.2%
Highlands
100.0%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.2%
Better than Avg
Here
99.2%
US
81.8%
FL
94.8%
Highlands
98.4%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility96.7%
Mixed vs Avgs
Here
96.7%
US
79.7%
FL
94.7%
Highlands
98.7%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.3%
Mixed vs Avgs
Here
1.3%
US
1.6%
FL
1.5%
Highlands
1.0%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
2penalties
Well above state avg (7.3)
1 complaint-triggered
$17,342 in fines

Royal Care of Avon Park shows a concerning pattern with 31 deficiencies across three surveys, particularly in medication management, quality of care, and infection control. The most recent 2024 survey found significant issues including pressure ulcer care, medication errors, and basic safety problems like missing handrails. While all deficiencies show correction dates, the recurring problems with medication management and infection control across multiple years suggest ongoing operational challenges that families should carefully consider.

Feb 19, 2026Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

May 9, 2024Routine
20
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0867Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0584Potential for harm · PatternCorrected

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.

0645Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0761Potential for harm · PatternCorrected

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0924Potential for harm · PatternCorrected

Environmental Deficiencies

Put firmly secured handrails on each side of hallways.

0024Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures for volunteers.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0374Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0694Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Dec 22, 2021Routine
2
0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Mar 13, 2020Routine
9
0760Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0291Potential for harm · IsolatedCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0921Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0761Potential for harm · IsolatedCorrected

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Federal Penalties

Fine

May 9, 2024

$4,017

Fine

May 9, 2024

$13,325

Ownership & Operations

Who Operates This Facility

Owner / Operator

Royal Care of Avon Park

Organization Type

for profit

Ownership & Management

Owners

Strohli, Eli

Owner

100%

Key personnel

Geldart, DonaldManagerMatheis, PamelaManagerGeldart, DonaldAdp of the SnfMatheis, PamelaAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 4 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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