Cycle 1
Health 2025-02-27 · Fire 2025-02-27
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Alwyn C Cashe State Veterans Nursing Home
1-star overall rating with 2-star inspections with abuse icon flag with $68,731 in total fines with 11 recent health deficiencies
5255 Raymond St, Orlando, FL
(407) 741-4614
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
90
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Florida Department Of Veterans' Affairs
Operator or chain grouping
Approved since
2023-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.55
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.61
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.92
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
6.08
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
84%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
83%
Annual nurse turnover · state 42% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | 10.42% |
42%
31.6 pts worse
|
Numerator 10 · Denominator 96 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.8% |
97.8%
36 pts worse
|
93.4%
31.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.1% · Q2 56.2% · Q3 62.7% · Q4 67.1% · 4Q avg 61.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.3% |
99.2%
12.9 pts worse
|
95.5%
9.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
2.6%
2.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
3.7%
1.1 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 7.3% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.9%
1.5 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.4% · Q3 3.9% · Q4 5.8% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.3% |
15.7%
9.4 pts better
|
19.6%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.1% · Q3 5.9% · Q4 7.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
9.8%
3.2 pts worse
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 18.2% · Q3 10.3% · Q4 13.9% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 52.0% |
11.7%
40.3 pts worse
|
16.3%
35.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 52.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 45.8% |
9.8%
36 pts worse
|
14.9%
30.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 50.0% · Q3 39.1% · Q4 45.9% · 4Q avg 45.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.7% |
0.4%
5.3 pts worse
|
1.0%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.4% · Q3 7.0% · Q4 3.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.3% |
0.8%
8.5 pts worse
|
1.7%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.3% · Q3 8.5% · Q4 13.0% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.3% |
12.5%
21.8 pts worse
|
19.8%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.1% · Q2 27.3% · Q3 36.0% · Q4 32.6% · 4Q avg 34.3% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.1%
1.7 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.6% · Q3 5.9% · Q4 10.2% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.2% |
94.3%
32.1 pts worse
|
81.7%
19.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 45.8% · Q3 72.5% · Q4 81.6% · 4Q avg 62.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
94.7%
44.7 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
11 health deficiencies
Top issue: Administration (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2026-02-16
D · Potential for more than minimal harm
2025-12-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-16
D · Potential for more than minimal harm
2025-12-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-16
D · Potential for more than minimal harm
2025-12-23
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2026-02-16
J · Immediate jeopardy
2025-09-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
J · Immediate jeopardy
2025-09-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
E · Potential for more than minimal harm
2025-02-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-02-24
G · Actual harm
2024-09-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-14
G · Actual harm
2024-09-14
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-14
E · Potential for more than minimal harm
2023-09-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-09
C · Minimal harm
2023-09-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-09
Penalties and ownership
What sits behind the stars
$17,345
2025-09-05
Fine
Fine · fine $17,345
Fine
$5,249
2025-01-24
Fine
Fine · fine $5,249
Fine
$5,249
2025-01-24
Fine
Fine · fine $5,249
Fine
$8,018
2024-09-14
Fine
Fine · fine $8,018
Fine
$8,783
2024-09-14
Fine
Fine · fine $8,783
Fine
$4,140
2024-02-20
Fine
Fine · fine $4,140
Fine
$3,764
2024-02-12
Fine
Fine · fine $3,764
Fine
$9,032
2024-01-22
Fine
Fine · fine $9,032
Fine
$2,258
2024-01-08
Fine
Fine · fine $2,258
Fine
$1,748
2024-01-02
Fine
Fine · fine $1,748
Fine
$3,145
2023-12-11
Fine
Fine · fine $3,145
Fine
Ownership
Florida Department Of Veterans Affairs
5% Or Greater Direct Ownership Interest · Organization
Colon Aponte, Omayra
Operational/Managerial Control · Individual
Mallard, Lindsay
Operational/Managerial Control · Individual
Perry Huff, Katiria
Corporate Director · Individual
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#3
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