11 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Apopka, FL
3-star overall rating with 3-star inspections with 11 recent health deficiencies
2001 Alston Bay Blvd, Apopka, FL
(407) 565-5990
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
158
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-12-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.66
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
5,183
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9904
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.02
Baseline 22.56% · Performance 17.85% · Measure score 8.02 · Achievement 7.74 · Improvement 8.02
Healthcare-associated infections
1.92
Baseline 11.35% · Performance 9.82% · Measure score 1.92 · Achievement 0 · Improvement 1.92
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.19
Baseline 3.83 hours · Performance 3.42 hours · Measure score 1.19 · Achievement 1.19 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 11.11% · Lower 95% interval 8.15% |
| Discharge to community | 51.43% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 45.35% · Lower 95% interval 43.72% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.45% |
95.27%
2.2 pts better
|
Numerator 191 · Denominator 196 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 196 |
| Discharge self-care score | 42.06% |
53.69%
11.6 pts worse
|
Numerator 53 · Denominator 126 |
| Discharge mobility score | 32.54% |
50.94%
18.4 pts worse
|
Numerator 41 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 7 · Denominator 196 · Adjusted rate 3.02% |
| Healthcare-associated infections requiring hospitalization | 9.82% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 13.61% · Lower 95% interval 6.54% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 285 |
| Staff flu vaccination coverage | 6.3% |
42%
35.7 pts worse
|
Numerator 25 · Denominator 397 |
| Discharge function score | 38.1% |
56.45%
18.4 pts worse
|
Numerator 48 · Denominator 126 |
| Transfer of health information to provider | 91.67% |
95.95%
4.3 pts worse
|
Numerator 55 · Denominator 60 |
| Transfer of health information to patient | 98.77% |
96.28%
2.5 pts better
|
Numerator 80 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 10.75% |
25.2%
14.4 pts worse
|
Numerator 10 · Denominator 93 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
97.8%
2 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.6%
1 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.6% · Q3 0.8% · Q4 0.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 4.4% |
5.9%
1.5 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.7% · Q3 4.6% · Q4 5.8% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
15.7%
0.7 pts worse
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 16.4% · Q3 15.5% · Q4 18.7% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
9.8%
5.6 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.3% · Q3 3.8% · Q4 2.3% · 4Q avg 4.2% · 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 | 6.4% |
11.7%
5.3 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 4.1% · Q3 5.5% · Q4 1.8% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
9.8%
3.6 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 3.8% · Q3 6.7% · Q4 4.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.9% |
12.5%
5.6 pts better
|
19.8%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 9.4% · Q3 9.5% · Q4 2.4% · 4Q avg 6.9% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.1%
0.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.8% · Q3 6.0% · Q4 6.3% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
94.3%
3.5 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 96.3% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.8% |
9.3%
7.5 pts worse
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 16.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 1.2% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
94.7%
0.6 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
26.2%
4.3 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 20.9% · Expected 22.7% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-02-28
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-05
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-05
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-05
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-05-05
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-05-05
Health
Assess the resident when there is a significant change in condition
Corrected 2024-05-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-05
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-05-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-05
Health
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.
Corrected 2024-05-05
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-05-05
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-06-13
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-06-13
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-13
Health
Provide activities to meet all resident's needs.
Corrected 2022-06-13
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-13
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-12-18
Penalties and ownership
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