Winter Garden, FL

Aviata At Colonial Lakes

1-star overall rating with 1-star inspections with $23,136 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

15204 W Colonial Dr, Winter Garden, FL

(407) 877-2394

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

180

Certified beds

Average residents

166

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Aviata Health Group

Operator or chain grouping

Approved since

1983-09-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

52 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

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

0.55

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.80

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.14

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.35

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.18

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.63

CMS adjusted RN staffing hours

Adjusted total hours

4.01

CMS adjusted total nurse staffing hours

Case-mix index

1.19

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

6,050

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.16

Composite VBP score used to determine payment impact.

Payment multiplier

0.9882

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.08

Baseline 20.17% · Performance 19.08% · Measure score 5.08 · Achievement 5.08 · Improvement 2.97

Healthcare-associated infections

0.52

Baseline 7.15% · Performance 7.68% · Measure score 0.52 · Achievement 0.52 · Improvement 0

Total nurse turnover

5.71

Baseline 57.79% · Performance 40.34% · Measure score 5.71 · Achievement 5.71 · Improvement 4.80

Adjusted total nurse staffing

2.35

Baseline 4.09 hours · Performance 3.75 hours · Measure score 2.35 · Achievement 2.35 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.09%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 66 · Observed rate 13.64% · Lower 95% interval 7.41%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.09	1.02 0.1 pts worse
Drug regimen review with follow-up	79.12%	95.27% 16.1 pts worse	Numerator 72 · Denominator 91
Falls with major injury	1.1%	0.77% 0.3 pts worse	Numerator 1 · Denominator 91
Discharge self-care score	44.62%	53.69% 9.1 pts worse	Numerator 29 · Denominator 65
Discharge mobility score	35.38%	50.94% 15.6 pts worse	Numerator 23 · Denominator 65
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 91 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.68%	7.12% 0.6 pts worse	No Different than the National Rate · Eligible stays 38 · Observed rate 10.53% · Lower 95% interval 3.56%
Staff COVID-19 vaccination coverage	5.69%	8.2% 2.5 pts worse	Numerator 7 · Denominator 123
Staff flu vaccination coverage	15.42%	42% 26.6 pts worse	Numerator 31 · Denominator 201
Discharge function score	55.38%	56.45% 1.1 pts worse	Numerator 36 · Denominator 65
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 27 · Denominator 27
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	18.37%	25.2% 6.8 pts worse	Numerator 9 · Denominator 49

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.9	2.1 0.8 pts worse	1.9 1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.9 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.2 0.1 pts worse	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.5%	97.8% 0.3 pts worse	93.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 98.8% · Q3 98.1% · Q4 97.5% · 4Q avg 97.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.4%	99.2% 0.2 pts better	95.5% 3.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4%
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 2.6% · Q2 1.9% · Q3 1.2% · Q4 0.6% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.6%	3.7% 0.1 pts better	11.4% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 2.6% · Q3 5.4% · Q4 5.4% · 4Q avg 3.6%
Percentage of long-stay residents who lose too much weight	4.7%	5.9% 1.2 pts better	5.4% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.4% · Q3 2.1% · Q4 7.5% · 4Q avg 4.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.0%	15.7% 5.3 pts worse	19.6% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 25.2% · Q3 21.1% · Q4 19.7% · 4Q avg 21.0%
Percentage of long-stay residents who received an antipsychotic medication	13.5%	9.8% 3.7 pts worse	16.7% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 16.1% · Q3 13.5% · Q4 13.9% · 4Q avg 13.5% · 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	13.0%	11.7% 1.3 pts worse	16.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 14.4% · Q3 13.0% · Q4 3.8% · 4Q avg 13.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.0%	9.8% 1.2 pts worse	14.9% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 12.4% · Q3 13.0% · Q4 8.1% · 4Q avg 11.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.4% 0.1 pts worse	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.0% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.8%	0.8% About the same	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.5%	12.5% 3 pts worse	19.8% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 24.9% · Q3 12.5% · Q4 8.9% · 4Q avg 15.5%
Percentage of long-stay residents with pressure ulcers	2.7%	5.1% 2.4 pts better	5.1% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.0% · Q3 2.5% · Q4 2.3% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	81.5%	94.3% 12.8 pts worse	81.7% 0.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 92.0% · Q3 80.0% · Q4 55.6% · 4Q avg 81.5%
Percentage of short-stay residents who had an outpatient emergency department visit	8.9%	9.3% 0.4 pts better	12.0% 3.1 pts better	Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.8% · Expected 12.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.9%	1.5% 1.4 pts worse	1.6% 1.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.6% · Q3 2.8% · Q4 4.7% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	94.7% 5.3 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.9%	26.2% 2.3 pts better	23.9% About the same	Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 25.5% · Expected 25.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-07-18 · Fire 2024-07-18

8 health deficiencies

Top issue: Infection Control (2 deficiencies)

5 fire-safety deficiencies

Top issue: Construction (2 deficiencies)

Cycle 2 Health 2022-08-18 · Fire 2022-08-18

22 health deficiencies

Top issue: Resident Assessment and Care Planning (9 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 3 Health 2021-01-28 · Fire 2021-01-28

8 health deficiencies

Top issue: Resident Rights (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-07-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-08

E · Potential for more than minimal harm 2024-07-18

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-08

D · Potential for more than minimal harm 2024-07-18

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-08-08

D · Potential for more than minimal harm 2024-07-18

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-08-08

D · Potential for more than minimal harm 2024-07-18

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-08-08

F · Potential for more than minimal harm 2022-08-18

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2022-09-19

F · Potential for more than minimal harm 2022-08-18

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-09-19

F · Potential for more than minimal harm 2022-08-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-09-19

F · Potential for more than minimal harm 2022-08-18

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-09-19

E · Potential for more than minimal harm 2022-08-18

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-09-19

F · Potential for more than minimal harm 2021-01-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-02-28

F · Potential for more than minimal harm 2021-01-28

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2021-02-28

D · Potential for more than minimal harm 2021-01-28

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2021-02-28

D · Potential for more than minimal harm 2021-01-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-02-28

D · Potential for more than minimal harm 2021-01-28

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2021-02-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-30

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-11-06

J · Immediate jeopardy 2025-01-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-02-07

J · Immediate jeopardy 2025-01-16

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-16

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 2025-02-07

E · Potential for more than minimal harm 2024-12-05

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-01-04

D · Potential for more than minimal harm 2024-12-05

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-01-04

E · Potential for more than minimal harm 2024-11-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-09-06

F778 · Administration Deficiencies

Health

Help the resident make transportation arrangements to and from radiology services.

Corrected 2024-10-03

F · Potential for more than minimal harm 2024-07-18

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-08-14

F · Potential for more than minimal harm 2024-07-18

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-08-14

E · Potential for more than minimal harm 2024-07-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-07-18

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-07-18

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-07-18

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-07-18

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-08-14

J · Immediate jeopardy 2023-03-08

F578 · Resident Rights Deficiencies

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 2023-04-07

J · Immediate jeopardy 2023-03-08

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2023-04-07

E · Potential for more than minimal harm 2022-08-18

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2022-09-19

E · Potential for more than minimal harm 2022-08-18

F635 · Resident Assessment and Care Planning Deficiencies

Health

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Corrected 2022-09-19

E · Potential for more than minimal harm 2022-08-18

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2022-09-19