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

Staffing

Hours and turnover

RN hours / resident day

0.55

Registered nurse staffing

LPN hours / resident day

0.80

Licensed practical nurse staffing

Aide hours / resident day

2.14

Nurse aide staffing

Weekend hours

3.18

Weekend nurse staffing

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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