Kissimmee, FL

Aviata At Kissimmee Gardens

4-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

1120 W Donegan Ave, Kissimmee, FL

(407) 847-2854

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

114

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Aviata Health Group

Operator or chain grouping

Approved since

2006-10-19

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

0.94

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.37

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.39

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.30

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.14

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.80

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.00

CMS adjusted RN staffing hours

Adjusted total hours

3.61

CMS adjusted total nurse staffing hours

Case-mix index

1.28

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

3,991

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

Performance score

41.84

Composite VBP score used to determine payment impact.

Payment multiplier

0.9947

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.52

Baseline 24.13% · Performance 20.57% · Measure score 4.52 · Achievement 1.87 · Improvement 4.52

Healthcare-associated infections

2.73

Baseline 7.84% · Performance 7.02% · Measure score 2.73 · Achievement 2.73 · Improvement 2.38

Total nurse turnover

7.88

Baseline 53.66% · Performance 31.46% · Measure score 7.88 · Achievement 7.88 · Improvement 7.21

Adjusted total nurse staffing

1.6

Baseline 4.07 hours · Performance 3.53 hours · Measure score 1.6 · Achievement 1.6 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.34%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 67 · Observed rate 10.45% · Lower 95% interval 7.7%
Discharge to community	32.94%	50.57% 17.6 pts worse	Worse than the National Rate · Eligible stays 38 · Observed rate 21.05% · Lower 95% interval 20.21%
Medicare spending per beneficiary	1.21	1.02 0.2 pts worse
Drug regimen review with follow-up	94.87%	95.27% 0.4 pts worse	Numerator 74 · Denominator 78
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 78
Discharge self-care score	40.74%	53.69% 12.9 pts worse	Numerator 22 · Denominator 54
Discharge mobility score	24.07%	50.94% 26.9 pts worse	Numerator 13 · Denominator 54
Pressure ulcers or injuries, new or worsened	5.13%	2.29% 2.8 pts worse	Numerator 4 · Denominator 78 · Adjusted rate 3.93%
Healthcare-associated infections requiring hospitalization	7.02%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 3.49%
Staff COVID-19 vaccination coverage	70.27%	8.2% 62.1 pts better	Numerator 104 · Denominator 148
Staff flu vaccination coverage	46.98%	42% 5 pts better	Numerator 70 · Denominator 149
Discharge function score	40.74%	56.45% 15.7 pts worse	Numerator 22 · Denominator 54
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	11.9%	25.2% 13.3 pts worse	Numerator 5 · Denominator 42

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.3	2.1 0.8 pts better	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	1.2 0.8 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	97.8% 1.9 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7%
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	2.3%	2.6% 0.3 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.0% · Q3 2.2% · Q4 2.0% · 4Q avg 2.3% · 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	7.5%	5.9% 1.6 pts worse	5.4% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 7.6% · Q3 7.0% · Q4 9.1% · 4Q avg 7.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.3%	15.7% 0.4 pts better	19.6% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 12.5% · Q3 8.5% · Q4 14.1% · 4Q avg 15.3%
Percentage of long-stay residents who received an antipsychotic medication	9.3%	9.8% 0.5 pts better	16.7% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 5.5% · Q3 3.8% · Q4 13.3% · 4Q avg 9.3% · 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	12.6%	11.7% 0.9 pts worse	16.3% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 22.9% · Q3 7.2% · Q4 3.6% · 4Q avg 12.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.1%	9.8% 0.7 pts better	14.9% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 13.9% · Q3 10.6% · Q4 2.8% · 4Q avg 9.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.4% 0.5 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.9% · Q4 0.8% · 4Q avg 0.9% · 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	19.9%	12.5% 7.4 pts worse	19.8% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 33.3% · Q3 9.2% · Q4 14.4% · 4Q avg 19.9%
Percentage of long-stay residents with pressure ulcers	3.3%	5.1% 1.8 pts better	5.1% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.4% · Q3 2.2% · Q4 5.3% · 4Q avg 3.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.7%	94.3% 0.4 pts better	81.7% 13 pts better	Short Stay · 2024Q4-2025Q3 · Q1 87.4% · Q2 92.4% · Q3 99.2% · Q4 99.2% · 4Q avg 94.7%
Percentage of short-stay residents who had an outpatient emergency department visit	6.5%	9.3% 2.8 pts better	12.0% 5.5 pts better	Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 6.1% · Expected 10.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.5% 1.1 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.1%	94.7% 1.4 pts better	79.7% 16.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.8%	26.2% 2.4 pts better	23.9% 0.1 pts better	Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 21.2% · Expected 21.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-04-18 · Fire 2024-04-18

12 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2023-10-26 · Fire 2023-10-26

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2023-04-07 · Fire 2023-04-07

13 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-04-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-18

F · Potential for more than minimal harm 2023-10-26

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-11-24

D · Potential for more than minimal harm 2023-10-26

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-11-24

F · Potential for more than minimal harm 2023-04-07

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-05-07

D · Potential for more than minimal harm 2023-04-07

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-05-07

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-04-18

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-05-18

E · Potential for more than minimal harm 2024-04-18

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 2024-05-18