6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lake Mary, FL
3-star overall rating with 2-star inspections with $192,413 in total fines with 6 recent health deficiencies
710 North Sun Drive, Lake Mary, FL
(407) 805-3131
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aviata Health Group
Operator or chain grouping
Approved since
2000-11-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.39
Registered nurse staffing
LPN hours / resident day
0.99
Licensed practical nurse staffing
Aide hours / resident day
2.02
Nurse aide staffing
Weekend hours
3.10
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
97.8%
0.5 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
2.6%
1.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
3.7%
3.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.9%
3.9 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.3% |
15.7%
7.6 pts worse
|
19.6%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
9.8%
3.2 pts better
|
16.7%
10.1 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 | 14.1% |
11.7%
2.4 pts worse
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
9.8%
2.3 pts worse
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.3% |
12.5%
1.8 pts worse
|
19.8%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.1%
1.6 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.3%
4.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
9.3%
2 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
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 | 18.4% |
26.2%
7.8 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-08-25
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-08-25
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-25
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 2024-08-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-11
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-11
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-05-11
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-11
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-05-11
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-11
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-01-09
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-09
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-09
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 2023-01-09
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2021-03-04
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2021-03-04
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-03-04
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-03-04
Penalties and ownership
Fine · fine $192,413
Fine
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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