Cycle 1
Health 2024-07-25 · Fire 2024-07-25
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
Aviata At Lake Mary
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
Facility snapshot
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
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
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
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.02
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
1.37
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,806
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.26
Baseline 23.80% · Performance 20.58% · Measure score 4.26 · Achievement 1.85 · Improvement 4.26
Healthcare-associated infections
0
Baseline 6.50% · Performance 8.33% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.13
Performance 50.89% · Measure score 3.13 · Achievement 3.13 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.60
Baseline 3.98 hours · Performance 3.53 hours · Measure score 1.60 · Achievement 1.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 158 · Observed rate 10.13% · Lower 95% interval 7.63% |
| Discharge to community | 61.49% |
50.57%
10.9 pts better
|
Better than the National Rate · Eligible stays 123 · Observed rate 56.1% · Lower 95% interval 53.09% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.67% |
95.27%
0.4 pts better
|
Numerator 221 · Denominator 231 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 231 |
| Discharge self-care score | 58.82% |
53.69%
5.1 pts better
|
Numerator 90 · Denominator 153 |
| Discharge mobility score | 39.87% |
50.94%
11.1 pts worse
|
Numerator 61 · Denominator 153 |
| Pressure ulcers or injuries, new or worsened | 2.6% |
2.29%
0.3 pts worse
|
Numerator 6 · Denominator 231 · Adjusted rate 2.36% |
| Healthcare-associated infections requiring hospitalization | 8.33% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 10.1% · Lower 95% interval 5.69% |
| Staff COVID-19 vaccination coverage | 49.53% |
8.2%
41.3 pts better
|
Numerator 53 · Denominator 107 |
| Staff flu vaccination coverage | 14.72% |
42%
27.3 pts worse
|
Numerator 24 · Denominator 163 |
| Discharge function score | 59.48% |
56.45%
3 pts better
|
Numerator 91 · Denominator 153 |
| Transfer of health information to provider | 94.44% |
95.95%
1.5 pts worse
|
Numerator 102 · Denominator 108 |
| Transfer of health information to patient | 98.48% |
96.28%
2.2 pts better
|
Numerator 65 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 9.85% |
25.2%
15.3 pts worse
|
Numerator 13 · Denominator 132 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 2.3 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| 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 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| 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 · Q1 97.3% · Q2 98.7% · Q3 98.6% · Q4 98.6% · 4Q avg 98.3% |
| 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 | 4.5% |
2.6%
1.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.6% · Q3 4.2% · Q4 4.3% · 4Q avg 4.5% · Used in QM five-star |
| 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 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| 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 · Q1 1.6% · Q2 3.2% · Q3 1.6% · Q4 1.6% · 4Q avg 2.0% |
| 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 · Q1 23.1% · Q2 27.7% · Q3 22.2% · Q4 20.3% · 4Q avg 23.3% |
| 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 · Q1 8.0% · Q2 7.3% · Q3 3.6% · Q4 7.8% · 4Q avg 6.6% · 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 | 14.1% |
11.7%
2.4 pts worse
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 16.8% · Q3 0.0% · Q4 8.1% · 4Q avg 14.1% · Used in QM five-star |
| 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 · Q1 30.2% · Q2 13.1% · Q3 0.0% · Q4 3.4% · 4Q avg 12.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 14.3% |
12.5%
1.8 pts worse
|
19.8%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 25.9% · Q3 0.0% · Q4 7.0% · 4Q avg 14.3% |
| 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 · Q1 3.3% · Q2 3.5% · Q3 2.4% · Q4 4.8% · 4Q avg 3.5% · Used in QM five-star |
| 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 · Q1 98.1% · Q2 99.3% · Q3 100.0% · Q4 98.8% · 4Q avg 99.1% |
| 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 · Adjusted 7.3% · Observed 7.7% · Expected 11.7% · Used in QM five-star |
| 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 · Q1 0.6% · Q2 0.6% · Q3 1.6% · Q4 2.0% · 4Q avg 1.2% · 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 | 18.4% |
26.2%
7.8 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 19.8% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-09 · Fire 2022-12-09
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-02-04 · Fire 2021-02-04
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-25
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
F756 · Pharmacy Service Deficiencies
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
E · Potential for more than minimal harm
2024-07-25
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 2024-08-25
D · Potential for more than minimal harm
2024-07-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-25
H · Actual harm
2023-04-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-11
G · Actual harm
2023-04-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-04-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-04-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-04-07
F580 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2023-04-07
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 2023-05-11
D · Potential for more than minimal harm
2023-04-07
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 2023-05-11
E · Potential for more than minimal harm
2022-12-09
F623 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2022-12-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-09
D · Potential for more than minimal harm
2022-12-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-09
D · Potential for more than minimal harm
2022-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-09
D · Potential for more than minimal harm
2022-12-09
F756 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2021-02-04
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2021-03-04
D · Potential for more than minimal harm
2021-02-04
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2021-03-04
D · Potential for more than minimal harm
2021-02-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-03-04
D · Potential for more than minimal harm
2021-02-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-03-04
Penalties and ownership
What sits behind the stars
$192,413
2023-04-07
Fine
Fine · fine $192,413
Fine
Ownership
Escander, Carolina
Operational/Managerial Control · Individual
Freund, Nochum
Operational/Managerial Control · Individual
Freund, Nochum
Corporate Officer · Individual
Nuriel, Gabriel
Operational/Managerial Control · Individual
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