Saint Cloud, FL

Aviata At St Cloud

3-star overall rating with 2-star inspections with $103,362 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

4641 Old Canoe Creek Road, Saint Cloud, FL

(407) 892-7344

Compare this facility

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

113

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Aviata Health Group

Operator or chain grouping

Approved since

1995-07-20

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

0.47

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.85

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.13

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.32

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

0.17

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.52

CMS adjusted RN staffing hours

Adjusted total hours

3.84

CMS adjusted total nurse staffing hours

Case-mix index

1.22

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

11,044

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

Performance score

18.21

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 22.22% · Performance 22.36% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 7.10% · Performance 10.13% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

6.05

Baseline 47.66% · Performance 38.95% · Measure score 6.05 · Achievement 6.05 · Improvement 3.32

Adjusted total nurse staffing

1.23

Baseline 4.06 hours · Performance 3.43 hours · Measure score 1.23 · Achievement 1.23 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.61%	10.72% 1.1 pts better	No Different than the National Rate · Eligible stays 134 · Observed rate 8.21% · Lower 95% interval 7.07%
Discharge to community	45.56%	50.57% 5 pts worse	No Different than the National Rate · Eligible stays 78 · Observed rate 39.74% · Lower 95% interval 37.48%
Medicare spending per beneficiary	1.09	1.02 0.1 pts worse
Drug regimen review with follow-up	95.06%	95.27% 0.2 pts worse	Numerator 154 · Denominator 162
Falls with major injury	1.85%	0.77% 1.1 pts worse	Numerator 3 · Denominator 162
Discharge self-care score	67.59%	53.69% 13.9 pts better	Numerator 73 · Denominator 108
Discharge mobility score	45.37%	50.94% 5.6 pts worse	Numerator 49 · Denominator 108
Pressure ulcers or injuries, new or worsened	4.32%	2.29% 2 pts worse	Numerator 7 · Denominator 162 · Adjusted rate 3.82%
Healthcare-associated infections requiring hospitalization	10.13%	7.12% 3 pts worse	No Different than the National Rate · Eligible stays 91 · Observed rate 14.29% · Lower 95% interval 6.41%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 122
Staff flu vaccination coverage	9.85%	42% 32.1 pts worse	Numerator 13 · Denominator 132
Discharge function score	59.26%	56.45% 2.8 pts better	Numerator 64 · Denominator 108
Transfer of health information to provider	65.38%	95.95% 30.6 pts worse	Numerator 34 · Denominator 52
Transfer of health information to patient	92%	96.28% 4.3 pts worse	Numerator 23 · Denominator 25
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 68

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.8	2.1 0.7 pts worse	1.9 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.7 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	1.2 0.3 pts worse	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.7%	97.8% 0.9 pts better	93.4% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.7%
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	2.6%	2.6% About the same	3.3% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.0% · Q3 2.0% · Q4 4.1% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.8%	3.7% 2.1 pts worse	11.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 6.4% · Q3 6.7% · Q4 7.8% · 4Q avg 5.8%
Percentage of long-stay residents who lose too much weight	3.0%	5.9% 2.9 pts better	5.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.4% · Q3 3.4% · Q4 4.6% · 4Q avg 3.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.9%	15.7% 0.2 pts worse	19.6% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 14.9% · Q3 13.5% · Q4 15.7% · 4Q avg 15.9%
Percentage of long-stay residents who received an antipsychotic medication	7.3%	9.8% 2.5 pts better	16.7% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.2% · Q3 5.4% · Q4 6.6% · 4Q avg 7.3% · 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	12.3%	11.7% 0.6 pts worse	16.3% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q2 18.1% · Q3 12.5% · Q4 6.3% · 4Q avg 12.3% · 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 13.7% · Q2 20.5% · Q3 5.3% · Q4 4.1% · 4Q avg 11.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.4% 0.1 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · 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	0.5%	0.8% 0.3 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	11.9%	12.5% 0.6 pts better	19.8% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 19.3% · Q3 4.9% · Q4 3.0% · 4Q avg 11.9%
Percentage of long-stay residents with pressure ulcers	1.4%	5.1% 3.7 pts better	5.1% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.6% · Q3 1.5% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.0%	94.3% 3.3 pts worse	81.7% 9.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 85.6% · Q3 97.0% · Q4 99.2% · 4Q avg 91.0%
Percentage of short-stay residents who had an outpatient emergency department visit	5.9%	9.3% 3.4 pts better	12.0% 6.1 pts better	Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 6.3% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.7%	1.5% 0.2 pts worse	1.6% 0.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.7% · Q4 3.2% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.4%	94.7% 5.3 pts worse	79.7% 9.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.7%	26.2% 5.5 pts better	23.9% 3.2 pts better	Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 22.1% · Expected 25.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-10 · Fire 2025-04-10

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-08-17 · Fire 2023-08-17

26 health deficiencies

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

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-11-18 · Fire 2021-11-18

7 health deficiencies

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

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-04-10

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 2025-05-10

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-10

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-11-28

E · Potential for more than minimal harm 2025-04-10

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-05-10

E · Potential for more than minimal harm 2025-04-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-10

E · Potential for more than minimal harm 2025-02-18

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

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 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-03-18

D · Potential for more than minimal harm 2024-12-10

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-12-10

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 2025-01-10

D · Potential for more than minimal harm 2024-12-10

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 2025-01-10

E · Potential for more than minimal harm 2024-09-19

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 2024-10-18

E · Potential for more than minimal harm 2024-09-19

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-19

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-19

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-19

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 2024-10-18

G · Actual harm 2024-06-20

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-07-22

G · Actual harm 2024-06-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-07-22

E · Potential for more than minimal harm 2024-06-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-07-22

E · Potential for more than minimal harm 2024-06-20

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 2024-07-22

D · Potential for more than minimal harm 2024-06-20

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 2024-07-22

D · Potential for more than minimal harm 2024-06-20

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 2024-07-22

E · Potential for more than minimal harm 2024-05-17

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-06-21

D · Potential for more than minimal harm 2024-05-17

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2024-06-21