Cycle 1
Health 2025-09-11 · Fire 2025-09-11
10 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Conway Lakes Health & Rehabilitation Center
2-star overall rating with 2-star inspections with $94,672 in total fines with 10 recent health deficiencies
5201 Curry Ford Road, Orlando, FL
(407) 384-8838
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 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
Clear Choice Healthcare
Operator or chain grouping
Approved since
1991-12-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 3 health / 4 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
0.76
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.42
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,408
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.09% · Performance 23.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.95% · Performance 9.04% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.25
Baseline 50.76% · Performance 46.32% · Measure score 4.25 · Achievement 4.25 · Improvement 1.21
Adjusted total nurse staffing
3.94
Baseline 4.21 hours · Performance 4.20 hours · Measure score 3.94 · Achievement 3.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 433 · Observed rate 12.93% · Lower 95% interval 9.02% |
| Discharge to community | 51.09% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 423 · Observed rate 43.5% · Lower 95% interval 46.32% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.82% |
95.27%
3.5 pts better
|
Numerator 336 · Denominator 340 |
| Falls with major injury | 1.76% |
0.77%
1 pts worse
|
Numerator 6 · Denominator 340 |
| Discharge self-care score | 33.97% |
53.69%
19.7 pts worse
|
Numerator 71 · Denominator 209 |
| Discharge mobility score | 48.8% |
50.94%
2.1 pts worse
|
Numerator 102 · Denominator 209 |
| Pressure ulcers or injuries, new or worsened | 1.47% |
2.29%
0.8 pts better
|
Numerator 5 · Denominator 340 · Adjusted rate 1.42% |
| Healthcare-associated infections requiring hospitalization | 9.04% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 246 · Observed rate 11.38% · Lower 95% interval 6.58% |
| Staff COVID-19 vaccination coverage | 14.68% |
8.2%
6.5 pts better
|
Numerator 32 · Denominator 218 |
| Staff flu vaccination coverage | 13.73% |
42%
28.3 pts worse
|
Numerator 28 · Denominator 204 |
| Discharge function score | 49.76% |
56.45%
6.7 pts worse
|
Numerator 104 · Denominator 209 |
| Transfer of health information to provider | 92.22% |
95.95%
3.7 pts worse
|
Numerator 154 · Denominator 167 |
| Transfer of health information to patient | 96.72% |
96.28%
0.4 pts better
|
Numerator 118 · Denominator 122 |
| Resident COVID-19 vaccinations up to date | 1.73% |
25.2%
23.5 pts worse
|
Numerator 3 · Denominator 173 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
97.8%
0.8 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 97.3% · Q3 100.0% · Q4 98.7% · 4Q avg 98.6% |
| 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 | 2.7% |
2.6%
0.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.4% · Q3 1.4% · Q4 1.3% · 4Q avg 2.7% · 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 | 3.7% |
5.9%
2.2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 6.2% · Q3 1.7% · Q4 4.8% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
15.7%
1.2 pts worse
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 18.5% · Q3 14.3% · Q4 17.2% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
9.8%
5.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 14.0% · Q3 14.6% · Q4 14.6% · 4Q avg 15.0% · 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 | 31.0% |
11.7%
19.3 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 42.9% · Q3 39.6% · Q4 24.8% · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.8% |
9.8%
14 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 30.5% · Q3 32.7% · Q4 10.9% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.4%
1.8 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.4% · Q3 2.7% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
0.8%
1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 2.9% · Q4 2.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
12.5%
9.3 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 18.1% · Q3 18.7% · Q4 26.1% · 4Q avg 21.8% |
| 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 · Q1 1.3% · Q2 3.1% · Q3 2.9% · Q4 3.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
94.3%
2.5 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 96.5% · Q3 96.9% · Q4 95.0% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
9.3%
0.6 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.8% · Expected 11.3% · 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 1.5% · Q2 1.1% · Q3 1.7% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
94.7%
3.2 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.5% |
26.2%
7.3 pts worse
|
23.9%
9.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.5% · Observed 34.4% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-11
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 2025-10-08
D · Potential for more than minimal harm
2025-09-11
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 2025-10-08
D · Potential for more than minimal harm
2025-09-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-07-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-02
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 2025-07-31
D · Potential for more than minimal harm
2025-07-02
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 2025-07-31
D · Potential for more than minimal harm
2025-07-02
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 2025-07-31
D · Potential for more than minimal harm
2025-07-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-28
J · Immediate jeopardy
2025-02-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-01
J · Immediate jeopardy
2025-02-01
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 2025-03-01
F · Potential for more than minimal harm
2025-02-01
F895 · Administration Deficiencies
Health
Have a Compliance and Ethics Program.
Corrected 2025-03-01
D · Potential for more than minimal harm
2025-02-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-01
D · Potential for more than minimal harm
2025-02-01
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 2025-03-01
G · Actual harm
2024-08-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-22
E · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-22
D · Potential for more than minimal harm
2024-08-22
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 2024-09-22
D · Potential for more than minimal harm
2024-05-16
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 2024-06-16
D · Potential for more than minimal harm
2024-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-16
D · Potential for more than minimal harm
2024-05-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-06-16
D · Potential for more than minimal harm
2023-02-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-09
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 2023-03-16
D · Potential for more than minimal harm
2023-02-09
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 2023-03-16
D · Potential for more than minimal harm
2023-02-09
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 2023-03-16
D · Potential for more than minimal harm
2023-02-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-09
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-16
Penalties and ownership
What sits behind the stars
$4,147
2025-06-10
Fine
Fine · fine $4,147
Fine
$4,147
2025-06-10
Fine
Fine · fine $4,147
Fine
$6,227
2025-06-10
Fine
Fine · fine $6,227
Fine
$61,636
2025-02-01
Fine
Fine · fine $61,636
Fine
$6,180
2024-08-22
Fine
Fine · fine $6,180
Fine
$12,335
2024-08-22
Fine
Fine · fine $12,335
Fine
Ownership
Sbk Capital, LLC
5% Or Greater Direct Ownership Interest · Organization
Burrowes, Adrian
Operational/Managerial Control · Individual
Clear Choice Health Care LLC
Operational/Managerial Control · Organization
Partee, Leslie
Operational/Managerial Control · Individual
Partee, Leslie
Corporate Officer · Individual
Sabarre, Brent
Corporate Officer · Individual
Truist
5% Or Greater Mortgage Interest · Organization
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#3
Solaris Healthcare East Orlando
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5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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