Cycle 1
Health 2025-07-18 · Fire 2025-07-18
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Orlando, FL
Delaney Park Health And Rehabilitation Center
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
215 Annie Street, Orlando, FL
(407) 841-4371
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
89
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.90
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.50
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
3.42
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,411
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.75
Baseline 24.52% · Performance 20.59% · Measure score 4.75 · Achievement 1.82 · Improvement 4.75
Healthcare-associated infections
0
Baseline 6.90% · Performance 8.36% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.39
Baseline 38.30% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 0
Adjusted total nurse staffing
0.60
Baseline 3.48 hours · Performance 3.25 hours · Measure score 0.60 · Achievement 0.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 377 · Observed rate 12.47% · Lower 95% interval 9.43% |
| Discharge to community | 59.99% |
50.57%
9.4 pts better
|
Better than the National Rate · Eligible stays 372 · Observed rate 51.88% · Lower 95% interval 54.78% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.21% |
95.27%
1.9 pts better
|
Numerator 244 · Denominator 251 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 251 |
| Discharge self-care score | 60.4% |
53.69%
6.7 pts better
|
Numerator 90 · Denominator 149 |
| Discharge mobility score | 48.32% |
50.94%
2.6 pts worse
|
Numerator 72 · Denominator 149 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 4 · Denominator 251 · Adjusted rate 1.1% |
| Healthcare-associated infections requiring hospitalization | 8.36% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 154 · Observed rate 11.04% · Lower 95% interval 5.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 68 |
| Staff flu vaccination coverage | 30% |
42%
12 pts worse
|
Numerator 27 · Denominator 90 |
| Discharge function score | 57.72% |
56.45%
1.3 pts better
|
Numerator 86 · Denominator 149 |
| Transfer of health information to provider | 96.81% |
95.95%
0.9 pts better
|
Numerator 91 · Denominator 94 |
| Transfer of health information to patient | 95.41% |
96.28%
0.9 pts worse
|
Numerator 104 · Denominator 109 |
| Resident COVID-19 vaccinations up to date | 6.62% |
25.2%
18.6 pts worse
|
Numerator 9 · Denominator 136 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.7 · Expected 3.1 · 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 1.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 1.0% |
2.6%
1.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 1.0% · 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 | 10.0% |
5.9%
4.1 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 14.0% · Q3 13.0% · Q4 7.7% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
15.7%
4.1 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 22.9% · Q3 17.0% · Q4 16.7% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
9.8%
1.7 pts worse
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 11.4% · Q3 6.5% · Q4 11.4% · 4Q avg 11.5% · 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 need for help with daily activities has increased | 10.6% |
9.8%
0.8 pts worse
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 10.8% · Q3 5.7% · Q4 12.5% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · 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 | 2.6% |
12.5%
9.9 pts better
|
19.8%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 2.3% · Q4 2.3% · 4Q avg 2.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.1%
0.5 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 5.4% · Q3 5.1% · Q4 5.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
94.3%
4.2 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 97.3% · Q3 100.0% · Q4 98.9% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
9.3%
1.9 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.7% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 3.7% · Q4 3.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
94.7%
4.9 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
26.2%
3.6 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 35.2% · Expected 28.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
4 health deficiencies
Top issue: Nutrition and Dietary (2 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
2025-07-18
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 2025-08-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-18
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-18
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 2025-08-18
E · Potential for more than minimal harm
2025-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-18
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 2025-08-18
D · Potential for more than minimal harm
2025-07-18
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-18
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-18
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 2025-08-18
D · Potential for more than minimal harm
2025-07-18
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-05-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-09
E · Potential for more than minimal harm
2024-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-05
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 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-05
E · Potential for more than minimal harm
2023-05-25
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 2023-06-26
D · Potential for more than minimal harm
2023-05-25
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-06-26
J · Immediate jeopardy
2023-03-03
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 2023-04-02
J · Immediate jeopardy
2023-03-03
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-04-02
Penalties and ownership
What sits behind the stars
Ownership
Orlando Rehabilitation Group , Inc.
5% Or Greater Direct Ownership Interest · Organization
Anu Health Management LLC
Operational/Managerial Control · Organization
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Dudley, Nate
Corporate Officer · Individual
Facility Support Company, LLC
Operational/Managerial Control · Organization
Garner, Alvin
Corporate Officer · Individual
Jaffe, Howard
Corporate Officer · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Mines, Matthew
Operational/Managerial Control · Individual
Mullen, Ann
Corporate Officer · Individual
Rombold, Lori
Corporate Officer · Individual
Wilkerson, Jennifer
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Westminster Towers
Orlando, FL
3-star overall rating with 2-star inspections with $22,133 in total fines with 7 recent health deficiencies
#2
South Orange Health And Rehabilitation Center
Orlando, FL
4-star overall rating with 4-star inspections with $14,442 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Commons At Orlando Lutheran Towers
Orlando, FL
4-star overall rating with 4-star inspections with 1 recent health deficiencies
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