Cycle 1
Health 2024-12-18 · Fire 2024-12-18
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Hunters Creek Nursing And Rehab Center
4-star overall rating with 3-star inspections with $67,191 in total fines with 4 recent health deficiencies
14155 Town Loop Blvd, Orlando, FL
(407) 541-2600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
116
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1998-05-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 overall / 3 health / 3 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
0.64
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,780
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.58
Baseline 26.62% · Performance 23.67% · Measure score 2.58 · Achievement 0 · Improvement 2.58
Healthcare-associated infections
0
Baseline 6.71% · Performance 9.71% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.28
Baseline 54.48% · Performance 25.74% · Measure score 9.28 · Achievement 9.28 · Improvement 9
Adjusted total nurse staffing
0.84
Baseline 3.43 hours · Performance 3.32 hours · Measure score 0.84 · Achievement 0.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 270 · Observed rate 10.74% · Lower 95% interval 7.5% |
| Discharge to community | 56.74% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 48.25% · Lower 95% interval 49.19% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 251 · Denominator 251 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 251 |
| Discharge self-care score | 67.65% |
53.69%
14 pts better
|
Numerator 92 · Denominator 136 |
| Discharge mobility score | 58.09% |
50.94%
7.2 pts better
|
Numerator 79 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 3.98% |
2.29%
1.7 pts worse
|
Numerator 10 · Denominator 251 · Adjusted rate 3.29% |
| Healthcare-associated infections requiring hospitalization | 9.71% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 192 · Observed rate 12.5% · Lower 95% interval 6.74% |
| Staff COVID-19 vaccination coverage | 2.75% |
8.2%
5.4 pts worse
|
Numerator 5 · Denominator 182 |
| Staff flu vaccination coverage | 25.97% |
42%
16 pts worse
|
Numerator 60 · Denominator 231 |
| Discharge function score | 63.97% |
56.45%
7.5 pts better
|
Numerator 87 · Denominator 136 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 160 · Denominator 176 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.01% |
25.2%
4.2 pts worse
|
Numerator 25 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · 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 | 1.9% |
2.6%
0.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.2% · Q3 2.2% · Q4 2.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.5% |
3.7%
5.8 pts worse
|
11.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 6.8% · Q3 3.9% · Q4 7.9% · 4Q avg 9.5% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.9%
5.2 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
15.7%
11.8 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.8% · Q3 3.9% · Q4 4.1% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
9.8%
1.1 pts worse
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 10.8% · Q3 13.2% · Q4 7.7% · 4Q avg 10.9% · 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 | 4.9% |
11.7%
6.8 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.6% · Q3 9.5% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
9.8%
4.3 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.9% · Q3 6.8% · Q4 1.6% · 4Q avg 5.5% · 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 | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.1% |
12.5%
6.4 pts better
|
19.8%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 2.7% · Q3 10.6% · Q4 0.0% · 4Q avg 6.1% |
| Percentage of long-stay residents with pressure ulcers | 14.0% |
5.1%
8.9 pts worse
|
5.1%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 17.8% · Q3 14.1% · Q4 10.3% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
9.3%
1.5 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 8.4% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.3% · Q4 1.3% · 4Q avg 0.8% · 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 | 27.4% |
26.2%
1.2 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 31.9% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-29 · Fire 2023-06-29
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-11-17 · Fire 2021-11-17
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-18
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 2025-01-19
E · Potential for more than minimal harm
2024-12-18
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 2025-01-19
D · Potential for more than minimal harm
2024-12-18
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 2025-01-19
D · Potential for more than minimal harm
2024-12-18
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-01-19
G · Actual harm
2024-11-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-12-14
J · Immediate jeopardy
2024-09-20
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 2024-09-13
J · Immediate jeopardy
2024-09-20
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 2024-09-13
D · Potential for more than minimal harm
2023-12-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-06-29
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 2023-07-31
D · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-31
D · Potential for more than minimal harm
2021-11-17
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-12-17
Penalties and ownership
What sits behind the stars
$51,545
2024-11-14
Fine
Fine · fine $51,545
Fine
$7,823
2024-09-20
Fine
Fine · fine $7,823
Fine
$7,823
2024-09-20
Fine
Fine · fine $7,823
Fine
Ownership
Sovereign Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
John J Notermann Business Tr
5% Or Greater Indirect Ownership Interest · Organization
Cronquist 2015 Family Tr
5% Or Greater Indirect Ownership Interest · Organization
Berkadia Commercial Mortgage LLC
5% Or Greater Security Interest · Organization
Britton, Mark
Operational/Managerial Control · Individual
Cronquist, Royce
Corporate Officer · Individual
Fl Hunters Creek Holdings LLC
5% Or Greater Security Interest · Organization
Health Services Properties LLC
5% Or Greater Security Interest · Organization
Jicha, Joseph
Operational/Managerial Control · Individual
Kelly, Michelle
Corporate Officer · Individual
Melton, Donald
Operational/Managerial Control · Individual
Melton, Donald
Corporate Officer · Individual
Notermann, William
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Sovereign Healthcare Disbursements LLC
Operational/Managerial Control · Organization
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#3
Terrace Of Kissimmee, The
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1-star overall rating with 1-star inspections with $38,724 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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