Cycle 1
Health 2025-12-18 · Fire 2025-12-18
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.
Lady Lake, FL
Lady Lake Specialty Care Center and Rehab
1-star overall rating with 1-star inspections with 7 recent health deficiencies
630 Griffin Avenue, Lady Lake, FL
(352) 750-6619
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
141
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
1999-03-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing
LPN hours / resident day
0.84
Licensed practical nurse staffing
Aide hours / resident day
2.10
Nurse aide staffing
Weekend hours
3.09
Weekend nurse staffing
RN turnover
32%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.3% |
97.8%
24.5 pts worse
|
93.4%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.6%
0.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 17.2% |
3.7%
13.5 pts worse
|
11.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.9%
0.4 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.8% |
15.7%
9.9 pts better
|
19.6%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
9.8%
1.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
11.7%
1 pts worse
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
9.8%
4.2 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.8% |
12.5%
6.7 pts better
|
19.8%
14 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
5.1%
2.3 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.8% |
94.3%
60.5 pts worse
|
81.7%
47.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
9.3%
1.2 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.5%
2.1 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.6% |
94.7%
18.1 pts worse
|
79.7%
3.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
26.2%
6.5 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-17 · Fire 2024-07-17
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
11 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-23
F · Potential for more than minimal harm
2023-03-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-04-17
F · Potential for more than minimal harm
2023-03-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-04-17
F · Potential for more than minimal harm
2023-03-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-04-17
F · Potential for more than minimal harm
2023-03-09
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-04-17
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-06
J · Immediate jeopardy
2025-12-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-18
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 2026-02-06
D · Potential for more than minimal harm
2025-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-06
E · Potential for more than minimal harm
2024-07-17
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 2024-08-23
E · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
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 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-17
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 2024-08-23
D · Potential for more than minimal harm
2024-07-17
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 2024-08-23
C · Minimal harm
2024-07-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-04-01
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 2024-04-27
E · Potential for more than minimal harm
2023-03-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-09
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 2023-04-17
E · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-09
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 2023-04-17
D · Potential for more than minimal harm
2023-03-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-09
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 2023-04-17
D · Potential for more than minimal harm
2023-03-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-09
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 2023-04-17
Penalties and ownership
What sits behind the stars
Ownership
Lady Lake SNF Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Copper Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Ellenbogen, Moss
Corporate Officer · Individual
Fl Hud Master Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Gold Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Oliver, Tonya
W-2 Managing Employee · Individual
Silver Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Villages Healthcare And Rehabilitation Center, The
Lady Lake, FL
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Freedom Pointe Health Center
The Villages, FL
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Chatham Glen Healthcare And Rehabilitation Center
The Villages, FL
5-star overall rating with 4-star inspections with 5 recent health deficiencies
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