Cycle 1
Health 2025-08-29 · Fire 2025-08-29
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Eustis, FL
Lake Eustis Healthcare And Rehabilitation Center
2-star overall rating with 1-star inspections with $26,685 in total fines with 10 recent health deficiencies
411 W Woodward Ave, Eustis, FL
(352) 357-3565
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
90
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
1976-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 2 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
0.51
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,449
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.58
Baseline 18.88% · Performance 19.31% · Measure score 4.58 · Achievement 4.58 · Improvement 0
Healthcare-associated infections
4.13
Baseline 5.27% · Performance 6.60% · Measure score 4.13 · Achievement 4.13 · Improvement 0
Total nurse turnover
2.15
Performance 54.90% · Measure score 2.15 · Achievement 2.15 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.26
Baseline 4.45 hours · Performance 3.72 hours · Measure score 2.26 · Achievement 2.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.15% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 6.45% · Lower 95% interval 6.6% |
| Discharge to community | 38.16% |
50.57%
12.4 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 29.23% · Lower 95% interval 28.26% |
| 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 86 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 35.94% |
53.69%
17.8 pts worse
|
Numerator 23 · Denominator 64 |
| Discharge mobility score | 18.75% |
50.94%
32.2 pts worse
|
Numerator 12 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 86 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 27.47% |
42%
14.5 pts worse
|
Numerator 25 · Denominator 91 |
| Discharge function score | 29.69% |
56.45%
26.8 pts worse
|
Numerator 19 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.17% |
25.2%
21 pts worse
|
Numerator 2 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
97.8%
0.5 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.7% · Q4 94.4% · 4Q avg 98.3% |
| 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 | 0.3% |
2.6%
2.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
3.7%
2.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.9%
3.1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.1% · Q4 5.4% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
15.7%
3.1 pts worse
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 14.9% · Q3 20.9% · Q4 17.5% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
9.8%
3.9 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 11.4% · Q3 2.0% · Q4 2.2% · 4Q avg 5.9% · 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 | 9.9% |
11.7%
1.8 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 18.1% · Q4 8.3% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.2% |
9.8%
2.6 pts better
|
14.9%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 3.3% · Q3 6.5% · Q4 3.8% · 4Q avg 7.2% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.3% |
12.5%
5.2 pts better
|
19.8%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.8% · Q3 9.6% · Q4 7.1% · 4Q avg 7.3% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
5.1%
3.9 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 1.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
94.3%
3.7 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 95.5% · Q4 97.8% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
9.3%
0.3 pts worse
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 10.0% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.7%
4.2 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.9% |
26.2%
9.3 pts better
|
23.9%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 16.0% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2024-05-31
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
5 health deficiencies
Top issue: Environmental (1 deficiency)
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
2024-05-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-31
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-05
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-29
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-10-03
J · Immediate jeopardy
2025-08-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-05
E · Potential for more than minimal harm
2025-08-29
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 2025-10-03
D · Potential for more than minimal harm
2025-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-29
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 2025-10-03
D · Potential for more than minimal harm
2025-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-03
E · Potential for more than minimal harm
2024-05-31
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
2024-05-31
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
2024-05-31
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 2024-07-05
D · Potential for more than minimal harm
2024-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-05
F · Potential for more than minimal harm
2023-01-26
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 2023-03-03
E · Potential for more than minimal harm
2023-01-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-26
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 2023-03-03
D · Potential for more than minimal harm
2023-01-26
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 2023-03-03
Penalties and ownership
What sits behind the stars
$13,342
2025-08-29
Fine
Fine · fine $13,342
Fine
$13,343
2025-08-29
Fine
Fine · fine $13,343
Fine
Ownership
Lake Eustis Operating Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bdcc Consutking Group LLC
5% Or Greater Indirect Ownership Interest · Organization
David, Rochel
5% Or Greater Indirect Ownership Interest · Individual
Fdz Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Friedman, Leah
5% Or Greater Indirect Ownership Interest · Individual
Jz Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Powers, Brian
5% Or Greater Indirect Ownership Interest · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Rubiweb Florida Services Group Usa LLC
5% Or Greater Indirect Ownership Interest · Organization
Weber, Aron
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Charles
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
Operational/Managerial Control · Individual
Zahler, Jacob
Corporate Officer · Individual
Nearby options
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4-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Ruleme Center
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2-star overall rating with 3-star inspections with $24,889 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Solaris Healthcare Waterman
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5-star overall rating with 4-star inspections with 3 recent health deficiencies
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