Cycle 1
Health 2025-02-13 · Fire 2025-02-13
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Leesburg, FL
Lake Port Square Health Center
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
701 Lake Port Blvd, Leesburg, FL
(352) 728-3366
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
1990-08-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 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
0.77
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,577
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9967
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.45
Baseline 24.37% · Performance 20.73% · Measure score 4.45 · Achievement 1.51 · Improvement 4.45
Healthcare-associated infections
5.97
Baseline 11.00% · Performance 7.12% · Measure score 5.97 · Achievement 2.40 · Improvement 5.97
Total nurse turnover
2.91
Performance 51.77% · Measure score 2.91 · Achievement 2.91 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.14
Baseline 4.18 hours · Performance 4.26 hours · Measure score 4.14 · Achievement 4.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 310 · Observed rate 9.68% · Lower 95% interval 8.32% |
| Discharge to community | 66.1% |
50.57%
15.5 pts better
|
Better than the National Rate · Eligible stays 297 · Observed rate 60.27% · Lower 95% interval 60.44% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.59% |
95.27%
4.3 pts better
|
Numerator 240 · Denominator 241 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 241 |
| Discharge self-care score | 52.8% |
53.69%
0.9 pts worse
|
Numerator 85 · Denominator 161 |
| Discharge mobility score | 21.12% |
50.94%
29.8 pts worse
|
Numerator 34 · Denominator 161 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 4 · Denominator 237 · Adjusted rate 1.5% |
| Healthcare-associated infections requiring hospitalization | 7.12% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 155 · Observed rate 6.45% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 4.48% |
8.2%
3.7 pts worse
|
Numerator 6 · Denominator 134 |
| Staff flu vaccination coverage | 15.11% |
42%
26.9 pts worse
|
Numerator 34 · Denominator 225 |
| Discharge function score | 39.75% |
56.45%
16.7 pts worse
|
Numerator 64 · Denominator 161 |
| Transfer of health information to provider | 87.36% |
95.95%
8.6 pts worse
|
Numerator 159 · Denominator 182 |
| Transfer of health information to patient | 92% |
96.28%
4.3 pts worse
|
Numerator 23 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 11.54% |
25.2%
13.7 pts worse
|
Numerator 15 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
97.8%
0.4 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 100.0% · Q4 96.0% · 4Q avg 98.2% |
| 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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.9% |
3.7%
1.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 8.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
5.9%
3.7 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 4.3% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
15.7%
0.6 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 17.4% · Q3 15.0% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.4% |
9.8%
8.4 pts better
|
16.7%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% · 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 | 23.2% |
9.8%
13.4 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 13.6% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.4%
0.6 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
12.5%
16.8 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.1% · Q2 18.2% · Q3 23.9% · Q4 36.2% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.1%
2.9 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 10.7% · Q3 9.2% · Q4 6.7% · 4Q avg 8.0% · 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 99.3% · Q2 96.9% · Q3 96.5% · Q4 98.9% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
9.3%
6.3 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 13.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.7%
2 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.4% |
26.2%
6.2 pts worse
|
23.9%
8.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.4% · Observed 28.3% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-05-06 · Fire 2022-05-06
10 health deficiencies
Top issue: Administration (2 deficiencies)
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
2025-02-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-25
E · Potential for more than minimal harm
2023-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-13
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 2025-03-25
D · Potential for more than minimal harm
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-13
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 2025-03-25
D · Potential for more than minimal harm
2025-02-13
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 2025-03-25
D · Potential for more than minimal harm
2025-02-13
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 2025-03-25
D · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-25
D · Potential for more than minimal harm
2024-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-01
E · Potential for more than minimal harm
2023-10-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-25
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 2023-11-28
D · Potential for more than minimal harm
2023-10-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-25
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 2023-11-28
D · Potential for more than minimal harm
2023-10-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-25
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 2023-11-28
D · Potential for more than minimal harm
2023-10-25
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 2023-11-28
D · Potential for more than minimal harm
2023-10-25
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-25
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 2023-11-28
D · Potential for more than minimal harm
2023-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-28
C · Minimal harm
2023-10-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-28
L · Immediate jeopardy
2022-05-06
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 2022-06-22
L · Immediate jeopardy
2022-05-06
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 2022-06-24
L · Immediate jeopardy
2022-05-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-06-24
F · Potential for more than minimal harm
2022-05-06
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 2022-06-22
F · Potential for more than minimal harm
2022-05-06
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 2022-06-05
F · Potential for more than minimal harm
2022-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-28
D · Potential for more than minimal harm
2022-05-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-06-05
D · Potential for more than minimal harm
2022-05-06
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 2022-06-05
D · Potential for more than minimal harm
2022-05-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-06-05
Penalties and ownership
What sits behind the stars
Ownership
Ccrc Opco Ventures, LLC
5% Or Greater Direct Ownership Interest · Organization
Beeler, Daniel
Operational/Managerial Control · Individual
Buettner, Markus
Operational/Managerial Control · Individual
Hcp S-H 2014 Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services LLC
Operational/Managerial Control · Organization
Martinez Irizarry, Axel
Operational/Managerial Control · Individual
S-H 2014 Opco Trs Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
South Campus Care Center And Rehab
Leesburg, FL
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
North Campus Rehabilitation And Nursing Center
Leesburg, FL
3-star overall rating with 3-star inspections with 2 recent health deficiencies
#3
Avante At Leesburg, Inc
Leesburg, FL
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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