Cycle 1
Health 2024-09-19 · Fire 2024-09-19
6 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Clermont, FL
Lakes Of Clermont Health And Rehabilitation Center
4-star overall rating with 3-star inspections with $14,335 in total fines with 6 recent health deficiencies
1775 Hooks Street, Clermont, FL
(352) 717-7980
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
2020-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
46 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 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
0.80
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.10
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,928
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.28
Baseline 23.85% · Performance 22.63% · Measure score 1.28 · Achievement 0 · Improvement 1.28
Healthcare-associated infections
0
Baseline 7.14% · Performance 8.88% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.94
Baseline 48.39% · Performance 47.56% · Measure score 3.94 · Achievement 3.94 · Improvement 0
Adjusted total nurse staffing
2.21
Baseline 4.14 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 463 · Observed rate 10.58% · Lower 95% interval 8.19% |
| Discharge to community | 66.01% |
50.57%
15.4 pts better
|
Better than the National Rate · Eligible stays 447 · Observed rate 61.3% · Lower 95% interval 62.18% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 335 · Denominator 335 |
| Falls with major injury | 0.3% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 335 |
| Discharge self-care score | 50.49% |
53.69%
3.2 pts worse
|
Numerator 103 · Denominator 204 |
| Discharge mobility score | 40.69% |
50.94%
10.2 pts worse
|
Numerator 83 · Denominator 204 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 5 · Denominator 335 · Adjusted rate 1.52% |
| Healthcare-associated infections requiring hospitalization | 8.88% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 303 · Observed rate 9.9% · Lower 95% interval 6.49% |
| Staff COVID-19 vaccination coverage | 5.77% |
8.2%
2.4 pts worse
|
Numerator 9 · Denominator 156 |
| Staff flu vaccination coverage | 20.11% |
42%
21.9 pts worse
|
Numerator 38 · Denominator 189 |
| Discharge function score | 49.02% |
56.45%
7.4 pts worse
|
Numerator 100 · Denominator 204 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 128 · Denominator 128 |
| Transfer of health information to patient | 96.65% |
96.28%
0.4 pts better
|
Numerator 173 · Denominator 179 |
| Resident COVID-19 vaccinations up to date | 12.2% |
25.2%
13 pts worse
|
Numerator 20 · Denominator 164 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.1 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.8 · 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% · 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 | 2.6% |
2.6%
About the same
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
3.7%
2.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.9%
4.5 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
15.7%
7.2 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.3% |
9.8%
6.5 pts better
|
16.7%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 3.3% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.1% |
11.7%
17.4 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
9.8%
5.9 pts worse
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · 4Q avg 15.7% · 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% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
12.5%
3.8 pts worse
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 13.2% |
5.1%
8.1 pts worse
|
5.1%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.5% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
94.3%
4.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.1% · Q3 99.5% · Q4 98.9% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
9.3%
4 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 5.4% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.4% · Q4 0.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
94.7%
1.9 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
26.2%
5.3 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 20.7% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-18 · Fire 2023-05-18
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-01-06 · Fire 2022-01-06
4 health deficiencies
Top issue: Infection Control (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
2023-05-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-02
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 2025-07-02
D · Potential for more than minimal harm
2024-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-19
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 2024-10-22
D · Potential for more than minimal harm
2024-09-19
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 2024-10-22
D · Potential for more than minimal harm
2024-09-19
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 2024-10-22
D · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-22
J · Immediate jeopardy
2023-10-20
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 2023-11-07
D · Potential for more than minimal harm
2023-05-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-18
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 2023-06-22
D · Potential for more than minimal harm
2023-05-18
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 2023-06-22
F · Potential for more than minimal harm
2022-01-06
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 2022-01-20
E · Potential for more than minimal harm
2022-01-06
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 2022-01-20
D · Potential for more than minimal harm
2022-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-20
Penalties and ownership
What sits behind the stars
$14,335
2023-10-20
Fine
Fine · fine $14,335
Fine
Ownership
Clermont SNF Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Copper Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Rm Irrv Tr 07012022
5% Or Greater Indirect Ownership Interest · Organization
Clemons, James
Operational/Managerial Control · Individual
Manela, Robert
Corporate Officer · Individual
Pathak, Rahul
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Skytop View Rehabilitation Center
Clermont, FL
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Clermont Health And Rehabilitation Center
Clermont, FL
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Aviata At Colonial Lakes
Winter Garden, FL
1-star overall rating with 1-star inspections with $23,136 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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