Cycle 1
Health 2024-10-03 · Fire 2024-10-03
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Lotus Nursing And Rehabilitation Center
3-star overall rating with 2-star inspections with $3,282 in total fines with 9 recent health deficiencies
7950 Lake Underhill Road, Orlando, FL
(407) 658-2046
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
180
Certified beds
Average residents
159
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ventura Services Florida
Operator or chain grouping
Approved since
1987-02-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 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
0.52
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.85
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
3.66
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
66%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,801
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1
Baseline 20.36% · Performance 20.97% · Measure score 1 · Achievement 1 · Improvement 0
Healthcare-associated infections
3.83
Baseline 7.10% · Performance 6.69% · Measure score 3.83 · Achievement 3.83 · Improvement 1.46
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.92
Baseline 3.89 hours · Performance 3.62 hours · Measure score 1.92 · Achievement 1.92 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.88% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 9.68% · Lower 95% interval 6.67% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.47% |
95.27%
3.2 pts better
|
Numerator 193 · Denominator 196 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 196 |
| Discharge self-care score | 62.69% |
53.69%
9 pts better
|
Numerator 84 · Denominator 134 |
| Discharge mobility score | 44.78% |
50.94%
6.2 pts worse
|
Numerator 60 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 196 · Adjusted rate 0.82% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.52% |
| Staff COVID-19 vaccination coverage | 3.07% |
8.2%
5.1 pts worse
|
Numerator 7 · Denominator 228 |
| Staff flu vaccination coverage | 18.24% |
42%
23.8 pts worse
|
Numerator 31 · Denominator 170 |
| Discharge function score | 55.97% |
56.45%
0.5 pts worse
|
Numerator 75 · Denominator 134 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 58 · Denominator 58 |
| Transfer of health information to patient | 96.72% |
96.28%
0.4 pts better
|
Numerator 59 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 3.17% |
25.2%
22 pts worse
|
Numerator 4 · Denominator 126 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · 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 | 2.6% |
2.6%
About the same
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.0% · Q3 2.4% · Q4 1.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
3.7%
1.5 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 6.1% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 10.0% |
5.9%
4.1 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.6% · Q3 12.3% · Q4 6.4% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
15.7%
4 pts better
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 11.6% · Q3 7.9% · Q4 10.3% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
9.8%
8 pts worse
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 10.1% · Q3 19.5% · Q4 23.3% · 4Q avg 17.8% · 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 | 13.7% |
11.7%
2 pts worse
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 9.5% · Q3 15.8% · Q4 21.5% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
9.8%
3.8 pts worse
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 9.7% · Q3 13.3% · Q4 24.1% · 4Q avg 13.6% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 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 6.8% · Q2 12.4% · Q3 4.4% · Q4 0.7% · 4Q avg 6.1% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.1%
1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.8% · Q3 4.7% · Q4 2.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.3%
5.6 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| 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 7.2% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.7% · Q3 3.8% · Q4 2.0% · 4Q avg 3.3% · 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 | 18.6% |
26.2%
7.6 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.6% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-03 · Fire 2023-03-03
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-04-21 · Fire 2021-04-21
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-03
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-04-07
E · Potential for more than minimal harm
2021-04-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-26
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 2025-07-26
D · Potential for more than minimal harm
2025-06-26
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-07-26
D · Potential for more than minimal harm
2025-02-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-25
E · Potential for more than minimal harm
2024-10-03
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-11
G · Actual harm
2023-03-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-03
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 2023-04-07
E · Potential for more than minimal harm
2023-03-03
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 2023-04-07
E · Potential for more than minimal harm
2023-03-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-03
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 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
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 2023-04-07
D · Potential for more than minimal harm
2023-03-03
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 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
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 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-07
E · Potential for more than minimal harm
2021-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-21
D · Potential for more than minimal harm
2021-04-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-21
D · Potential for more than minimal harm
2021-04-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-05-21
Penalties and ownership
What sits behind the stars
$3,282
2023-12-26
Fine
Fine · fine $3,282
Fine
Ownership
Rio Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bengio, Jacob
Operational/Managerial Control · Individual
Gilliam, Trisha
Operational/Managerial Control · Individual
Paritzky, Jeremie
Operational/Managerial Control · Individual
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