Cycle 1
Health 2024-12-12 · Fire 2024-12-12
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Orange City, FL
Majestic Oaks
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
901 Veteran's Memorial Parkway, Orange City, FL
(386) 775-2008
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
121
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-09-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.08
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.59
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
5.22
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,843
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.89
Baseline 21.05% · Performance 21.02% · Measure score 0.89 · Achievement 0.89 · Improvement 0
Healthcare-associated infections
0
Baseline 6.31% · Performance 7.69% · Measure score 0 · Achievement 0 · Improvement 0
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
6.76
Baseline 5.12 hours · Performance 5 hours · Measure score 6.76 · Achievement 6.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 308 · Observed rate 10.06% · Lower 95% interval 7.38% |
| Discharge to community | 65.41% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 295 · Observed rate 58.31% · Lower 95% interval 58.02% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.7% |
95.27%
0.6 pts worse
|
Numerator 268 · Denominator 283 |
| Falls with major injury | 1.06% |
0.77%
0.3 pts worse
|
Numerator 3 · Denominator 283 |
| Discharge self-care score | 62.05% |
53.69%
8.4 pts better
|
Numerator 121 · Denominator 195 |
| Discharge mobility score | 63.08% |
50.94%
12.1 pts better
|
Numerator 123 · Denominator 195 |
| Pressure ulcers or injuries, new or worsened | 4.59% |
2.29%
2.3 pts worse
|
Numerator 13 · Denominator 283 · Adjusted rate 4.69% |
| Healthcare-associated infections requiring hospitalization | 7.69% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 8.2% · Lower 95% interval 5.39% |
| Staff COVID-19 vaccination coverage | 1.77% |
8.2%
6.4 pts worse
|
Numerator 6 · Denominator 339 |
| Staff flu vaccination coverage | 32.99% |
42%
9 pts worse
|
Numerator 160 · Denominator 485 |
| Discharge function score | 66.15% |
56.45%
9.7 pts better
|
Numerator 129 · Denominator 195 |
| Transfer of health information to provider | 98.73% |
95.95%
2.8 pts better
|
Numerator 78 · Denominator 79 |
| Transfer of health information to patient | 99.3% |
96.28%
3 pts better
|
Numerator 142 · Denominator 143 |
| Resident COVID-19 vaccinations up to date | 12.41% |
25.2%
12.8 pts worse
|
Numerator 17 · Denominator 137 |
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 1.9 · Expected 1.6 · 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 1.0 · 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 | 5.7% |
2.6%
3.1 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.2% · Q3 7.3% · Q4 3.2% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
3.7%
3.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.9%
2.9 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 1.8% · Q3 3.3% · Q4 1.6% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
15.7%
0.3 pts worse
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 17.7% · Q3 14.5% · Q4 17.2% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
9.8%
4.2 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.6% · Q3 5.1% · Q4 6.9% · 4Q avg 5.6% · 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 | 26.1% |
11.7%
14.4 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 25.1% · Q3 23.3% · Q4 30.1% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.6% |
9.8%
24.8 pts worse
|
14.9%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 25.4% · Q3 34.5% · Q4 36.7% · 4Q avg 34.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.4%
0.4 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.6% · Q3 0.9% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 0.0% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.2% |
12.5%
21.7 pts worse
|
19.8%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.4% · Q2 40.1% · Q3 31.3% · Q4 28.1% · 4Q avg 34.2% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.1%
1.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.6% · Q3 3.8% · Q4 3.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.3%
5.4 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.5% · Q4 99.5% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
9.3%
2.1 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 6.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 0.8% · Q4 1.5% · 4Q avg 1.2% · 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 | 19.2% |
26.2%
7 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 18.2% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-01 · Fire 2023-02-01
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-07-01 · Fire 2021-07-01
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-12
E · Potential for more than minimal harm
2024-12-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-12
D · Potential for more than minimal harm
2021-07-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-08-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-12
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 2025-01-12
Penalties and ownership
What sits behind the stars
Ownership
Buxton, Michael
Operational/Managerial Control · Individual
Pohl, Cynthia
Operational/Managerial Control · Individual
Trainor, Joe
Operational/Managerial Control · Individual
Nearby options
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#2
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3-star overall rating with 2-star inspections with $88,215 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Debary Health And Rehabilitation Center
Debary, FL
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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