11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Maitland, FL
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1700 Monroe Ave, Maitland, FL
(407) 647-2092
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
166
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedrock Care
Operator or chain grouping
Approved since
1983-03-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
RN hours / resident day
0.46
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.77
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
9,792
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.53
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
Readmission
3.48
Baseline 24.58% · Performance 21.58% · Measure score 3.48 · Achievement 0 · Improvement 3.48
Healthcare-associated infections
0
Baseline 8.01% · Performance 11.34% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.07
Performance 51.15% · Measure score 3.07 · Achievement 3.07 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.47
Baseline 3.69 hours · Performance 3.78 hours · Measure score 2.47 · Achievement 2.47 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.79% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 13.73% · Lower 95% interval 8.17% |
| Discharge to community | 27.23% |
50.57%
23.3 pts worse
|
Worse than the National Rate · Eligible stays 56 · Observed rate 10.71% · Lower 95% interval 18.03% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 227 · Denominator 227 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 227 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 68 · Denominator 136 |
| Discharge mobility score | 45.59% |
50.94%
5.3 pts worse
|
Numerator 62 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 0.44% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 227 · Adjusted rate 0.28% |
| Healthcare-associated infections requiring hospitalization | 11.34% |
7.12%
4.2 pts worse
|
Worse than the National Rate · Eligible stays 60 · Observed rate 26.67% · Lower 95% interval 7.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 261 |
| Staff flu vaccination coverage | 26.67% |
42%
15.3 pts worse
|
Numerator 60 · Denominator 225 |
| Discharge function score | 47.79% |
56.45%
8.7 pts worse
|
Numerator 65 · Denominator 136 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 97 · Denominator 97 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.56% |
25.2%
4.6 pts worse
|
Numerator 22 · Denominator 107 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.3 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
97.8%
0.8 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 95.4% · 4Q avg 98.6% |
| 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 | 1.2% |
2.6%
1.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.4% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
3.7%
1.3 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.5% · Q3 2.5% · Q4 1.7% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.9%
1 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 9.6% · Q3 9.8% · Q4 4.3% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
15.7%
2.9 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 10.1% · Q3 8.6% · Q4 11.6% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
9.8%
2.6 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.6% · Q3 6.9% · Q4 3.6% · 4Q avg 7.2% · 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 · Q1 2.9% · Q2 12.2% · Q3 18.7% · Q4 4.8% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
9.8%
0.5 pts worse
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.5% · Q3 17.1% · Q4 6.3% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.4%
0.3 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · 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 | 6.3% |
12.5%
6.2 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.0% · Q3 8.6% · Q4 10.9% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.1%
0.7 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.7% · Q3 5.2% · Q4 6.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
94.3%
3 pts worse
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 94.3% · Q3 99.0% · Q4 84.9% · 4Q avg 91.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
9.3%
0.7 pts worse
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 12.6% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 1.1% · Q4 0.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.7%
1.5 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| 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 26.9% · Expected 33.4% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-20
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-03-19
Fire Safety
Use approved construction type or materials.
Corrected 2021-03-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-03-19
Inspection history
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-01-15
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-15
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-01-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-15
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-23
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-23
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-23
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-23
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-30
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-30
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 2024-09-30
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-30
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-30
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 2024-09-30
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-30
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-30
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-23
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-15
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-03-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-15
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-03-15
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-07-14
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-14
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-14
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-07-14
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-14
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2022-11-28
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-11-28
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-28
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-11-28
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 2022-11-28
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-28
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 2022-11-28
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-11-28
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-03-19
Health
Keep all essential equipment working safely.
Corrected 2021-03-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-03-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-03-19
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-03-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-03-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-03-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-03-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-03-19
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-03-19
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 2021-03-19
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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