Cycle 1
Health 2025-03-05 · Fire 2025-03-05
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Clermont, FL
Skytop View Rehabilitation Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2145 North Don Wickham Drive, Clermont, FL
(352) 241-7104
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
28
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-07-22
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.74
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.08
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.53
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.44
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
5.23
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.45
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.60
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.90
CMS adjusted RN staffing hours
Adjusted total hours
6.03
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
867
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.80
Composite VBP score used to determine payment impact.
Payment multiplier
1.0176
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.38
Baseline 22.26% · Performance 19.18% · Measure score 5.38 · Achievement 4.85 · Improvement 5.38
Healthcare-associated infections
7.51
Baseline 6.46% · Performance 5.59% · Measure score 7.51 · Achievement 7.51 · Improvement 5.44
Total nurse turnover
2.23
Baseline 58.06% · Performance 54.55% · Measure score 2.23 · Achievement 2.23 · Improvement 0.56
Adjusted total nurse staffing
10
Performance 6.16 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.16% |
10.72%
2.4 pts worse
|
Worse than the National Rate · Eligible stays 487 · Observed rate 11.7% · Lower 95% interval 10.95% |
| Discharge to community | 66.05% |
50.57%
15.5 pts better
|
Better than the National Rate · Eligible stays 468 · Observed rate 69.44% · Lower 95% interval 61.83% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.58% |
95.27%
4.3 pts better
|
Numerator 238 · Denominator 239 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 239 |
| Discharge self-care score | 32.32% |
53.69%
21.4 pts worse
|
Numerator 64 · Denominator 198 |
| Discharge mobility score | 30.81% |
50.94%
20.1 pts worse
|
Numerator 61 · Denominator 198 |
| Pressure ulcers or injuries, new or worsened | 1.68% |
2.29%
0.6 pts better
|
Numerator 4 · Denominator 238 · Adjusted rate 1.89% |
| Healthcare-associated infections requiring hospitalization | 5.59% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 270 · Observed rate 3.33% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 66 |
| Staff flu vaccination coverage | 30.56% |
42%
11.4 pts worse
|
Numerator 22 · Denominator 72 |
| Discharge function score | 36.87% |
56.45%
19.6 pts worse
|
Numerator 73 · Denominator 198 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 213 · Denominator 213 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 21 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 13.27% |
25.2%
11.9 pts worse
|
Numerator 15 · Denominator 113 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
9.3%
1.7 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 6.7% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 1.2% · Q4 0.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.2% |
94.7%
0.5 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
26.2%
4.7 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 16.5% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-21 · Fire 2023-11-21
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-16 · Fire 2022-06-16
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-04
F · Potential for more than minimal harm
2022-06-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-16
F · Potential for more than minimal harm
2022-06-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-16
E · Potential for more than minimal harm
2022-06-16
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2022-07-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-03-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
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 2025-04-04
D · Potential for more than minimal harm
2024-08-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-18
D · Potential for more than minimal harm
2023-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-21
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 2023-12-28
F · Potential for more than minimal harm
2022-06-16
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 2022-07-16
E · Potential for more than minimal harm
2022-06-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-16
D · Potential for more than minimal harm
2022-06-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-16
D · Potential for more than minimal harm
2022-06-16
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-07-16
D · Potential for more than minimal harm
2022-06-16
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-07-16
B · Minimal harm
2022-06-16
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-07-16
Penalties and ownership
What sits behind the stars
Ownership
Orlando Health Inc
5% Or Greater Direct Ownership Interest · Organization
Aggarwal, Amit
Operational/Managerial Control · Individual
Lewis, Tasia
Operational/Managerial Control · Individual
Miller, John
Corporate Director · Individual
Napier, Michele
Corporate Officer · Individual
Orlando Health Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Lakes Of Clermont Health And Rehabilitation Center
Clermont, FL
4-star overall rating with 3-star inspections with $14,335 in total fines with 6 recent health deficiencies
#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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