Cycle 1
Health 2025-05-15 · Fire 2025-05-15
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Orlando, FL
Solaris Healthcare College Park
3-star overall rating with 3-star inspections with $46,804 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
730 Courtland Street, Orlando, FL
(407) 975-3800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Solaris Healthcare
Operator or chain grouping
Approved since
2000-07-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 4 overall / 3 health / 4 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
0.53
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.94
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
3.64
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,904
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.33
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
3.68
Baseline 24.45% · Performance 21.35% · Measure score 3.68 · Achievement 0 · Improvement 3.68
Healthcare-associated infections
0
Baseline 5.25% · Performance 9.73% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Baseline 53.79% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.81
Adjusted total nurse staffing
3.11
Baseline 4.56 hours · Performance 3.96 hours · Measure score 3.11 · Achievement 3.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.71% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 198 · Observed rate 10.61% · Lower 95% interval 7.12% |
| Discharge to community | 50.66% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 41.13% · Lower 95% interval 39.77% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 163 · Denominator 163 |
| Falls with major injury | 0.61% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 163 |
| Discharge self-care score | 29.82% |
53.69%
23.9 pts worse
|
Numerator 34 · Denominator 114 |
| Discharge mobility score | 29.82% |
50.94%
21.1 pts worse
|
Numerator 34 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 1.23% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 163 · Adjusted rate 0.8% |
| Healthcare-associated infections requiring hospitalization | 9.73% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 16% · Lower 95% interval 6.31% |
| Staff COVID-19 vaccination coverage | 0.65% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 153 |
| Staff flu vaccination coverage | 29.3% |
42%
12.7 pts worse
|
Numerator 63 · Denominator 215 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 38 · Denominator 114 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 14.13% |
25.2%
11.1 pts worse
|
Numerator 13 · Denominator 92 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.5 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · 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% · 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 | 3.4% |
2.6%
0.8 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.2% · Q3 3.3% · Q4 4.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
3.7%
0.5 pts worse
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.9% · Q3 3.6% · Q4 2.5% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.9%
3.3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 2.8% · Q4 2.7% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
15.7%
3.4 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 15.7% · Q3 11.5% · Q4 9.6% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
9.8%
2 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 8.3% · Q3 8.5% · Q4 8.2% · 4Q avg 7.8% · 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 | 27.3% |
11.7%
15.6 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 35.0% · Q3 23.4% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
9.8%
3.4 pts better
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.9% · Q3 4.5% · Q4 4.4% · 4Q avg 6.4% · 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 | 1.4% |
0.8%
0.6 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 1.2% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.0% |
12.5%
3.5 pts better
|
19.8%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 10.5% · Q3 9.2% · Q4 4.2% · 4Q avg 9.0% |
| 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 4.3% · Q2 3.8% · Q3 3.2% · Q4 4.9% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
94.3%
2.1 pts worse
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 96.0% · Q3 92.5% · Q4 85.6% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
9.3%
0.4 pts worse
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 11.4% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.0% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
94.7%
0.9 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
26.2%
2.6 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 29.3% · Expected 29.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
15 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-01-06 · Fire 2022-01-06
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (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
2025-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-24
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 2025-08-24
D · Potential for more than minimal harm
2025-07-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-05-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-15
J · Immediate jeopardy
2024-12-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-21
J · Immediate jeopardy
2024-12-04
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 2024-11-21
G · Actual harm
2023-09-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-09-14
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 2023-10-14
E · Potential for more than minimal harm
2023-09-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-09-14
F693 · Quality of Life and Care Deficiencies
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-09-14
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 2023-10-14
D · Potential for more than minimal harm
2023-09-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-05-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-02
D · Potential for more than minimal harm
2022-01-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-02-07
Penalties and ownership
What sits behind the stars
$8,226
2024-12-04
Fine
Fine · fine $8,226
Fine
$8,226
2024-12-04
Fine
Fine · fine $8,226
Fine
$30,352
2023-09-14
Fine
Fine · fine $30,352
Fine
Ownership
Seam Trust
5% Or Greater Direct Ownership Interest · Organization
Acc Ii SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Burrowes, Adrian
Contracted Managing Employee · Individual
Ch Acc Ii Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Klein, Solomon
Corporate Officer · Individual
Orlando North SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sk Acc Ii Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wilder, Norman
Operational/Managerial Control · Individual
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