Cycle 1
Health 2024-07-11 · Fire 2024-07-11
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Orlando, FL
Solaris Healthcare Windermere
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4875 Cason Cove Drive, Orlando, FL
(407) 420-2090
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
117
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Solaris Healthcare
Operator or chain grouping
Approved since
1997-06-18
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
0.64
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.50
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
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
14%
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
831
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0179
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.03
Baseline 26.40% · Performance 18.41% · Measure score 8.03 · Achievement 6.52 · Improvement 8.03
Healthcare-associated infections
5.39
Baseline 10.82% · Performance 7.39% · Measure score 5.39 · Achievement 1.48 · Improvement 5.39
Total nurse turnover
10
Baseline 30.48% · Performance 22.83% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.85
Baseline 4.35 hours · Performance 3.60 hours · Measure score 1.85 · Achievement 1.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 358 · Observed rate 8.1% · Lower 95% interval 7.4% |
| Discharge to community | 65.85% |
50.57%
15.3 pts better
|
Better than the National Rate · Eligible stays 352 · Observed rate 60.51% · Lower 95% interval 61.35% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.1% |
95.27%
0.8 pts better
|
Numerator 271 · Denominator 282 |
| Falls with major injury | 1.06% |
0.77%
0.3 pts worse
|
Numerator 3 · Denominator 282 |
| Discharge self-care score | 67.18% |
53.69%
13.5 pts better
|
Numerator 131 · Denominator 195 |
| Discharge mobility score | 55.38% |
50.94%
4.4 pts better
|
Numerator 108 · Denominator 195 |
| Pressure ulcers or injuries, new or worsened | 1.07% |
2.29%
1.2 pts better
|
Numerator 3 · Denominator 281 · Adjusted rate 0.79% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 6.97% · Lower 95% interval 4.97% |
| Staff COVID-19 vaccination coverage | 1.14% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 176 |
| Staff flu vaccination coverage | 19.28% |
42%
22.7 pts worse
|
Numerator 43 · Denominator 223 |
| Discharge function score | 56.41% |
56.45%
About the same
|
Numerator 110 · Denominator 195 |
| Transfer of health information to provider | 96.81% |
95.95%
0.9 pts better
|
Numerator 91 · Denominator 94 |
| Transfer of health information to patient | 94.93% |
96.28%
1.3 pts worse
|
Numerator 131 · Denominator 138 |
| Resident COVID-19 vaccinations up to date | 17.42% |
25.2%
7.8 pts worse
|
Numerator 27 · Denominator 155 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.4 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 1.9 · 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 | 2.2% |
2.6%
0.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 3.1% · Q4 3.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
3.7%
0.8 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 3.3% · Q4 4.4% · 4Q avg 2.9% |
| 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 4.1% · Q2 1.3% · Q3 4.9% · Q4 1.5% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
15.7%
3.1 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 11.0% · Q3 12.6% · Q4 10.4% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
9.8%
5.6 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.8% · Q3 4.5% · Q4 6.2% · 4Q avg 4.2% · 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 | 12.3% |
11.7%
0.6 pts worse
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 14.0% · Q3 15.8% · Q4 8.8% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
9.8%
2.2 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 9.7% · Q3 11.4% · Q4 3.3% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.6% |
12.5%
4.9 pts better
|
19.8%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 10.6% · Q3 8.5% · Q4 6.1% · 4Q avg 7.6% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.1%
0.9 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 5.4% · Q3 3.6% · Q4 5.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
94.3%
2.6 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 97.7% · Q3 95.9% · Q4 97.7% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
9.3%
2.2 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.4% · Expected 11.6% · 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 0.9% · Q2 1.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
94.7%
0.3 pts worse
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
26.2%
1.5 pts better
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 27.4% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-23 · Fire 2023-03-23
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-05-13 · Fire 2021-05-13
3 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-11
F · Potential for more than minimal harm
2023-03-23
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 2023-04-24
F · Potential for more than minimal harm
2023-03-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-24
F · Potential for more than minimal harm
2021-05-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-06-15
F · Potential for more than minimal harm
2021-05-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-15
F · Potential for more than minimal harm
2021-05-13
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 2021-06-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-11
E · Potential for more than minimal harm
2023-03-23
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 2023-04-24
D · Potential for more than minimal harm
2023-03-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-24
G · Actual harm
2021-05-13
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 2021-06-15
D · Potential for more than minimal harm
2021-05-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-05-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-15
Penalties and ownership
What sits behind the stars
Ownership
Windermere Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Barrett, Jessica
Operational/Managerial Control · Individual
Barrett, Jessica
Corporate Director · Individual
Barrett, Jessica
Corporate Officer · Individual
Bell, Thomas
Corporate Director · Individual
Bell, Thomas
Corporate Officer · Individual
Berkowitz, Michael
Corporate Director · Individual
Buxbaum, Miriam
Corporate Director · Individual
Corley, Shawn
Operational/Managerial Control · Individual
Corley, Shawn
Corporate Officer · Individual
Herzka, Chaim
Corporate Director · Individual
Medina, Paulina
Operational/Managerial Control · Individual
Medina, Paulina
Corporate Director · Individual
Medina, Paulina
Corporate Officer · Individual
Oberlander, Joseph
Corporate Director · Individual
Pate, Bobby
Operational/Managerial Control · Individual
Pate, Bobby
Corporate Director · Individual
Pate, Bobby
Corporate Officer · Individual
Solaris Foundation Inc.
5% Or Greater Indirect Ownership Interest · Organization
Solaris Healthcare Properties LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Metro West Nursing And Rehab Center
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3-star overall rating with 3-star inspections with 6 recent health deficiencies
#2
Guardian Care Nursing & Rehabilitation Center
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3-star overall rating with 2-star inspections with $15,737 in total fines with 12 recent health deficiencies
#3
Orlando Health And Rehabilitation Center
Orlando, FL
1-star overall rating with 1-star inspections with abuse icon flag with $65,951 in total fines with 22 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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