Cycle 1
Health 2025-02-13 · Fire 2025-02-13
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Orlando, FL
South Orange Health And Rehabilitation Center
4-star overall rating with 4-star inspections with $14,442 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1730 Lucerne Terrace, Orlando, FL
(407) 423-1612
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
115
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Robert Schoenfeld
Operator or chain grouping
Approved since
1986-08-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
0.56
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.53
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,575
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.78% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.62% · Performance 7.91% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.83
Baseline 66.36% · Performance 44.23% · Measure score 4.83 · Achievement 4.76 · Improvement 4.83
Adjusted total nurse staffing
3.13
Baseline 3.85 hours · Performance 3.97 hours · Measure score 3.13 · Achievement 3.13 · Improvement 0.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.56% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 10.91% · Lower 95% interval 6.97% |
| Discharge to community | 50.77% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 40.74% · Lower 95% interval 31.82% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.07% |
95.27%
4.2 pts worse
|
Numerator 51 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 36.84% |
53.69%
16.8 pts worse
|
Numerator 14 · Denominator 38 |
| Discharge mobility score | 39.47% |
50.94%
11.5 pts worse
|
Numerator 15 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.91% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 3.16% |
| Staff COVID-19 vaccination coverage | 6.41% |
8.2%
1.8 pts worse
|
Numerator 10 · Denominator 156 |
| Staff flu vaccination coverage | 4.83% |
42%
37.2 pts worse
|
Numerator 7 · Denominator 145 |
| Discharge function score | 52.63% |
56.45%
3.8 pts worse
|
Numerator 20 · Denominator 38 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| 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 2.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.2
1.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.8%
1.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 0.8% |
2.6%
1.8 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 4.9% |
5.9%
1 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.2% · Q3 9.6% · Q4 3.7% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.7% |
15.7%
11 pts better
|
19.6%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.5% · Q3 1.9% · Q4 1.8% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
9.8%
3.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 9.6% · Q3 5.5% · Q4 5.0% · 4Q avg 6.6% · 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 | 10.6% |
11.7%
1.1 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 10.3% · Q3 3.6% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
9.8%
1.2 pts worse
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 10.5% · Q3 6.5% · Q4 4.2% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.2% · 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 1.1% · Q2 0.0% · 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 | 19.8% |
12.5%
7.3 pts worse
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 18.5% · Q3 13.0% · Q4 20.9% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.1%
1.4 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 3.9% · Q4 2.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
94.3%
1.2 pts worse
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 90.5% · Q3 93.0% · Q4 97.7% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
9.3%
1.2 pts worse
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 9.8% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.2% |
94.7%
6.5 pts worse
|
79.7%
8.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
26.2%
2.2 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 25.5% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-29 · Fire 2023-06-29
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2021-08-11 · Fire 2021-08-11
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-13
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 2025-03-14
F · Potential for more than minimal harm
2023-06-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-06-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-06-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-06-29
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 2023-08-10
F · Potential for more than minimal harm
2023-06-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-06-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-06-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-10
F · Potential for more than minimal harm
2021-08-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-11
F · Potential for more than minimal harm
2021-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-13
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 2025-03-13
D · Potential for more than minimal harm
2025-02-13
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 2025-03-13
D · Potential for more than minimal harm
2025-02-13
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 2025-03-13
E · Potential for more than minimal harm
2024-12-11
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 2025-01-11
D · Potential for more than minimal harm
2024-12-11
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 2025-01-11
D · Potential for more than minimal harm
2024-11-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-09
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 2024-12-09
D · Potential for more than minimal harm
2024-11-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-09
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 2024-12-09
E · Potential for more than minimal harm
2023-06-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-29
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-08-10
E · Potential for more than minimal harm
2021-08-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-09-11
D · Potential for more than minimal harm
2021-08-11
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 2021-09-11
Penalties and ownership
What sits behind the stars
$5,689
2024-11-09
Fine
Fine · fine $5,689
Fine
$8,753
2024-11-09
Fine
Fine · fine $8,753
Fine
Ownership
Orlando Fl Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Fl Hc Opco LLC
5% Or Greater Indirect Ownership Interest · Organization
Pierre, Jessica
W-2 Managing Employee · Individual
Schoenfeld, Robert
5% Or Greater Indirect Ownership Interest · Individual
Schoenfeld, Robert
Corporate Officer · Individual
Schoenfeld, Sharon
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
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Delaney Park Health And Rehabilitation Center
Orlando, FL
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Westminster Towers
Orlando, FL
3-star overall rating with 2-star inspections with $22,133 in total fines with 7 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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