Cycle 1
Health 2025-04-24 · Fire 2025-04-24
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Saint Cloud, FL
Terrace Of St Cloud, The
4-star overall rating with 4-star inspections with $8,512 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3855 Old Canoe Creek Road, Saint Cloud, FL
(407) 957-2280
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-02-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.49
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,353
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9932
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.25
Baseline 22.60% · Performance 19.40% · Measure score 5.25 · Achievement 4.39 · Improvement 5.25
Healthcare-associated infections
5.01
Baseline 8.47% · Performance 6.56% · Measure score 5.01 · Achievement 4.28 · Improvement 5.01
Total nurse turnover
4.30
Baseline 50.00% · Performance 46.09% · Measure score 4.30 · Achievement 4.30 · Improvement 1.06
Adjusted total nurse staffing
1.57
Baseline 3.93 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.86% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 128 · Observed rate 21.09% · Lower 95% interval 9.72% |
| Discharge to community | 36.75% |
50.57%
13.8 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 24.59% · Lower 95% interval 24.7% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 147 · Denominator 147 |
| Falls with major injury | 1.36% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 147 |
| Discharge self-care score | 57.78% |
53.69%
4.1 pts better
|
Numerator 52 · Denominator 90 |
| Discharge mobility score | 63.33% |
50.94%
12.4 pts better
|
Numerator 57 · Denominator 90 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 7 · Denominator 147 · Adjusted rate 3.59% |
| Healthcare-associated infections requiring hospitalization | 6.56% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 7.69% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 208 |
| Staff flu vaccination coverage | 10.34% |
42%
31.7 pts worse
|
Numerator 24 · Denominator 232 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 50 · Denominator 90 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 73 · Denominator 73 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 32.53% |
25.2%
7.3 pts better
|
Numerator 27 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.5 |
2.1
2.4 pts worse
|
1.9
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 3.7 · Expected 1.6 · 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 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
97.8%
0.9 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.9% · Q3 97.0% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
99.2%
2.1 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
2.6%
1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.2% · Q3 3.0% · Q4 4.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
3.7%
0.4 pts worse
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.8% · Q3 2.3% · Q4 3.4% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.9%
1.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 4.8% · Q3 10.0% · Q4 5.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.3% |
15.7%
6.6 pts worse
|
19.6%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 25.8% · Q3 21.3% · Q4 23.4% · 4Q avg 22.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
9.8%
4 pts worse
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 15.4% · Q3 15.1% · Q4 12.5% · 4Q avg 13.8% · 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 | 10.4% |
11.7%
1.3 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 6.0% · Q3 12.5% · Q4 4.5% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
9.8%
3.3 pts worse
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 8.6% · Q3 20.5% · Q4 7.1% · 4Q avg 13.1% · 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 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.6% |
12.5%
0.9 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 15.8% · Q3 13.0% · Q4 5.1% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.1%
0.6 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.7% · Q3 4.9% · Q4 3.5% · 4Q avg 4.5% · 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 92.1% · Q2 91.2% · Q3 92.2% · Q4 93.7% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
9.3%
2 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 8.8% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
94.7%
2.2 pts worse
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
26.2%
2.1 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 35.0% · Expected 29.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
4 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-12-09 · Fire 2021-12-09
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-24
F · Potential for more than minimal harm
2023-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-05
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 2025-12-05
D · Potential for more than minimal harm
2025-04-24
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-24
G · Actual harm
2024-07-24
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 2024-08-24
D · Potential for more than minimal harm
2024-05-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-05
E · Potential for more than minimal harm
2023-08-24
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 2023-09-25
E · Potential for more than minimal harm
2023-08-24
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-24
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-06-21
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 2023-08-04
D · Potential for more than minimal harm
2023-06-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-04
J · Immediate jeopardy
2021-12-09
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 2022-01-05
J · Immediate jeopardy
2021-12-09
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 2022-01-05
E · Potential for more than minimal harm
2021-12-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-05
E · Potential for more than minimal harm
2021-12-09
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 2022-01-05
D · Potential for more than minimal harm
2021-12-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-05
C · Minimal harm
2021-12-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-01-05
Penalties and ownership
What sits behind the stars
$8,512
2024-07-24
Fine
Fine · fine $8,512
Fine
Ownership
Sc Ltc Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Tapia, Jill
5% Or Greater Indirect Ownership Interest · Individual
Roth, Daniel
Operational/Managerial Control · Individual
Sc Ltc Holdings LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Solaris Healthcare Osceola
Saint Cloud, FL
4-star overall rating with 4-star inspections with $19,036 in total fines with 1 fire-safety deficiencies in the latest cycle
#2
Avante At St Cloud Inc
Saint Cloud, FL
4-star overall rating with 3-star inspections with $5,710 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Aviata At St Cloud
Saint Cloud, FL
3-star overall rating with 2-star inspections with $103,362 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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