Cycle 1
Health 2025-12-11 · Fire 2025-12-11
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Kissimmee, FL
The Good Samaritan Society-Kissimmee Village
1-star overall rating with 1-star inspections with $276,319 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1500 Southgate Drive, Kissimmee, FL
(407) 846-7201
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
161
Certified beds
Average residents
134
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1987-05-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,780
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9957
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.56
Baseline 22.47% · Performance 19.17% · Measure score 5.56 · Achievement 4.88 · Improvement 5.56
Healthcare-associated infections
2.19
Baseline 7.50% · Performance 7.18% · Measure score 2.19 · Achievement 2.19 · Improvement 0.76
Total nurse turnover
5.84
Baseline 54.31% · Performance 39.82% · Measure score 5.84 · Achievement 5.84 · Improvement 4.42
Adjusted total nurse staffing
3.50
Baseline 4.25 hours · Performance 4.07 hours · Measure score 3.50 · Achievement 3.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.64% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 10.53% · Lower 95% interval 7.46% |
| Discharge to community | 49.07% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 44.78% · Lower 95% interval 38.64% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 36 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 12 · Denominator 24 |
| Discharge mobility score | 41.67% |
50.94%
9.3 pts worse
|
Numerator 10 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 3.42% |
8.2%
4.8 pts worse
|
Numerator 4 · Denominator 117 |
| Staff flu vaccination coverage | 95.17% |
42%
53.2 pts better
|
Numerator 138 · Denominator 145 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 12 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
97.8%
8.9 pts worse
|
93.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.0% · Q2 87.5% · Q3 93.9% · Q4 94.1% · 4Q avg 88.9% |
| 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 | 1.3% |
2.6%
1.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 0.9% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
3.7%
2.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.9% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.9%
3 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 14.4% · Q3 4.1% · Q4 5.2% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.1% |
15.7%
13.6 pts better
|
19.6%
17.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.1% · Q3 1.0% · Q4 3.1% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
9.8%
5.5 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 6.3% · Q4 3.4% · 4Q avg 4.3% · 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 | 27.9% |
11.7%
16.2 pts worse
|
16.3%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 33.9% · Q3 25.8% · Q4 32.2% · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
9.8%
12.3 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 16.3% · Q3 16.9% · Q4 25.9% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.4%
1.3 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.0% · Q3 0.6% · Q4 1.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
12.5%
7.7 pts worse
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 20.1% · Q3 15.6% · Q4 24.1% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
5.1%
4.2 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 14.5% · Q3 9.8% · Q4 5.6% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.4% |
94.3%
25.9 pts worse
|
81.7%
13.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.3% · Q2 61.7% · Q3 66.0% · Q4 82.9% · 4Q avg 68.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
9.3%
1.1 pts worse
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 10.0% · Expected 10.7% · 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 0.0% · Q2 0.0% · Q3 2.4% · Q4 1.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.8% |
94.7%
30.9 pts worse
|
79.7%
15.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.0% |
26.2%
7.8 pts worse
|
23.9%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.0% · Observed 35.0% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-24 · Fire 2022-03-24
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-01-26
F · Potential for more than minimal harm
2025-12-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-26
F · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-26
E · Potential for more than minimal harm
2025-12-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2026-01-26
E · Potential for more than minimal harm
2025-12-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-01-26
F · Potential for more than minimal harm
2024-02-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-28
F · Potential for more than minimal harm
2022-03-24
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-04-25
F · Potential for more than minimal harm
2022-03-24
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-04-25
F · Potential for more than minimal harm
2022-03-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-06-23
F · Potential for more than minimal harm
2022-03-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-23
E · Potential for more than minimal harm
2025-12-11
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-11
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 2026-01-23
D · Potential for more than minimal harm
2025-12-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-23
D · Potential for more than minimal harm
2024-02-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-02-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-02-01
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 2024-02-23
D · Potential for more than minimal harm
2024-02-01
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 2024-02-23
G · Actual harm
2023-11-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-04
J · Immediate jeopardy
2023-08-10
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 2023-09-08
J · Immediate jeopardy
2023-08-10
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 2023-09-08
J · Immediate jeopardy
2023-08-10
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 2023-10-30
J · Immediate jeopardy
2023-08-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-08-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-08-10
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 2023-10-30
G · Actual harm
2023-05-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-05-30
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-06-09
E · Potential for more than minimal harm
2022-03-24
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 2022-04-25
E · Potential for more than minimal harm
2022-03-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-04-25
D · Potential for more than minimal harm
2022-03-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-04-25
C · Minimal harm
2022-03-24
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-04-25
Penalties and ownership
What sits behind the stars
$11,629
2023-11-10
Fine
Fine · fine $11,629
Fine
$234,504
2023-08-10
Fine
Fine · fine $234,504
Fine
$30,186
2023-05-30
Fine
Fine · fine $30,186
Fine
Ownership
Cain, James
Corporate Director · Individual
Chappel, Christopher
Contracted Managing Employee · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
W-2 Managing Employee · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
W-2 Managing Employee · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Rogers, Michael
Corporate Officer · Individual
Sanford
5% Or Greater Direct Ownership Interest · Organization
Schema, Nathan
Corporate Officer · Individual
Shulkin, David
Corporate Director · Individual
Spies, Dorene
W-2 Managing Employee · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Nearby options
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#2
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#3
Aviata At Kissimmee Gardens
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4-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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