Cycle 1
Health 2025-02-07 · Fire 2025-02-07
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Winter Garden, FL
Winter Garden Rehabilitation And Nursing Center
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
12751 W Colonial Drive, Winter Garden, FL
(407) 877-6636
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
120
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aston Health
Operator or chain grouping
Approved since
1985-12-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 3 overall / 3 health / 2 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
0.36
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
62%
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
3,545
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9968
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.74
Baseline 22.57% · Performance 20.22% · Measure score 3.74 · Achievement 2.61 · Improvement 3.74
Healthcare-associated infections
6.46
Baseline 7.04% · Performance 5.90% · Measure score 6.46 · Achievement 6.46 · Improvement 5.07
Total nurse turnover
5.06
Performance 43.01% · Measure score 5.06 · Achievement 5.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.27
Baseline 3.72 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 11.9% · Lower 95% interval 7.54% |
| Discharge to community | 39.54% |
50.57%
11 pts worse
|
Worse than the National Rate · Eligible stays 101 · Observed rate 30.69% · Lower 95% interval 29.69% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.62% |
95.27%
2.4 pts better
|
Numerator 123 · Denominator 126 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 1 · Denominator 126 |
| Discharge self-care score | 43.66% |
53.69%
10 pts worse
|
Numerator 31 · Denominator 71 |
| Discharge mobility score | 29.58% |
50.94%
21.4 pts worse
|
Numerator 21 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 3.97% |
2.29%
1.7 pts worse
|
Numerator 5 · Denominator 126 · Adjusted rate 4.11% |
| Healthcare-associated infections requiring hospitalization | 5.9% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 4.23% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 78.71% |
8.2%
70.5 pts better
|
Numerator 122 · Denominator 155 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 35.21% |
56.45%
21.2 pts worse
|
Numerator 25 · Denominator 71 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 45 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 10.45% |
25.2%
14.8 pts worse
|
Numerator 7 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.9% |
97.8%
18.9 pts worse
|
93.4%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.1% · Q2 73.6% · Q3 81.2% · Q4 88.2% · 4Q avg 78.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
99.2%
0.2 pts worse
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.6%
0.3 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.4% · Q3 3.5% · Q4 2.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
3.7%
3.7 pts worse
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 9.1% · Q3 9.2% · Q4 7.8% · 4Q avg 7.4% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.9%
2.8 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.9% · Q3 18.3% · Q4 7.0% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
15.7%
4.6 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.8% · Q3 9.5% · Q4 8.1% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
9.8%
1.8 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.6% · Q3 7.9% · Q4 7.6% · 4Q avg 8.0% · 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 | 7.0% |
11.7%
4.7 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.1% · Q3 8.8% · Q4 9.9% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
9.8%
1.3 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 5.6% · Q3 11.8% · Q4 7.2% · 4Q avg 8.5% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 14.3% |
12.5%
1.8 pts worse
|
19.8%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.1% · Q3 16.0% · Q4 28.5% · 4Q avg 14.3% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.1%
1.3 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.7% · Q3 7.0% · Q4 2.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
94.3%
1.4 pts worse
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 90.9% · Q3 94.7% · Q4 95.5% · 4Q avg 92.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
9.3%
4.2 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 4.8% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
94.7%
3.1 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
26.2%
1.4 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 23.8% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
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
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-09-25
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 2025-11-17
E · Potential for more than minimal harm
2025-02-07
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 2025-03-07
E · Potential for more than minimal harm
2025-02-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-07
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 2025-03-07
D · Potential for more than minimal harm
2025-02-07
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 2025-03-07
D · Potential for more than minimal harm
2025-02-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2023-10-11
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 2023-11-08
E · Potential for more than minimal harm
2023-06-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-02
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 2023-07-18
D · Potential for more than minimal harm
2023-06-02
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 2023-07-18
D · Potential for more than minimal harm
2023-06-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-02
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-18
F · Potential for more than minimal harm
2021-11-04
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 2021-12-04
E · Potential for more than minimal harm
2021-11-04
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2021-12-04
D · Potential for more than minimal harm
2021-11-04
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 2021-12-04
D · Potential for more than minimal harm
2021-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-04
Penalties and ownership
What sits behind the stars
Ownership
Wg Rehab Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Friedman, Leopold
5% Or Greater Indirect Ownership Interest · Individual
Gutman, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Britton, Mark
Operational/Managerial Control · Individual
Jack, Alecia
Operational/Managerial Control · Individual
Richardson, Neema
Operational/Managerial Control · Individual
Thacker, Tricia
Corporate Officer · Individual
Thomas, Chana
Operational/Managerial Control · Individual
Nearby options
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#2
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4-star overall rating with 4-star inspections with $16,801 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lake Bennet Center For Rehabilitation & Healing
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2-star overall rating with 1-star inspections with abuse icon flag with $74,744 in total fines with 5 recent health deficiencies
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