Tag 0867 · Severity E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Deficient, Provider has date of correction 2025-11-143920 Rosewood Way, Orlando, FL 32808
(407) 298-9335 · Aviata Health Group
| Ownership | For profit - Corporation | Certified beds | 120 |
|---|---|---|---|
| Estimated occupancy | 91.3% | Latest inspection | 2025-09-18 |
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 3 of 5 | 3 of 5 | 3 of 5 |
| Health-inspection score | 52.0 points | 50.9 points | 38.5 points |
| Total nurse staffing | 3.29 hours/day | 3.66 hours/day | 3.63 hours/day |
| RN staffing | 0.59 hours/day | 0.66 hours/day | 0.62 hours/day |
| Staff turnover | 42.2% | 41.7% | 41.8% |
| Latest health deficiencies | 6 deficiencies | 4.5 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Immediate-jeopardy citations: 0
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Deficient, Provider has date of correction 2025-11-14Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2025-11-14Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2025-11-14Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-11-14Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-11-14Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-11-14Immediate-jeopardy citations: 0
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2024-05-26Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-26Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-26Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-05-26Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-05-26Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-05-26Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-26Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-26Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-26Ensure 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-26Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-26Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-05-26Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · Deficient, Provider has date of correction 2024-05-26Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-26Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2024-05-26Immediate-jeopardy citations: 0
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2023-02-11Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2023-02-11Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-02-11Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-02-11Reported averages, not a real-time staffing schedule.
These group measures do not predict an individual resident’s experience.
How many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingWhat fall-prevention program is used, and how are families notified after a fall?
Suggested because of: falls major injuryHow does the care team prevent and treat pressure injuries?
Suggested because of: pressure ulcersHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.09647 |
| Lpn hours | 0.60618 |
| Rn hours | 0.58692 |
| Reported total hours | 3.28958 |
| Weekend total hours | 3.14098 |
| Weekend rn hours | 0.58408 |
| Adjusted total hours | 3.52639 |
| Total turnover percent | 42.2 |
| Rn turnover percent | 52.9 |
| Administrators left | 0 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
0
| Name | Role | Share |
|---|---|---|
| 3920 ROSEWOOD WAY OPCO PARENT LLC | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| 3920 ROSEWOOD WAY OPCO HOLDCO LLC | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| FREUND, NOCHUM | CORPORATE OFFICER | NOT APPLICABLE |
| BRITTON, MARK | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| DYER-FARRELL, LINKA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| FREUND, NOCHUM | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| DAGAN, AMITAI | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| GOLDBERGER, ABRAHAM | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| GOLDBERGER, FAIGY | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| HERSKOWITZ, ELIEZER | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| HERSKOWITZ, YAAKOV | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| TRAVITSKY, AARON | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| ASPIRE MGT LLC | ADP OF THE SNF | NOT APPLICABLE |
| BRITTON, MARK | ADP OF THE SNF | NOT APPLICABLE |
| DYER-FARRELL, LINKA | ADP OF THE SNF | NOT APPLICABLE |
Educational information, not medical or legal advice. Data & methodology