Tag 0695 · Severity D
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-04-04At a glance
CMS data snapshot: 2026-08-01 · Sources and limitations
| Ownership | For profit - Individual | Certified beds | 30 |
|---|---|---|---|
| Estimated occupancy | 88.0% | Latest inspection | 2025-03-05 |
County and Florida comparison
Navy: facility · Teal: county · Gray: Florida
Overall rating
Facility: 5 of 5
Health-inspection score
Facility: 15.0 points
Total nurse staffing
Facility: 5.95 hours/day
RN staffing
Facility: 1.80 hours/day
Staff turnover
Facility: 43.8%
Latest health deficiencies
Facility: 4 deficiencies
View data table
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 5 of 5 | 4 of 5 | 3 of 5 |
| Health-inspection score | 15.0 points | 35.0 points | 38.5 points |
| Total nurse staffing | 5.95 hours/day | 3.66 hours/day | 3.63 hours/day |
| RN staffing | 1.80 hours/day | 0.51 hours/day | 0.62 hours/day |
| Staff turnover | 43.8% | 46.0% | 41.8% |
| Latest health deficiencies | 4 deficiencies | 7 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Inspection history
2025-03-05
4 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 0758 · Severity D
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-04-04Tag 0761 · Severity D
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-04-042023-11-21
3 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 0695 · Severity D
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-12-28Tag 0842 · Severity D
Safeguard 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 2023-12-282022-06-16
6 deficiencies
Highest severity: F
Immediate-jeopardy citations: 0
Tag 0761 · Severity F
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2022-07-16Tag 0695 · Severity E
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2022-07-16Tag 0684 · Severity D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2022-07-16Tag 0801 · Severity D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2022-07-16Tag 0882 · Severity D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Infection Control Deficiencies · Deficient, Provider has date of correction 2022-07-16Tag 0661 · Severity B
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2022-07-16Staffing composition
3.22 hours/dayNurse aide
0.94 hours/dayLPN
1.80 hours/dayRN
- Total staffing
- 5.95 hours/day
- County median
- 3.66 hours/day
- Florida median
- 3.63 hours/day
- Weekend total
- 5.82 hours/day
- Staff turnover
- 43.8%
- RN turnover
- 25.0%
Reported averages, not a real-time staffing schedule.
Resident outcomes
Lower is generally better
Hospitalizations
Not reported: cms footnoteunavailableFlorida: 2.1 per 1,000 days · County: 1.8 per 1,000 days20250101-20251231
Emergency-department visits
Not reported: cms footnoteunavailableFlorida: 1.0 per 1,000 days · County: 1.3 per 1,000 days20250101-20251231
Falls with major injury
Not reported: cms footnoteunavailableFlorida: 2.2% · County: 1.8%2025Q2-2026Q1
Pressure ulcers
Not reported: cms footnoteunavailableFlorida: 4.2% · County: 4.6%2025Q2-2026Q1
Urinary tract infections
Not reported: cms footnoteunavailableFlorida: 0.0% · County: 0.0%2025Q2-2026Q1
Antipsychotic medication use
Not reported: cms footnoteunavailableFlorida: 7.0% · County: 5.1%2025Q2-2026Q1
These group measures do not predict an individual resident’s experience.
Questions to ask
Use these prompts during a tour or phone call
How will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning
Facility Details
- County
- Lake County
- Certified beds
- 30
- Average daily residents
- 26.4
- Ownership
- For profit - Individual
- Provider type
- Medicare
- In hospital
- Yes
- Date certified
- 2015-07-22
- CCN
- 106105
Staffing Data
| Reported measure | Value |
|---|---|
| Nurse aide hours | 3.21822 |
| Lpn hours | 0.93522 |
| Rn hours | 1.80056 |
| Reported total hours | 5.954 |
| Weekend total hours | 5.81622 |
| Weekend rn hours | 1.49596 |
| Adjusted total hours | 6.77182 |
| Total turnover percent | 43.8 |
| Rn turnover percent | 25 |
| Administrators left | 0 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
Penalties & Enforcement
$0.00Total fines
0Number of fines
0Payment denials
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Citations
4Health citations
9Fire safety citations
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
Serious Deficiencies
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
0
Ownership & Operators
| Name | Role | Share |
|---|---|---|
| ORLANDO HEALTH INC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| MILLER, JOHN | CORPORATE DIRECTOR | NOT APPLICABLE |
| NAPIER, MICHELE | CORPORATE OFFICER | NOT APPLICABLE |
| ORLANDO HEALTH INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| AGGARWAL, AMIT | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LEWIS, TASIA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ORLANDO HEALTH INC | ADP OF THE SNF | NOT APPLICABLE |
| AGGARWAL, AMIT | ADP OF THE SNF | NOT APPLICABLE |
| LEWIS, TASIA | ADP OF THE SNF | NOT APPLICABLE |
Helpful resources
Educational information, not medical or legal advice. Data & methodology