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South Orange Health And Rehabilitation Center

1730 Lucerne Terrace, Orlando, FL 32806 · For profit - Limited Liability company · 115 certified beds · (407) 423-1612 Medicare & Medicaid certified

Call the home — (407) 423-1612 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 2024$14,442 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,442 in federal fines (most recent 2024-11-09)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1723 Lucerne Ter · (407) 843-1180 · Call to confirm hours
Pharmacy
1809 S Orange Ave · (407) 723-7240 · Call to confirm hours
Grocery
1809 S Orange Ave · (407) 710-1794 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2200 S Orange Ave · (407) 856-4999

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.3%8.7%15.4%better
Long-stay residents who lose too much weight7.5%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms7.3%4.6%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.0%2.5%3.3%better
Long-stay residents whose ability to walk worsened2.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication3.7%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.1%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control15.0%10.5%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table2.2%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine88.2%94.7%79.4%better
Short-stay residents rehospitalized after admission24.7%26.1%22.6%typical
Short-stay residents with an outpatient ER visit8.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.112.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.371.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.8%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
55.8%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 55.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 43 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.8%CMS range 31.8–64.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.0–16.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge58.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified88.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 3.2–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.70
RN hours/ resident / day
0.74
LPN hours/ resident / day
3.06
Aide hours/ resident / day
4.50
Total nurse hours/ resident / day
0.41
RN hoursweekends
39.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 115 beds and averages 104.2 residents a day — about 91% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.06 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.20 hrs/resident/day on weekends vs 4.63 on weekdays — 9% thinner on weekends. RN hours go from 0.82 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2025-02-13)
3
at the previous standard inspection (2023-06-29)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

  • Potential for harm · E2025-02-13 · tag F0694 — pattern
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer intravenous (IV) antibiotic and maintain an intravenous access site according to professional standards for 1 of 1 resident sampled for IVs, of a total sample of 40 residents, (#91). Findings: Review of resident #91's medical record revealed he was admitted to the facility on [DATE] with diagnoses of chronic osteomyelitis left ankle and foot, other specified noninfective gastroenteritis and colitis, generalized abdominal pain, pressure ulcer of left heel, unspecified stage. Review of resident #91's medical record revealed a physician's order dated 1/15/2025 for the antibiotic, Linezolid by intravenous 600 milligrams (mg) per 300 milliters (ml) over 120 minutes at a rate of 150 milliliters per hour (ml/hr) every 12 hours for chronic osteomyelitis for 34 days. On 2/10/2025 at 9:49 AM, resident #91 was seated in his wheelchair with his left upper arm intravenous catheter connected via tubing to a intravenous bag labeled, Linezolid…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written copy/summary of the initial care plan to the resident/representative for 2 of 4 residents reviewed for care plans, of a total sample of 40 residents, (#2, #97). Findings 1. Resident #2, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included chronic respiratory failure, pleural effusion, diabetes type II, difficulty walking, malignant neoplasm of nasal cavity, and repeated falls. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14 of 15. On 2/10/25 at 10:18 AM, and on 2/12/25 at 9:37 AM, resident #2 stated he had not been to a care plan meeting and was not sure if his son or granddaughter received any invitation to a care plan meeting. The resident said he did not get a copy or summary of his initial care plan. Review of the resident's clinical records revealed no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0693 — failed to provide proper feeding-tube care — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure enteral feeding was infused according to physician's orders for 3 of 8 residents reviewed for tube feedings from a total sample of 40 residents, (#42, #73, #84) Findings: 1. Review of resident #84's medical record revealed an admission date of 11/4/24. Her diagnoses included gastrostomy malfunction, unspecified protein-calorie malfunction, and unspecified dementia. Her quarterly Minimum Data Set assessment dated [DATE] indicated her cognitive skills for daily decision making were severely impaired and she rarely/never made decisions. Review of resident #84's medical record contained a physician's order dated 10/18/24 to receive Jevity 1.5 (nutrition) at a rate of 65 milliliters per hour (ml/hr) for 20 hours until 1300 ml infused and to receive free water at the rate of 20 ml/hr for 20 hours until 400 ml infused via tube feed. On 2/11/25 at 4:52 PM, resident #84's assigned nurse Licensed Practical Nurse (LPN) D verified that resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately document medications for 1 of 7 resident reviewed, out of a total sample of 40 residents, (#222). Findings: Resident #222 was admitted to the facility on [DATE] with diagnoses of nondisplaced fracture of the 7th cervical vertebra, hypertension, hypokalemia, atrial fibrillation, syncope, type 2 diabetes, and bradycardia. Review of the resident hospital records from 2/2/25 revealed the resident was admitted after sustaining a fall. The record showed the resident had Cervical 7 compression fracture. Surgical intervention was not recommended, and a cervical collar was ordered. On 2/13/24 at 12:27 PM, licensed practical nurse (LPN) A prepared resident #222's scheduled medications. She removed 1 tablet of Potassium Chloride extended release (ER) 20 milliequivalents (mEq), 1 table of Hydralazine 100 milligrams (mg), and 1 tablet of Methocarbamol 500 mg. When LPN A finished preparing the resident's medication, she proceeded to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-11 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as per physician's orders and according to accepted professional standards of practice for 8 of 8 residents reviewed for medication administration, of a total sample of 13 residents, (#6, #7, #8, #9, #10, #11, #12, and #13). Findings: On 12/10/24 at 10:01 AM, Registered Nurse (RN) A was at her medication cart preparing medications. The RN stated she still had morning medications to give and had just started giving medications on the short hallway. On 12/10/24 at 10:23 AM, RN A was observed still at her medication cart preparing medications. On 12/10/24 at 10:49 AM, RN A stated she was now giving her last resident their scheduled 9:00 AM medications. The RN said she was the Unit Manager and was working on a medication cart because they had a call out. She acknowledged that she was behind with the medications. On 12/11/24 at 10:28 AM, Licensed Practical Nurse (LPN) B was at her medication cart preparing medications, and stated she had to give 9:00 AM medications to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure documentation was complete and accurate for 1 of 5 residents reviewed, of a total sample of 13 residents, (#5). Findings: Resident #5, a [AGE] year-old male was admitted to the facility on [DATE]. Review of the census showed the resident was discharged on 11/06/24. Clinical record review revealed no progress note, change in condition documentation, no physician's order, or transfer documentation to indicate the resident's condition, reason for the discharge, or any care and services provided for the resident. An Orders Administration Note dated 11/06/24 at 7:04 PM, read hospitalized but did not give any further explanation. On 12/11/24 at 3:00 PM, the Director of Nursing (DON) stated if a resident was transferred to the hospital or discharged from the facility, the protocol was that staff should obtain a physician's order for transfer/discharge, document a change in condition, a transfer out note, and nurses were supposed to document a progress…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-09 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed failed to ensure a resident was assessed to self-administer medication safely for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 14 residents, (#4). Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, and contractures of his left and right knees. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of 8/30/24 revealed resident #4 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. Review of resident #4's Admit/Readmit Screener evaluation dated 6/02/24 revealed he was his own responsible party. Review of the care plan revealed a focus for, At risk for decrease ability to perform ADLS (Activities of Daily Living) . revised on 9/25/24. One of the interventions instructed nurses to, monitor medications,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility neglected to provide the appropriate care and services after a fall with injury for 1 of 2 residents reviewed for neglect, of a total sample of 14 residents, (#12). Findings: Resident #12, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included wedge compression fracture of the lumbar vertebra, repeated falls, generalized weakness, functional quadriplegia, and dementia. Review of the resident's clinical records revealed a physician's order dated 10/17/24 for the resident to be sent out to the hospital for further evaluation and treatment on 9/03/24 after a fall. Review of the resident's MDS assessment dated [DATE] revealed resident #12 was rarely/never understood and had short- and long-term memory problem. The assessment noted the resident was dependent on the assistance of staff for toileting hygiene, to roll left and right, transfer from sitting to lying, and for chair/bed-to chair transfer. A progress note documented by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to conduct a thorough investigation pertaining to a fall with fracture for 1 of 7 residents reviewed for falls, of a total sample of 14 residents, (#2). Findings: Resident #2, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included traumatic subdural hemorrhage, altered mental status, cognitive communication deficit, schizophrenia, history of falling, and difficulty walking. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was severely impaired, with a Brief Interview For Mental Status score of 06 out of 15. The assessment noted the resident required substantial/maximal assistance of staff for personal hygiene, and chair/bed-to chair transfer. Physician orders dated 9/20/24 was for stat (immediate) x-ray 2 Views of the left hip and left leg. Physician order on 9/24/24 was for stat anterior-posterior lateral 4 views x-ray of the resident's bilateral hips,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture for 1 of 7 residents reviewed for falls, of a total sample of 14 residents, (#2). Findings: Resident #2, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included traumatic subdural hemorrhage, altered mental status, cognitive communication deficit, schizophrenia, history of falling, and difficulty walking. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was severely impaired, with a Brief Interview For Mental Status score of 06 out of 15. The assessment noted the resident required substantial/maximal assistance of staff for personal hygiene, and chair/bed-to chair transfers. Section J of the assessment revealed resident #2 had a fall in the last two to six months prior to admission and a fall without injury and a fall with non major injury since admission. Review of the Morse Fall Scale…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 5 citations
  • Potential for harm · E2023-06-29 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement a system to monitor and reconcile Pharmacy Recommendations to ensure all residents were being reviewed monthly for 3 of 5 residents (#37, #46, #22) and failed to implement a pharmacy recommendation for 1 of 5 residents reviewed (#16) reviewed for Unnecessary Medication Regimen Review, of a total sample of 37 residents. Findings: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, hyperlipidemia, unspecified dementia and depression. Review of resident #37's electronic medical record revealed he received Temazepam 7.5 milligrams (mg) daily for insomnia, Novolog insulin 100 unit/milliliter injected per sliding scale before meals and at bedtime for diabetes, Levemir insulin 20 units injected subcutaneously two times a day for Diabetes, Duloxetine 30 mg two times a day for depression and Atorvastatin 40 mg at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an alleged violation of verbal abuse for 1 of 2 residents reviewed for abuse of a total sample of 37 residents, (#77). Findings: Resident #77 was admitted to the facility on [DATE] with admitting diagnoses of hereditary and idiopathic neuropathy, insomnia, major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 12/27/22 revealed resident #77 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. A care plan for behavioral symptoms related to hollering out at others, easily agitated, involved himself in others' care, easily frustrated and did not follow facility guidelines was initiated 4/08/22. Interventions included to observe behaviors and document and report to physician of changes in behavior and/or if interventions were ineffective. Review of resident #77's progress notes for the month of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-29 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Discharge Return Not Anticipated Minimum Data Set (MDS) assessment was completed within 14 days and submitted to the Centers for Medicare and Medicaid Services (CMS) after a resident was discharged from the facility for 1 of 1 resident identified for Resident Assessment review of a total sample of 37 residents, (#54). Findings: Review of resident #54's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Cellulitis of left orbit with sudden visual loss, Chronic Kidney Disease, Heart Failure, and Diabetes Mellitus. Review of the resident's medical record revealed an Entry MDS assessment dated [DATE] and an admission MDS assessment dated [DATE]. The record contained no other MDS assessments. Review of a Nursing Progress Note dated 03/06/23 at 9:49 AM showed the resident was discharged to home via ambulance on 03/06/23. On 06/28/23 at 12:50 PM, an interview was conducted with MDS Coordinator A and MDS Coordinator B.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-08-11 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to maintain the dumpster area in a sanitary manner and ensure the dumpster lids remained closed, to prevent the harborage and feeding of pests. Finding: On Sunday, 8/8/21 at 9:20 AM, the facility's dumpster was over filled with clear garbage bags and the lids to the dumpster were pushed all the way back. The clear garbage bags were filled with milk/food cartons, personal protection equipment and other facility refuse. On the ground in front and back of the dumpster were 2 face shields and clear garbage bags filled with refuse as well as other debris. On 8/8/21 at 9:27 AM, the Assistant Maintenance Staff stated the dumpster does not get emptied on Sundays. He did not explain why the dumpster lids were not closed and stated he had never seen the dumpster this full. He acknowledged there were garbage bags on the ground, on the lids of the dumpster, as well as other debris on the ground. On 8/11/21 at 11:44 AM, the Maintenance Director said the dumpster was emptied by a disposal company everyday except Sundays. He…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were ordered timely upon admission. The facility also failed to get physician authorization for giving medication outside of the prescribed time for 1 of 5 residents reviewed for unnecessary medications out of a total sample of 49 residents (resident #156). Findings: Resident #156 was a [AGE] year-old woman admitted to the facility on [DATE] at 12 PM. Her diagnoses included metabolic encephalopathy, insomnia, delusional disorder, dementia, anxiety disorder and psychosis. A review of the physician admission orders included a written prescription for antianxiety medication, Alprazolam 1 milligram tablet at bedtime. Review of the Medication Administration Record (MAR) from 8/06/21 to 8/09/21 documented that Alprazolam was scheduled to be given at 9 PM. A review of the MAR noted on 8/06/21 at 10:23 PM, Alprazolam was not administered as the drug was not available. On 8/07/21 at 9:53 PM, a note on the MAR showed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,442 in federal fines across 2 penalties.

  • $5,689 — penalty dated 2024-11-09
  • $8,753 — penalty dated 2024-11-09

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ROBERT SCHOENFELD — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.4+1.6 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 7 homes this chain runs (chain average 3.4★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
ORLANDO FL HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/11/2023
PIERRE, JESSICAIndividualW-2 MANAGING EMPLOYEEsince 08/11/2023
SCHOENFELD, ROBERTIndividualCORPORATE OFFICERsince 08/11/2023

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.6M
Net patient revenuemost recent cost report
-7.5%
Operating marginrevenue minus expenses
$988K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 5%Other / private 22%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $988K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$318per resident / day
operating cost
$9,658per month
≈ monthly operating cost
$296per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105546. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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