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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 239th out of 252 homes in Florida. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Total Nursing (Weekend)
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
|
3h 24m per day |
Occupancy higher than 95% suggests steady demand, but availability may be limited.
The Springs Lady Lake Assisted Living Facility and Rehab is legally operated by The Springs Lady Lake Assisted Living Facility And Rehab, Llc, and administrated by Casandra Lewis Duncan.
Key information about the people who lead and staff this community.
In Florida, the Agency for Health Care Administration (AHCA) is the primary authority that conducts unannounced inspections and completes official health quality reports for all healthcare facilities.
Formal stipulations and orders filed by Florida regulators against this facility, including fines and total monetary penalties.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Florida state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Citations
|
This Facility | FL Average | vs. FL Avg |
|---|---|---|---|
|
Total citations
Formal regulatory issues recorded by inspectors across all inspection types.
|
51 | 33 | This facility has 55% more total citations than a typical Florida nursing home (51 vs. FL avg 33).↑ 55% worse |
|
Citations per year
Average citations per year since 2012.
|
3.6 | 2.4 | This facility has 50% more citations per year than a typical Florida nursing home (3.6 vs. FL avg 2.4).↑ 50% worse |
|
Citations per inspection
Average citations per inspection.
|
1.3 | 1.3 | This facility has citations per inspection in line with the Florida average (1.3 vs. FL avg 1.3).— At avg |
Inspections
|
This Facility | FL Average | vs. FL Avg |
|---|---|---|---|
|
Total inspections
Combined count of all routine and focused inspections. Excludes complaint investigations.
|
40 | 26 | This facility has 54% more total inspections than a typical Florida nursing home (40 vs. FL avg 26).↑ 54% worse |
|
Inspections with citations
Inspections that resulted in at least one regulatory citation.
|
25 | 16 | This facility has 56% more inspections with citations than a typical Florida nursing home (25 vs. FL avg 16).↑ 56% worse |
|
Inspection citation rate
Percentage of inspections that resulted in at least one citation.
|
63% | 62% | This facility has 1 percentage point higher inspection citation rate than a typical Florida nursing home (63% vs. FL avg 62%).↑ 1% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
THE SPRINGS LADY LAKE ASSISTED LIVING FACILITY AND REHAB's latest inspection on 2024-09-11 reported no deficiencies cited. Over the reporting period from 2012-07-05 to 2024-09-11, a total of 36 inspections were conducted, with all but one resulting in deficiencies being cited. The facility accumulated 44 line-item deficiencies across these inspections, which predominantly fell under three key themes: records and documentation, resident care and rights, and infection control. To address the noted issues, corrections were made to rectify the cited deficiencies, ultimately leading to a current status of no deficiencies.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsFlorida average 4.3
Last Health inspection on Jul 2024
Florida average 19.7
Florida average 4.48
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
22 of 27 citations resulted from standard inspections; 1 of 27 resulted from complaint investigations; and 4 of 27 came from combined inspections (standard and complaint).
100% better than Florida average
Florida average: 0.8
100% better than Florida average
Florida average: 0.4
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
18% worse than Florida average
0% compared with Florida average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.3 hours
No contractors work on this role.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hours
No contractors work on this role.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hours
This role is partially covered by contractors.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
692 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 90 | 2 | 92 | 28,223 | 92 | 100% | 7.6 |
| Licensed Practical Nurse | 25 | 0 | 25 | 8,513 | 92 | 100% | 7.6 |
| Registered Nurse | 14 | 0 | 14 | 4,132 | 92 | 100% | 8.3 |
| Speech Language Pathologist | 6 | 0 | 6 | 2,533 | 88 | 96% | 7.9 |
| RN Director of Nursing | 5 | 0 | 5 | 2,164 | 92 | 100% | 7.7 |
| Clinical Nurse Specialist | 7 | 0 | 7 | 1,588 | 78 | 85% | 8.1 |
| Physical Therapy Aide | 5 | 0 | 5 | 1,580 | 73 | 79% | 7.2 |
| Mental Health Service Worker | 3 | 0 | 3 | 1,015 | 72 | 78% | 8.2 |
| Physical Therapy Assistant | 3 | 0 | 3 | 763 | 79 | 86% | 6.8 |
| Respiratory Therapy Technician | 2 | 0 | 2 | 556 | 56 | 61% | 9.9 |
| Administrator | 1 | 0 | 1 | 528 | 66 | 72% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 520 | 61 | 66% | 8.5 |
| Dietitian | 1 | 0 | 1 | 504 | 63 | 68% | 8 |
| Qualified Social Worker | 2 | 0 | 2 | 472 | 55 | 60% | 6.2 |
| Other Dietary Services Staff | 1 | 0 | 1 | 260 | 37 | 40% | 7 |
| Occupational Therapy Aide | 0 | 1 | 1 | 208 | 26 | 28% | 8 |
| Medical Director | 0 | 1 | 1 | 39 | 13 | 14% | 3 |
| Nurse Aide in Training | 1 | 0 | 1 | 6 | 1 | 1% | 6.3 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
81% lower than Florida average
Florida average: $72K
24% fewer fines than Florida average
Florida average: 2.6
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
0
100% fewer payment denials than Florida average
Florida average: 0.1
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
6.8
8% better than Florida average
Florida average: 7.4
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
10.2
18% better than Florida average
Florida average: 12.4
Percent of long-stay residents whose need for help with daily activities has increased
7.8%
25% better than Florida average
Florida average: 10.5%
Percent of long-stay residents whose ability to move independently worsened
16.7%
29% worse than Florida average
Florida average: 12.9%
Percent of low risk long-stay residents who lose control of their bowels or bladder
6.1%
55% better than Florida average
Florida average: 13.5%
Percent of long-stay residents experiencing one or more falls with major injury
1.4%
47% better than Florida average
Florida average: 2.6%
Percent of long-stay high risk residents with pressure ulcers
3.0%
44% better than Florida average
Florida average: 5.4%
Percent of long-stay residents with a urinary tract infection
0.0%
100% better than Florida average
Florida average: 0.9%
Percent of long-stay residents who lose too much weight
5.2%
14% better than Florida average
Florida average: 6.0%
Percent of long-stay residents who have depressive symptoms
18.6%
455% worse than Florida average
Florida average: 3.3%
Percent of long-stay residents who received an antipsychotic medication
6.7%
17% better than Florida average
Florida average: 8.0%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
79.4%
19% worse than Florida average
Florida average: 97.7%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
100.0%
In line with Florida average
Florida average: 99.2%
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
36.1%
62% worse than Florida average
Florida average: 94.0%
Percent of short-stay residents who newly received an antipsychotic medication
3.8%
153% worse than Florida average
Florida average: 1.5%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
76.6%
19% worse than Florida average
Florida average: 94.7%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
40% of new residents, usually for short-term rehab.
51% of new residents, often for short stays.
9% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
137
Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for The Springs Lady Lake Assisted Living Facility and Rehab based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #232 / 256Payroll — State benchmarkedThis home is ranked 232nd out of 256 homes in Florida. Shows total annual staff payroll benchmarked to the Florida average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
This home supports both short-term rehab and long-term care, with residents staying for a wide range of durations.
16.3 miles from city center
Estimated distance in miles from Lady Lake's city center to The Springs Lady Lake Assisted Living Facility and Rehab's address, calculated via Google Maps.
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The Springs Lady Lake Assisted Living Facility and Rehab is located in LADY LAKE, Florida.
Here are the financial assistance programs available to residents in Florida.
The team at The Springs Lady Lake Assisted Living Facility and Rehab speaks English.
The Springs Lady Lake Assisted Living Facility and Rehab has a walk score of 1. Car-dependent. Most errands require a car, with limited nearby walkable options.
According to FL state health department records, The Springs Lady Lake Assisted Living Facility and Rehab's license number is 9531.
According to FL state health department records, The Springs Lady Lake Assisted Living Facility and Rehab's license expires on July 31, 2027.
The Springs Lady Lake Assisted Living Facility and Rehab accepts Medicaid and VA.
The Springs Lady Lake Assisted Living Facility and Rehab is registered as a for-profit in FL.
Casandra Lewis Duncan is the administrator of The Springs Lady Lake Assisted Living Facility and Rehab.
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