Cycle 1
Health 2024-09-19 · Fire 2024-09-19
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
The Villages, FL
Chatham Glen Healthcare And Rehabilitation Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies
16605 Se 74th Soulliere Avenue, The Villages, FL
(210) 338-5220
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-04-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.49
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.66
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
25%
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
2,707
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.98
Baseline 19.90% · Performance 18.66% · Measure score 5.98 · Achievement 5.98 · Improvement 3.81
Healthcare-associated infections
8.44
Baseline 7.64% · Performance 5.31% · Measure score 8.44 · Achievement 8.44 · Improvement 8.30
Total nurse turnover
2.77
Baseline 64.23% · Performance 52.34% · Measure score 2.77 · Achievement 2.77 · Improvement 2.52
Adjusted total nurse staffing
2.08
Baseline 4.38 hours · Performance 3.67 hours · Measure score 2.08 · Achievement 2.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.35% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 857 · Observed rate 8.52% · Lower 95% interval 7.72% |
| Discharge to community | 72.35% |
50.57%
21.8 pts better
|
Better than the National Rate · Eligible stays 861 · Observed rate 68.87% · Lower 95% interval 68.59% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 589 · Denominator 589 |
| Falls with major injury | 0.17% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 589 |
| Discharge self-care score | 71.01% |
53.69%
17.3 pts better
|
Numerator 316 · Denominator 445 |
| Discharge mobility score | 57.3% |
50.94%
6.4 pts better
|
Numerator 255 · Denominator 445 |
| Pressure ulcers or injuries, new or worsened | 2.21% |
2.29%
0.1 pts better
|
Numerator 13 · Denominator 589 · Adjusted rate 2.78% |
| Healthcare-associated infections requiring hospitalization | 5.31% |
7.12%
1.8 pts better
|
Better than the National Rate · Eligible stays 499 · Observed rate 4.21% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 194 |
| Staff flu vaccination coverage | 23.55% |
42%
18.4 pts worse
|
Numerator 69 · Denominator 293 |
| Discharge function score | 53.71% |
56.45%
2.7 pts worse
|
Numerator 239 · Denominator 445 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 521 · Denominator 521 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.86% |
25.2%
15.3 pts worse
|
Numerator 29 · Denominator 294 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.2
0.6 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
2.6%
2.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.9% · Q3 7.7% · Q4 6.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
3.7%
0.9 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.9%
5.9 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 17.7% |
15.7%
2 pts worse
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 13.9% · Q3 19.4% · Q4 24.3% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.5% |
9.8%
7.3 pts better
|
16.7%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.9% · Q3 2.4% · Q4 0.0% · 4Q avg 2.5% · 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 | 8.1% |
11.7%
3.6 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.4% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
9.8%
5.5 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 6.5% · Q4 5.4% · 4Q avg 4.3% · 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 | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.2% |
12.5%
5.3 pts better
|
19.8%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.8% · Q3 12.3% · Q4 6.4% · 4Q avg 7.2% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.1%
1.2 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.8% · Q3 6.4% · Q4 3.7% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
9.3%
0.9 pts worse
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.3% · Expected 10.2% · 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 0.6% · 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 | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
26.2%
2 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 24.6% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-01-13 · Fire 2022-01-13
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-05-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
C · Minimal harm
2024-09-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-14
E · Potential for more than minimal harm
2023-05-25
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 2023-06-19
D · Potential for more than minimal harm
2023-05-25
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-25
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 2023-06-19
F · Potential for more than minimal harm
2022-01-13
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 2022-02-14
D · Potential for more than minimal harm
2022-01-13
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 2022-02-14
D · Potential for more than minimal harm
2022-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-14
Penalties and ownership
What sits behind the stars
Ownership
The Villages Invesco, LLC
5% Or Greater Direct Ownership Interest · Organization
Kr Management, LLC
Operational/Managerial Control · Organization
Rockefeller, Kevin
Operational/Managerial Control · Individual
Rockefeller, Kevin
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Villages Healthcare And Rehabilitation Center, The
Lady Lake, FL
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lady Lake Specialty Care Center and Rehab
Lady Lake, FL
1-star overall rating with 1-star inspections with 7 recent health deficiencies
#3
Freedom Pointe Health Center
The Villages, FL
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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