Cycle 1
Health 2025-01-30 · Fire 2025-01-30
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
The Villages, FL
Club Healthcare And Rehabilitation Center At The V
2-star overall rating with 2-star inspections with 9 recent health deficiencies
16529 Se 86th Belle Meade Circle, The Villages, FL
(352) 385-8200
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
2012-10-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
46 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.00
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.30
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.50
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,033
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.71% · Performance 23.04% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.31% · Performance 7.82% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.13
Baseline 80.95% · Performance 55.00% · Measure score 4.13 · Achievement 2.12 · Improvement 4.13
Adjusted total nurse staffing
1.57
Baseline 3.39 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 383 · Observed rate 11.49% · Lower 95% interval 8.85% |
| Discharge to community | 62.81% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 379 · Observed rate 57.52% · Lower 95% interval 57.34% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.09% |
95.27%
2.8 pts better
|
Numerator 359 · Denominator 366 |
| Falls with major injury | 0.55% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 366 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 100 · Denominator 225 |
| Discharge mobility score | 51.11% |
50.94%
0.2 pts better
|
Numerator 115 · Denominator 225 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 4 · Denominator 366 · Adjusted rate 1.06% |
| Healthcare-associated infections requiring hospitalization | 7.82% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 225 · Observed rate 8.44% · Lower 95% interval 5.39% |
| Staff COVID-19 vaccination coverage | 14.07% |
8.2%
5.9 pts better
|
Numerator 19 · Denominator 135 |
| Staff flu vaccination coverage | 8.21% |
42%
33.8 pts worse
|
Numerator 11 · Denominator 134 |
| Discharge function score | 52.89% |
56.45%
3.6 pts worse
|
Numerator 119 · Denominator 225 |
| Transfer of health information to provider | 92.67% |
95.95%
3.3 pts worse
|
Numerator 278 · Denominator 300 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 20 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 0.52% |
25.2%
24.7 pts worse
|
Numerator 1 · Denominator 191 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
2.6%
1.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
3.7%
3.4 pts worse
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.9%
1.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
15.7%
7.2 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.8% |
9.8%
7 pts better
|
16.7%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
9.8%
3.2 pts worse
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
12.5%
6.8 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
5.1%
6.3 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.3%
5.4 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.3% |
9.3%
10 pts worse
|
12.0%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 19.5% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.4% · Q3 1.6% · Q4 1.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.7%
3.9 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
26.2%
2.6 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 24.6% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-04-27 · Fire 2022-04-27
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-10-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-30
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-30
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 2025-03-10
D · Potential for more than minimal harm
2025-01-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-10
D · Potential for more than minimal harm
2024-04-23
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 2024-05-20
E · Potential for more than minimal harm
2023-10-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-19
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 2023-11-24
D · Potential for more than minimal harm
2023-10-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-19
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 2023-11-24
D · Potential for more than minimal harm
2023-10-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-24
F · Potential for more than minimal harm
2022-04-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-06-06
F · Potential for more than minimal harm
2022-04-27
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 2022-06-06
F · Potential for more than minimal harm
2022-04-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-06-06
F · Potential for more than minimal harm
2022-04-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-04-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-27
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 2022-06-06
D · Potential for more than minimal harm
2022-04-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-06-06
Penalties and ownership
What sits behind the stars
Ownership
The Club SNF Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Copper Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Fl Master Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Gold Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Palmer, Devon
W-2 Managing Employee · Individual
Shelby, Jack
Corporate Officer · Individual
Silver Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
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
#2
Buffalo Crossings Healthcare & Rehabilitation Cen
The Villages, FL
5-star overall rating with 4-star inspections with 7 recent health deficiencies
#3
Lady Lake Specialty Care Center and Rehab
Lady Lake, FL
1-star overall rating with 1-star inspections with 7 recent health deficiencies
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