Cycle 1
Health 2023-10-04 · Fire 2023-10-04
7 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Davenport, FL
Davenport Nursing And Rehab Center
4-star overall rating with 3-star inspections with $8,172 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
206 W Orange St, Davenport, FL
(863) 422-4961
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
60
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eliyahu Mirlis
Operator or chain grouping
Approved since
1992-06-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
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
0.85
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.87
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
0.92
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,246
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.76
Baseline 19.51% · Performance 19.23% · Measure score 4.76 · Achievement 4.76 · Improvement 0.64
Healthcare-associated infections
0
Baseline 6.86% · Performance 9.24% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 56.92% · Performance 67.19% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.53
Baseline 3.88 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.69% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 18.31% · Lower 95% interval 8.86% |
| Discharge to community | 56.77% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 50.91% · Lower 95% interval 42.46% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 69 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 18 · Denominator 42 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 18 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 7.25% |
2.29%
5 pts worse
|
Numerator 5 · Denominator 69 · Adjusted rate 4.96% |
| Healthcare-associated infections requiring hospitalization | 9.24% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 15.91% · Lower 95% interval 5.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 45.24% |
56.45%
11.2 pts worse
|
Numerator 19 · Denominator 42 |
| Transfer of health information to provider | 96.55% |
95.95%
0.6 pts better
|
Numerator 28 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.86% |
25.2%
7.3 pts worse
|
Numerator 5 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.7 · 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 | 0.5% |
2.6%
2.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.1% |
3.7%
5.4 pts worse
|
11.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 11.6% · Q3 5.7% · Q4 9.5% · 4Q avg 9.1% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.9%
0.4 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 2.9% · Q4 17.9% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
15.7%
5.7 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.1% · Q3 8.6% · Q4 12.8% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.8% |
9.8%
8 pts better
|
16.7%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 7.1% · 4Q avg 1.8% · 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 · 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 | 10.3% |
11.7%
1.4 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
9.8%
1.3 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 2.6% · Q3 6.2% · Q4 5.7% · 4Q avg 8.5% · 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 | 3.3% |
0.8%
2.5 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 0.0% · Q3 2.4% · Q4 2.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.5% |
12.5%
5 pts better
|
19.8%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 2.2% · Q3 9.4% · Q4 2.2% · 4Q avg 7.5% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.1%
0.2 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.5% · Q3 4.9% · Q4 4.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
94.3%
2.8 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.1% · Q3 95.9% · Q4 98.1% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.3% |
9.3%
7 pts better
|
12.0%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.3% · Observed 2.4% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
94.7%
0.6 pts worse
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
26.2%
5.3 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 22.0% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-10 · Fire 2021-09-10
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-02-20 · Fire 2020-02-20
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2023-10-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-04
D · Potential for more than minimal harm
2021-09-10
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-10
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-10-11
D · Potential for more than minimal harm
2020-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-08-17
D · Potential for more than minimal harm
2020-02-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-10-04
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 2023-11-04
E · Potential for more than minimal harm
2023-10-04
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-04
E · Potential for more than minimal harm
2023-10-04
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-04
E · Potential for more than minimal harm
2023-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-04
E · Potential for more than minimal harm
2023-10-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-04
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-04
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-11-04
E · Potential for more than minimal harm
2021-09-10
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 2021-10-11
D · Potential for more than minimal harm
2021-09-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-10
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 2021-10-11
D · Potential for more than minimal harm
2021-09-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-11
D · Potential for more than minimal harm
2020-02-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-15
D · Potential for more than minimal harm
2020-02-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-03-15
Penalties and ownership
What sits behind the stars
$8,172
2023-10-04
Fine
Fine · fine $8,172
Fine
Ownership
206 W Orange St Davenport Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Albors-Mora, Melanie
Operational/Managerial Control · Individual
Becher, Sarah
5% Or Greater Indirect Ownership Interest · Individual
Mirlis, Eliyahu
5% Or Greater Indirect Ownership Interest · Individual
Valentino-Keesling, Catherine
Operational/Managerial Control · Individual
Vrd 10 Hldco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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#2
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1-star overall rating with 1-star inspections with 25 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Solaris Healthcare Celebration
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3-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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