Cycle 1
Health 2025-05-01 · Fire 2025-05-01
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Pensacola, FL
De Luna Health And Rehabilitation Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
9310 Fowler Ave, Pensacola, FL
(941) 780-3581
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-03-18
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
0.70
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
2.77
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.88
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.28
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.36
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.79
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,031
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 23.34% · Performance 23.19% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.92% · Performance 9.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.81
Performance 52.21% · Measure score 2.81 · Achievement 2.81 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.76
Baseline 4.96 hours · Performance 3.29 hours · Measure score 0.76 · Achievement 0.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 816 · Observed rate 10.05% · Lower 95% interval 9.34% |
| Discharge to community | 64.65% |
50.57%
14.1 pts better
|
Better than the National Rate · Eligible stays 846 · Observed rate 61.58% · Lower 95% interval 60.45% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 632 · Denominator 632 |
| Falls with major injury | 0.16% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 632 |
| Discharge self-care score | 60.61% |
53.69%
6.9 pts better
|
Numerator 257 · Denominator 424 |
| Discharge mobility score | 63.21% |
50.94%
12.3 pts better
|
Numerator 268 · Denominator 424 |
| Pressure ulcers or injuries, new or worsened | 1.42% |
2.29%
0.9 pts better
|
Numerator 9 · Denominator 632 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 9.09% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 553 · Observed rate 8.32% · Lower 95% interval 7.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 239 |
| Staff flu vaccination coverage | 5.7% |
42%
36.3 pts worse
|
Numerator 13 · Denominator 228 |
| Discharge function score | 55.9% |
56.45%
0.6 pts worse
|
Numerator 237 · Denominator 424 |
| Transfer of health information to provider | 97.54% |
95.95%
1.6 pts better
|
Numerator 198 · Denominator 203 |
| Transfer of health information to patient | 96.82% |
96.28%
0.5 pts better
|
Numerator 396 · Denominator 409 |
| Resident COVID-19 vaccinations up to date | 7.79% |
25.2%
17.4 pts worse
|
Numerator 24 · Denominator 308 |
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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
3.7%
1.1 pts worse
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 30.0% |
5.9%
24.1 pts worse
|
5.4%
24.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
15.7%
2.7 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% |
| 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 | 9.5% |
9.8%
0.3 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · 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 pressure ulcers | 47.6% |
5.1%
42.5 pts worse
|
5.1%
42.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 47.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
94.3%
1.4 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 96.0% · Q3 95.0% · Q4 94.7% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
9.3%
7.3 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 14.1% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.3% · Q3 1.8% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.9% |
94.7%
9.8 pts worse
|
79.7%
5.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
26.2%
1.9 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 25.3% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-20 · Fire 2023-01-20
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
D · Potential for more than minimal harm
2023-01-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-02-03
Inspection history
Recent health citations
B · Minimal harm
2025-05-01
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 2025-05-16
Penalties and ownership
What sits behind the stars
Ownership
De Luna Operating Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bengio, Jacob
Corporate Officer · Individual
Berube, Scott
W-2 Managing Employee · Individual
Dawn Ogc Panhandle Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Dn Ogc Panhandle Ventura Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
J & R Ogc Panhandle Family Investments LLC
5% Or Greater Indirect Ownership Interest · Organization
J & R Ogc Panhandle Family Trust
5% Or Greater Indirect Ownership Interest · Organization
L Friedman 2018 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
L Friedman Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
M Friedman 2018 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Philipson Family Limited Liability Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Schaffer, Daniel
5% Or Greater Indirect Ownership Interest · Individual
Ventura P2 Opco Holdco Lc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Pruitthealth - Pensacola, LLC
Pensacola, FL
0-star overall rating with 0-star inspections
#2
Specialty Health And Rehabilitation Center
Pensacola, FL
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Solaris Healthcare Pensacola
Pensacola, FL
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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