Cycle 1
Health 2026-01-29 · Fire 2026-01-29
5 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
The Villages, FL
Freedom Pointe Health Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1460 El Camino Real Drive, The Villages, FL
(352) 750-0866
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
2009-11-12
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
1.11
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.29
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,928
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.54
Baseline 22.22% · Performance 20.64% · Measure score 2.54 · Achievement 1.71 · Improvement 2.54
Healthcare-associated infections
3.81
Baseline 8.28% · Performance 6.87% · Measure score 3.81 · Achievement 3.24 · Improvement 3.81
Total nurse turnover
4.51
Baseline 34.09% · Performance 45.24% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Adjusted total nurse staffing
4.36
Baseline 4.42 hours · Performance 4.32 hours · Measure score 4.36 · Achievement 4.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.44% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 920 · Observed rate 11.09% · Lower 95% interval 9.82% |
| Discharge to community | 72.55% |
50.57%
22 pts better
|
Better than the National Rate · Eligible stays 919 · Observed rate 67.79% · Lower 95% interval 69.3% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 535 · Denominator 540 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 5 · Denominator 540 |
| Discharge self-care score | 55.14% |
53.69%
1.5 pts better
|
Numerator 204 · Denominator 370 |
| Discharge mobility score | 47.03% |
50.94%
3.9 pts worse
|
Numerator 174 · Denominator 370 |
| Pressure ulcers or injuries, new or worsened | 2.41% |
2.29%
0.1 pts worse
|
Numerator 13 · Denominator 540 · Adjusted rate 2.96% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 539 · Observed rate 6.31% · Lower 95% interval 4.96% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 186 |
| Staff flu vaccination coverage | 7.53% |
42%
34.5 pts worse
|
Numerator 18 · Denominator 239 |
| Discharge function score | 41.08% |
56.45%
15.4 pts worse
|
Numerator 152 · Denominator 370 |
| Transfer of health information to provider | 98.36% |
95.95%
2.4 pts better
|
Numerator 300 · Denominator 305 |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 220 · Denominator 230 |
| Resident COVID-19 vaccinations up to date | 12.89% |
25.2%
12.3 pts worse
|
Numerator 33 · Denominator 256 |
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 | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| 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 | 0.0% |
15.7%
15.7 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| 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 | 23.8% |
9.8%
14 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · 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 | 3.4% |
0.8%
2.6 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.9% |
12.5%
23.4 pts worse
|
19.8%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.9% |
| Percentage of long-stay residents with pressure ulcers | 13.0% |
5.1%
7.9 pts worse
|
5.1%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
94.3%
3 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 99.8% · Q3 99.6% · Q4 99.6% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
9.3%
4.7 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 12.5% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.1% · Q4 0.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.5% |
94.7%
0.2 pts worse
|
79.7%
14.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
26.2%
0.7 pts better
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 24.0% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-13 · Fire 2023-04-13
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
E · Potential for more than minimal harm
2026-01-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
D · Potential for more than minimal harm
2023-04-13
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2023-06-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-28
D · Potential for more than minimal harm
2026-01-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-28
D · Potential for more than minimal harm
2026-01-29
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 2026-02-28
D · Potential for more than minimal harm
2026-01-29
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 2026-02-28
D · Potential for more than minimal harm
2026-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-28
E · Potential for more than minimal harm
2024-08-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
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 2024-09-24
D · Potential for more than minimal harm
2024-08-22
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 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-23
E · Potential for more than minimal harm
2023-04-13
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-13
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 2023-06-01
D · Potential for more than minimal harm
2023-04-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-04-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-04-13
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 2023-06-01
D · Potential for more than minimal harm
2023-04-13
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 2023-06-01
Penalties and ownership
What sits behind the stars
Ownership
Ccrc Opco Ventures, LLC
5% Or Greater Direct Ownership Interest · Organization
Boutin, Allen
Operational/Managerial Control · Individual
Fera-Mcilwain, Ralph
Operational/Managerial Control · Individual
Hcp S-H 2014 Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services LLC
Operational/Managerial Control · Organization
S-H 2014 Opco Trs Inc
5% Or Greater Indirect Ownership Interest · Organization
Vallejo Agudelo, Andres
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lady Lake Specialty Care Center and Rehab
Lady Lake, FL
1-star overall rating with 1-star inspections with 7 recent health deficiencies
#2
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
#3
Chatham Glen Healthcare And Rehabilitation Center
The Villages, FL
5-star overall rating with 4-star inspections with 5 recent health deficiencies
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