Cycle 1
Health 2025-09-18 · Fire 2025-09-18
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Deland, FL
Villa Healthcare & Rehabilitation Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
120 Chipola Ave, Deland, FL
(386) 738-3433
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
Gold Fl Trust Ii
Operator or chain grouping
Approved since
1996-09-27
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.18
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
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,735
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9918
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.61
Baseline 21.61% · Performance 17.91% · Measure score 7.61 · Achievement 7.61 · Improvement 7.59
Healthcare-associated infections
0
Baseline 6.99% · Performance 8.36% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.96
Baseline 64.75% · Performance 35.24% · Measure score 6.96 · Achievement 6.96 · Improvement 6.90
Adjusted total nurse staffing
0.94
Baseline 3.88 hours · Performance 3.35 hours · Measure score 0.94 · Achievement 0.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.34% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 11.41% · Lower 95% interval 7.93% |
| Discharge to community | 53.36% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 48.41% · Lower 95% interval 45.36% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 0% |
95.27%
95.3 pts worse
|
Numerator 0 · Denominator 174 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 174 |
| Discharge self-care score | 36.28% |
53.69%
17.4 pts worse
|
Numerator 41 · Denominator 113 |
| Discharge mobility score | 29.2% |
50.94%
21.7 pts worse
|
Numerator 33 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 174 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.36% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 10.68% · Lower 95% interval 5.3% |
| Staff COVID-19 vaccination coverage | 1.99% |
8.2%
6.2 pts worse
|
Numerator 3 · Denominator 151 |
| Staff flu vaccination coverage | 26.35% |
42%
15.6 pts worse
|
Numerator 39 · Denominator 148 |
| Discharge function score | 38.94% |
56.45%
17.5 pts worse
|
Numerator 44 · Denominator 113 |
| Transfer of health information to provider | 20.41% |
95.95%
75.5 pts worse
|
Numerator 10 · Denominator 49 |
| Transfer of health information to patient | 96.1% |
96.28%
0.2 pts worse
|
Numerator 74 · Denominator 77 |
| Resident COVID-19 vaccinations up to date | 2.06% |
25.2%
23.1 pts worse
|
Numerator 2 · Denominator 97 |
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 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.4 · 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 | 4.4% |
2.6%
1.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.4% · Q3 3.2% · Q4 4.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
3.7%
3.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.9%
1.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.1% · Q3 3.8% · Q4 1.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
15.7%
0.7 pts worse
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 17.1% · Q3 15.2% · Q4 11.8% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
9.8%
0.8 pts worse
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 14.0% · Q3 6.9% · Q4 6.7% · 4Q avg 10.6% · 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 | 9.9% |
11.7%
1.8 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 19.4% · Q3 11.3% · Q4 3.8% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.1% |
9.8%
5.7 pts better
|
14.9%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.6% · Q3 1.4% · Q4 2.9% · 4Q avg 4.1% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 5.1% |
12.5%
7.4 pts better
|
19.8%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.2% · Q3 1.2% · Q4 6.1% · 4Q avg 5.1% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.1%
0.6 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.8% · Q3 6.0% · Q4 3.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.3%
4.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 98.3% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
9.3%
3.7 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 6.5% · Expected 12.9% · 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 | 99.5% |
94.7%
4.8 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
26.2%
6.1 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 23.1% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
4 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
D · Potential for more than minimal harm
2025-09-18
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-18
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-18
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-18
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-11-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
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 2025-11-10
D · Potential for more than minimal harm
2025-04-23
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 2025-05-19
D · Potential for more than minimal harm
2023-09-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-28
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 2023-10-31
D · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-31
F · Potential for more than minimal harm
2021-12-02
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 2021-12-27
D · Potential for more than minimal harm
2021-12-02
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 2021-12-27
D · Potential for more than minimal harm
2021-12-02
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 2021-12-27
D · Potential for more than minimal harm
2021-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-27
Penalties and ownership
What sits behind the stars
Ownership
Villa 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
Shelby, Jack
Corporate Officer · Individual
Silver Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Zabele, Mary
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Alliance Health And Rehabilitation Center
Deland, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Parkside Health And Rehabilitation Center
Deland, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Athens Post Acute LLC
Deland, FL
3-star overall rating with 4-star inspections with $61,744 in total fines with 14 fire-safety deficiencies in the latest cycle
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