Lady Lake, FL

Villages Healthcare And Rehabilitation Center, The

3-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

900 Highway 466, Lady Lake, FL

(352) 430-0017

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 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

120

Certified beds

Average residents

116

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Gold Fl Trust Ii

Operator or chain grouping

Approved since

2013-04-12

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

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

0.51

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

1.21

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.33

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

4.05

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.72

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.73

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.14

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.22

CMS adjusted total nurse staffing hours

Case-mix index

1.72

Higher values indicate more complex resident acuity

RN turnover

58%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,262

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

20.95

Composite VBP score used to determine payment impact.

Payment multiplier

0.9825

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 15.18% · Performance 23.35% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.77

Baseline 5.65% · Performance 6.71% · Measure score 3.77 · Achievement 3.77 · Improvement 0

Total nurse turnover

1.09

Baseline 56.74% · Performance 59.24% · Measure score 1.09 · Achievement 1.09 · Improvement 0

Adjusted total nurse staffing

3.53

Baseline 4.09 hours · Performance 4.08 hours · Measure score 3.53 · Achievement 3.53 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.96%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 525 · Observed rate 10.48% · Lower 95% interval 8.82%
Discharge to community	55.95%	50.57% 5.4 pts better	Better than the National Rate · Eligible stays 493 · Observed rate 52.54% · Lower 95% interval 52.43%
Medicare spending per beneficiary	1.19	1.02 0.2 pts worse
Drug regimen review with follow-up	98.28%	95.27% 3 pts better	Numerator 573 · Denominator 583
Falls with major injury	1.37%	0.77% 0.6 pts worse	Numerator 8 · Denominator 583
Discharge self-care score	51.97%	53.69% 1.7 pts worse	Numerator 198 · Denominator 381
Discharge mobility score	49.61%	50.94% 1.3 pts worse	Numerator 189 · Denominator 381
Pressure ulcers or injuries, new or worsened	1.2%	2.29% 1.1 pts better	Numerator 7 · Denominator 583 · Adjusted rate 1.17%
Healthcare-associated infections requiring hospitalization	6.71%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 315 · Observed rate 6.03% · Lower 95% interval 4.47%
Staff COVID-19 vaccination coverage	28.76%	8.2% 20.6 pts better	Numerator 67 · Denominator 233
Staff flu vaccination coverage	10.4%	42% 31.6 pts worse	Numerator 26 · Denominator 250
Discharge function score	50.66%	56.45% 5.8 pts worse	Numerator 193 · Denominator 381
Transfer of health information to provider	94.13%	95.95% 1.8 pts worse	Numerator 401 · Denominator 426
Transfer of health information to patient	89.91%	96.28% 6.4 pts worse	Numerator 98 · Denominator 109
Resident COVID-19 vaccinations up to date	11.15%	25.2% 14 pts worse	Numerator 33 · Denominator 296

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	74.6%	97.8% 23.2 pts worse	93.4% 18.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 74.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	86.4%	99.2% 12.8 pts worse	95.5% 9.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 86.4%
Percentage of long-stay residents experiencing one or more falls with major injury	3.4%	2.6% 0.8 pts worse	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	33.9%	3.7% 30.2 pts worse	11.4% 22.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 33.9%
Percentage of long-stay residents who lose too much weight	8.9%	5.9% 3 pts worse	5.4% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.5%	15.7% 5.2 pts better	19.6% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5%
Percentage of long-stay residents who received an antipsychotic medication	5.3%	9.8% 4.5 pts better	16.7% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · 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 ability to walk independently worsened	19.5%	11.7% 7.8 pts worse	16.3% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 19.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.6%	9.8% 0.2 pts better	14.9% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	0.4% 0.4 pts worse	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.8% · 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	24.7%	12.5% 12.2 pts worse	19.8% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 24.7%
Percentage of long-stay residents with pressure ulcers	7.9%	5.1% 2.8 pts worse	5.1% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	69.3%	94.3% 25 pts worse	81.7% 12.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 60.4% · Q2 66.7% · Q3 69.7% · Q4 79.7% · 4Q avg 69.3%
Percentage of short-stay residents who had an outpatient emergency department visit	13.7%	9.3% 4.4 pts worse	12.0% 1.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.9% · Expected 11.4% · 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 1.0% · Q2 1.1% · Q3 1.5% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	70.1%	94.7% 24.6 pts worse	79.7% 9.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 70.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.8%	26.2% 1.4 pts better	23.9% 0.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 26.0% · Expected 25.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-08 · Fire 2025-05-08

14 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2024-02-15 · Fire 2024-02-15

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

5 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2022-09-09 · Fire 2022-09-09

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-08

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-05-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-05-08

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-06-13

E · Potential for more than minimal harm 2024-02-15

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-03-16

E · Potential for more than minimal harm 2024-02-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-16

E · Potential for more than minimal harm 2024-02-15

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-03-16

D · Potential for more than minimal harm 2024-02-15

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-03-16

D · Potential for more than minimal harm 2024-02-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-03-16

F · Potential for more than minimal harm 2022-09-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-10-06

E · Potential for more than minimal harm 2022-09-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-10-06

D · Potential for more than minimal harm 2022-09-09

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-10-06

D · Potential for more than minimal harm 2022-09-09

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-10-06

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-12

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2026-02-10

D · Potential for more than minimal harm 2025-12-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-02-10

D · Potential for more than minimal harm 2025-12-12

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2026-02-10

D · Potential for more than minimal harm 2025-12-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2026-02-10

D · Potential for more than minimal harm 2025-12-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-02-10

D · Potential for more than minimal harm 2025-11-13

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-07-17

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 2025-08-21

D · Potential for more than minimal harm 2025-07-17