Cycle 1
Health 2025-01-30 · Fire 2025-01-30
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Deltona, FL
West Volusia Healthcare And Rehabilitation Center
3-star overall rating with 2-star inspections with $88,215 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1851 Elkcam Blvd, Deltona, FL
(386) 789-3769
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
1983-09-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 2 health / 3 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
0.54
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,763
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.39% · Performance 21.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.25% · Performance 8.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.42
Baseline 61.05% · Performance 57.86% · Measure score 1.42 · Achievement 1.42 · Improvement 0.38
Adjusted total nurse staffing
2.82
Baseline 3.57 hours · Performance 3.88 hours · Measure score 2.82 · Achievement 2.82 · Improvement 0.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 12.2% · Lower 95% interval 8.03% |
| Discharge to community | 57.12% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 51.06% · Lower 95% interval 43.8% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.12% |
95.27%
1.9 pts better
|
Numerator 135 · Denominator 139 |
| Falls with major injury | 2.16% |
0.77%
1.4 pts worse
|
Numerator 3 · Denominator 139 |
| Discharge self-care score | 62.07% |
53.69%
8.4 pts better
|
Numerator 54 · Denominator 87 |
| Discharge mobility score | 62.07% |
50.94%
11.1 pts better
|
Numerator 54 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 2.16% |
2.29%
0.1 pts better
|
Numerator 3 · Denominator 139 · Adjusted rate 2.19% |
| Healthcare-associated infections requiring hospitalization | 8.96% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 15.38% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 155 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 68.97% |
56.45%
12.5 pts better
|
Numerator 60 · Denominator 87 |
| Transfer of health information to provider | 94.34% |
95.95%
1.6 pts worse
|
Numerator 50 · Denominator 53 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.39% |
25.2%
23.8 pts worse
|
Numerator 1 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
97.8%
5.9 pts worse
|
93.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.6% · Q2 95.7% · Q3 100.0% · Q4 100.0% · 4Q avg 91.9% |
| 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 | 5.3% |
2.6%
2.7 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.5% · Q3 3.3% · Q4 5.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
3.7%
3.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.9%
3.8 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 1.4% · Q4 1.4% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
15.7%
3.8 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 23.8% · Q3 13.2% · Q4 17.3% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
9.8%
2.2 pts worse
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 11.3% · Q3 14.8% · Q4 15.3% · 4Q avg 12.0% · 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 | 8.0% |
11.7%
3.7 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.1% · Q3 2.5% · Q4 11.8% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
9.8%
0.4 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.3% · Q3 8.5% · Q4 10.0% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.3% |
12.5%
3.2 pts better
|
19.8%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 12.5% · Q3 6.8% · Q4 9.8% · 4Q avg 9.3% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.1%
0.1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 8.5% · Q3 1.2% · Q4 3.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
94.3%
0.9 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.7% · Q2 95.8% · Q3 99.4% · Q4 100.0% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
9.3%
0.1 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 10.9% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.7%
3.9 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
26.2%
1.8 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 26.6% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-23 · Fire 2023-02-23
9 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-23
E · Potential for more than minimal harm
2025-01-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-23
E · Potential for more than minimal harm
2025-01-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-23
F · Potential for more than minimal harm
2023-02-23
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-02-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-23
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-04-03
D · Potential for more than minimal harm
2023-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-30
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 2025-02-23
F · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-30
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 2025-02-23
D · Potential for more than minimal harm
2025-01-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-23
D · Potential for more than minimal harm
2024-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-14
E · Potential for more than minimal harm
2023-08-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-10
E · Potential for more than minimal harm
2023-08-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-10
E · Potential for more than minimal harm
2023-03-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-02-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-21
F · Potential for more than minimal harm
2023-02-23
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 2023-04-06
E · Potential for more than minimal harm
2023-02-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-02-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-02-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-06
F · Potential for more than minimal harm
2021-07-22
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 2021-08-22
E · Potential for more than minimal harm
2021-07-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-22
D · Potential for more than minimal harm
2021-07-22
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 2021-08-22
D · Potential for more than minimal harm
2021-07-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2021-08-22
D · Potential for more than minimal harm
2021-07-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-08-22
D · Potential for more than minimal harm
2021-07-22
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 2021-08-22
Penalties and ownership
What sits behind the stars
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$13,762
2023-12-11
Fine
Fine · fine $13,762
Fine
$4,587
2023-11-20
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-13
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-06
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-30
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-23
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-17
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-10
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-02
Fine
Fine · fine $4,587
Fine
$13,409
2023-09-11
Fine
Fine · fine $13,409
Fine
$3,882
2023-08-28
Fine
Fine · fine $3,882
Fine
$3,529
2023-08-21
Fine
Fine · fine $3,529
Fine
$3,176
2023-08-14
Fine
Fine · fine $3,176
Fine
$2,823
2023-08-07
Fine
Fine · fine $2,823
Fine
$6,351
2023-07-17
Fine
Fine · fine $6,351
Fine
Ownership
Deltona Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
David, Rochel
5% Or Greater Indirect Ownership Interest · Individual
Fdz Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Friedman, Leah
5% Or Greater Indirect Ownership Interest · Individual
Miller, Yocheved
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Charles
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
Operational/Managerial Control · Individual
Zahler, Jacob
Corporate Officer · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Orange City Nursing And Rehab Center
Debary, FL
4-star overall rating with 3-star inspections with $16,801 in total fines with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Debary Health And Rehabilitation Center
Debary, FL
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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