JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Villages Regional Hospital, the

4 / 5

At a glance

Villages Regional Hospital, the carries a 4-star CMS overall rating — above the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 and worse on 0. For 30-day readmissions, it beats the national rate on 1 measure and trails on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.372Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.820Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4353Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.421Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases4Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.169Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.751Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit3.396Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4630Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.077Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases7Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)1.717Same as national
SSI - Colon Surgery: Lower Confidence LimitSame as national
SSI - Colon Surgery: Upper Confidence Limit1.292Same as national
SSI - Colon Surgery: Number of Procedures109Same as national
SSI - Colon Surgery: Predicted Cases2.319Same as national
SSI - Colon Surgery: Observed Cases0Same as national
SSI - Colon Surgery0.000Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures28Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.173Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.605Same as national
MRSA Bacteremia: Upper Confidence Limit3.103Same as national
MRSA Bacteremia: Patient Days70478Same as national
MRSA Bacteremia: Predicted Cases4.022Same as national
MRSA Bacteremia: Observed Cases6Same as national
MRSA Bacteremia1.492Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.323Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.842Better than national
Clostridium Difficile (C.Diff): Patient Days70478Better than national
Clostridium Difficile (C.Diff): Predicted Cases31.670Better than national
Clostridium Difficile (C.Diff): Observed Cases17Better than national
Clostridium Difficile (C.Diff)0.537Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patients3.7Same as national101
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4Same as national2736
Death rate for heart attack patients13Same as national415
Death rate for CABG surgery patientsNot available
Death rate for COPD patients10.6Same as national236
Death rate for heart failure patients10.9Same as national821
Death rate for pneumonia patients18.4Worse than national839
Death rate for stroke patients11.5Same as national224
Pressure ulcer rate0.12Same as national8659
Death rate among surgical inpatients with serious treatable complications154.83Same as national72
Iatrogenic pneumothorax rate0.21Same as national9932
In-hospital fall-associated fracture rate0.26Same as national10274
Postoperative hemorrhage or hematoma rate1.97Same as national1486
Postoperative acute kidney injury requiring dialysis rate1.54Same as national364
Postoperative respiratory failure rate5.77Same as national370
Perioperative pulmonary embolism or deep vein thrombosis rate3.60Same as national1559
Postoperative sepsis rate4.09Same as national357
Postoperative wound dehiscence rate1.60Same as national384
Abdominopelvic accidental puncture or laceration rate0.79Same as national1295
CMS Medicare PSI 90: Patient safety and adverse events composite0.69Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients-7.8Not available357
Hospital return days for heart failure patients-0.3Not available906
Hospital return days for pneumonia patients12.5Not available854
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)13.9Better than national4255
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.6Same as national90
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national534
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.1Same as national357
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.5Same as national252
Heart failure (HF) 30-Day Readmission Rate19.1Same as national906
Rate of readmission after hip/knee replacement4.9Same as national100
Pneumonia (PN) 30-Day Readmission Rate16.5Same as national854

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating33445
Doctor communication - star rating23445
Communication about medicines - star rating33445
Discharge information - star rating43445
Cleanliness - star rating43445
Quietness - star rating33445
Overall hospital rating - star rating33445
Recommend hospital - star rating33445
Summary star rating33445

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volumevery high
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination632482
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better163425
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better160404
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better33412
Left before being seen160734
Head CT results6216
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10015
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)6733
Safe Use of Opioids - Concurrent Prescribing152530
Appropriate care for severe sepsis and septic shock62160
Septic Shock 3-Hour Bundle8257
Septic Shock 6-Hour Bundle8636
Severe Sepsis 3-Hour Bundle77160
Severe Sepsis 6-Hour Bundle9283
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 285176
Venous Thromboembolism Prophylaxis989429
Intensive Care Unit Venous Thromboembolism Prophylaxis991307

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureNot Applicable (our hospital does not provide inpatient labor/delivery care)

Frequently asked questions

How is Villages Regional Hospital, the rated?
Villages Regional Hospital, the has a 4 out of 5 CMS overall star rating as of the latest CMS release.
Does Villages Regional Hospital, the have emergency services?
Yes. Villages Regional Hospital, the operates a 24/7 emergency department.
Where is Villages Regional Hospital, the located?
Villages Regional Hospital, the is located at 1451 El Camino Real, the Villages, FL 32159.
What type of hospital is Villages Regional Hospital, the?
Villages Regional Hospital, the is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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