Pinnacle Home Care of the Villages Inc.
A home health agency in The Villages, Florida 32162
8483 SE 165th Mulberry Ln, The Villages, Florida 32162. (352) 314-9500.
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The short answer
Record last released by CMS on Oct 21, 2026.
- 3.5of 5 quality of patient care rating
- 3of 5 patient survey rating
- 1 deficiencies cited in the last three years
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on May 29, 2025: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited May 2025. Most serious: Element-level. The last 3 years, to Oct 24, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
May 29, 2025: complaint inspection1 deficiency
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Promptly Alert Relevant Physician Of Changes
The inspectors’ words, 336 words
“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to communicate and follow up with the physician of the patient’s laboratory results according to professional standards of practice for 1 of 3 patients, Patient #1. Findings include: Review of Patient #1’s medical record documented the patient had a urine analysis results reported on 12/03/2024, via fax. The results were not forwarded or communicated to the physician. During the review of the home visit note dated 12/09/2024 an attempt was made to contact the physician without success. This attempt was not followed through by the nurse or escalated to a Case Manager as per the agency policy. During an interview on 5/29/25 at 11:30 AM the Clinical Director stated, “I would expect a prudent nurse to follow up with these results.” Review of the policy and procedure titled, “MONITORING PATIENT’S RESPONSE/REPORTING TO PHYSICIAN. Policy No. 4-012.1.” read, “PURPOSE To provide guidelines for monitoring the patient’s response to care, and for reporting to the patient’s physician. POLICY: Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress of goals will be measured at regular intervals. Clinicians will monitor and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. 3. The patient’s physician will be contacted on the same day when any of the following occur: G. When results are received for relevant laboratory test ordered. 5. When unable to contact the patient’s physician for medical consultation warranted by change in patient’s condition, the following procedures will be followed: A. The nurse or therapist will immediately notify the Clinical Manager or designee regarding the need for medical consultation and problems encountered.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| May 29, 2025 | Complaint inspection | 1 deficiency cited |
Is it certified?
- Medicare-certified home health agency since Jul 1, 2011.
- Ownership: proprietary (for profit).
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
CMS, Home Health Care Agencies. Released Oct 21, 2026. Updated quarterly.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for home health agencies, so none are shown.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
Who does the caring?
- Offers nursing care, physical therapy, occupational therapy, speech pathology, medical social services and home health aide services.
- CMS doesn’t publish staffing levels for home health agencies.
CMS, Home Health Care Agencies. Released Oct 21, 2026. Updated quarterly.
Who owns it?
- 4 owners or officers are people: Shane Donaldson (owns 5% or more directly, 100%); Shane Donaldson (corporate officer, 100%); Shane Donaldson (managing employee (on the payroll), 100%); Shane Donaldson (corporate director).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Home Health Agency All Owners and Home Health Agency Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Pinnacle Home CARE Holdings LLC. | Owns 5% or more through other companies | 100% | Jul 13, 2018 |
How do patients fare?
- CMS rates its quality of patient care 3.5 of 5.
- Patients rate it 3 of 5 in CMS’s patient survey (362 surveys completed): 84% rated it 9 or 10 out of 10, and 76% would definitely recommend it.
- CMS compares it with the national rate: discharged to the community, better; potentially preventable hospital stays, the same; potentially preventable readmissions after discharge, worse.
CMS, Home Health Care Agencies and Home Health Patient Survey. Released Oct 21, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Quality of patient care ratingCMS star rating, 1 to 5 in half stars | 3.5 of 5 |
| Patient survey ratingCMS star rating from its survey of the agency’s patients, 1 to 5 | 3 of 5 |
| Discharged to the communityCMS’s risk-adjusted rate, compared with the national rate | 88.71% (better than the national rate) |
| Potentially preventable hospital staysCMS’s risk-adjusted rate, compared with the national rate | 10.13% (same as the national rate) |
| Potentially preventable readmissions after dischargeCMS’s risk-adjusted rate, compared with the national rate | 5.00% (worse than the national rate) |
How does it compare nearby?
- Of the 45 agencies CMS’s data show serving patients in ZIP code 32162, where this agency’s office is, 42 have a quality of patient care rating; the middle one is 3.5 of 5, and this one is rated 3.5 of 5.
CMS, Home Health ZIP Codes and Home Health Care Agencies. Released Oct 21, 2026. Updated quarterly.
| Place | Quality rating |
|---|---|
| Amedisys Home Health | 4.5 |
| Concierge Home Care | 4 |
| HCA Florida Healthcare at Home | 4 |
| Pinnacle Home Care of the Villages Inc. This home health agency | 3.5 |
| Advanced Nursing Concepts LLC | 3.5 |
| Centerwell Home Health | 4.5 |
| Better @ Home | 3.5 |
| Alternative Health | Not given |
| Trilogy Home Healthcare | 4.5 |
| Munroe Regional Homecare LLC | 3 |
| Adventhealth Home Health | 4.5 |
| Accomplished Home Care | 3 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for home health agencies, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- QCOR says some of its home health reports are accurate or available only through May 19, 2021, because of a systems migration.
- Many home health agencies are inspected by a private accrediting organisation instead of the state, and QCOR’s home health file doesn’t appear to include those inspections: no inspection on record here doesn’t mean none took place.
Sources
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Centers for Medicare & Medicaid Services, Home Health Care Agencies (6jpm-sxkc).
Released Oct 21, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health Patient Survey (ccn4-8vby).
Released Oct 21, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR home health inspection reports (HHA_2567s_2018_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 24, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health Agency All Owners (fc009b2d-7846-44b1-b4a1-692f0c143879).
Released Sep 29, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health Agency Enrollments (15f64ab4-3172-4a27-b589-ebd67a6d28aa).
Released Sep 29, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health ZIP Codes (m5eg-upu5).
Released Oct 21, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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This copy of the record was made on Oct 24, 2026.
From the agency
The public record above comes first. Anything the agency adds will appear here, below it, and say who wrote it.
Replies
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Paid listing
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