Cycle 1
Health 2025-12-11 · Fire 2025-12-11
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Jacksonville, FL
Aviata At Jacksonville
3-star overall rating with 3-star inspections with $4,778 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4101 Southpoint Drive East, Jacksonville, FL
(904) 296-6800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aviata Health Group
Operator or chain grouping
Approved since
1996-08-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 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
2.11
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.39
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
3.21
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,926
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.20
Baseline 69.00% · Performance 61.48% · Measure score 1.20 · Achievement 0.54 · Improvement 1.20
Adjusted total nurse staffing
1.73
Baseline 2.90 hours · Performance 3.54 hours · Measure score 1.73 · Achievement 1.64 · Improvement 1.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 6.63% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.83% |
95.27%
2.6 pts better
|
Numerator 90 · Denominator 92 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 92 |
| Discharge self-care score | 29.51% |
53.69%
24.2 pts worse
|
Numerator 18 · Denominator 61 |
| Discharge mobility score | 18.03% |
50.94%
32.9 pts worse
|
Numerator 11 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 0.76% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 90.32% |
8.2%
82.1 pts better
|
Numerator 84 · Denominator 93 |
| Staff flu vaccination coverage | 32.38% |
42%
9.6 pts worse
|
Numerator 34 · Denominator 105 |
| Discharge function score | 27.87% |
56.45%
28.6 pts worse
|
Numerator 17 · Denominator 61 |
| Transfer of health information to provider | 91.23% |
95.95%
4.7 pts worse
|
Numerator 52 · Denominator 57 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5.56% |
25.2%
19.6 pts worse
|
Numerator 3 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 0.6% |
2.6%
2 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
3.7%
1.2 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.4% · Q3 3.8% · Q4 2.5% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.9%
1.3 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.7% · Q3 7.4% · Q4 1.2% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.5% |
15.7%
1.8 pts worse
|
19.6%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 12.8% · Q3 17.3% · Q4 19.8% · 4Q avg 17.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
9.8%
3.4 pts worse
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 14.8% · Q3 14.0% · Q4 10.9% · 4Q avg 13.2% · 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 | 5.5% |
11.7%
6.2 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 0.0% · Q3 3.7% · Q4 6.2% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
9.8%
5.3 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 1.2% · Q3 3.9% · Q4 2.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 2.0% · 4Q avg 0.7% · 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 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.2% |
12.5%
2.3 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 6.6% · Q3 11.2% · Q4 11.3% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.1%
1.2 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.4% · Q3 4.6% · Q4 6.2% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
9.3%
2.6 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 14.3% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 2.4% · Q4 3.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
94.7%
3.1 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
26.2%
1.2 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 40.5% · Expected 35.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-13 · Fire 2023-12-13
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-02-17 · Fire 2022-02-17
11 health deficiencies
Top issue: Resident Rights (4 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
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-11
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-18
D · Potential for more than minimal harm
2023-12-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-11
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 2026-01-18
D · Potential for more than minimal harm
2025-12-11
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-11
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-11
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 2026-01-18
D · Potential for more than minimal harm
2023-12-13
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 2024-01-09
D · Potential for more than minimal harm
2023-12-13
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 2024-01-09
D · Potential for more than minimal harm
2023-12-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-10-10
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-06-14
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 2023-07-13
E · Potential for more than minimal harm
2022-02-17
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 2022-03-22
E · Potential for more than minimal harm
2022-02-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-22
E · Potential for more than minimal harm
2022-02-17
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 2022-03-22
D · Potential for more than minimal harm
2022-02-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-17
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-03-22
Penalties and ownership
What sits behind the stars
$4,778
2023-10-10
Fine
Fine · fine $4,778
Fine
Ownership
Freund, Nochum
Operational/Managerial Control · Individual
Freund, Nochum
Corporate Officer · Individual
Jones, Deanna
Operational/Managerial Control · Individual
Yazji, George
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Woodland Grove Healthcare & Rehabilitation Center
Jacksonville, FL
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Jacksonville
Jacksonville, FL
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#3
Riverwood Center
Jacksonville, FL
2-star overall rating with 2-star inspections with $34,778 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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