Cycle 1
Health 2024-05-23 · Fire 2024-05-23
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Jacksonville, FL
Bartram Crossing
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
6209 Brooks Bartram Drive, Jacksonville, FL
(904) 824-3326
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
111
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.90
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.14
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,440
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.70
Composite VBP score used to determine payment impact.
Payment multiplier
1.0118
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.82
Baseline 18.41% · Performance 21.05% · Measure score 0.82 · Achievement 0.82 · Improvement 0
Healthcare-associated infections
9.06
Baseline 4.49% · Performance 5.13% · Measure score 9.06 · Achievement 9.06 · Improvement 0
Total nurse turnover
7.36
Baseline 41.18% · Performance 33.61% · Measure score 7.36 · Achievement 7.36 · Improvement 4.14
Adjusted total nurse staffing
5.44
Baseline 4.36 hours · Performance 4.63 hours · Measure score 5.44 · Achievement 5.44 · Improvement 1.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.7% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 1310 · Observed rate 10.46% · Lower 95% interval 10.22% |
| Discharge to community | 61.86% |
50.57%
11.3 pts better
|
Better than the National Rate · Eligible stays 1312 · Observed rate 59.3% · Lower 95% interval 59.53% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 82.97% |
95.27%
12.3 pts worse
|
Numerator 614 · Denominator 740 |
| Falls with major injury | 0.27% |
0.77%
0.5 pts better
|
Numerator 2 · Denominator 740 |
| Discharge self-care score | 36.09% |
53.69%
17.6 pts worse
|
Numerator 218 · Denominator 604 |
| Discharge mobility score | 46.03% |
50.94%
4.9 pts worse
|
Numerator 278 · Denominator 604 |
| Pressure ulcers or injuries, new or worsened | 0.95% |
2.29%
1.3 pts better
|
Numerator 7 · Denominator 739 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 5.13% |
7.12%
2 pts better
|
Better than the National Rate · Eligible stays 695 · Observed rate 4.03% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 1.16% |
8.2%
7 pts worse
|
Numerator 2 · Denominator 172 |
| Staff flu vaccination coverage | 60.32% |
42%
18.3 pts better
|
Numerator 149 · Denominator 247 |
| Discharge function score | 47.02% |
56.45%
9.4 pts worse
|
Numerator 284 · Denominator 604 |
| Transfer of health information to provider | 97.25% |
95.95%
1.3 pts better
|
Numerator 106 · Denominator 109 |
| Transfer of health information to patient | 99.51% |
96.28%
3.2 pts better
|
Numerator 615 · Denominator 618 |
| Resident COVID-19 vaccinations up to date | 35.49% |
25.2%
10.3 pts better
|
Numerator 126 · Denominator 355 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.3 · Expected 1.2 · Used in QM five-star |
| 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 | 97.1% |
99.2%
2.1 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
3.7%
0.5 pts worse
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 3.4% · Q4 6.9% · 4Q avg 4.2% |
| 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 · Q1 8.7% · Q2 13.0% · Q3 10.0% · Q4 4.2% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
15.7%
3.4 pts worse
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 17.4% · Q3 18.2% · Q4 16.0% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
9.8%
7.1 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q4 20.0% · 4Q avg 16.9% · 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 | 9.9% |
11.7%
1.8 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
9.8%
5.9 pts worse
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 13.6% · Q3 10.0% · Q4 16.7% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.4%
0.9 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 2.6% · 4Q avg 1.3% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
12.5%
2.9 pts worse
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 25.4% · Q3 15.1% · Q4 17.1% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 9.9% |
5.1%
4.8 pts worse
|
5.1%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.3% · Q3 8.9% · Q4 14.0% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.3%
4.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 99.2% · Q3 99.2% · Q4 99.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
9.3%
0.3 pts worse
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.8% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.5% · Q3 1.0% · Q4 0.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.5% |
94.7%
1.8 pts better
|
79.7%
16.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
26.2%
3 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 24.9% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-23 · Fire 2022-06-23
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-12-18 · Fire 2020-12-18
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-05-23
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 2024-06-20
D · Potential for more than minimal harm
2023-11-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-03
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-03
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-12-01
F · Potential for more than minimal harm
2022-06-23
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 2022-07-23
D · Potential for more than minimal harm
2022-06-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
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 2022-07-23
D · Potential for more than minimal harm
2022-06-23
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 2022-07-23
D · Potential for more than minimal harm
2020-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-01-29
D · Potential for more than minimal harm
2020-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-01-29
D · Potential for more than minimal harm
2020-12-18
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 2021-01-29
Penalties and ownership
What sits behind the stars
Ownership
Brooks Skilled Nursing, Inc.
5% Or Greater Direct Ownership Interest · Organization
Genesis Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Allen, Jennifer
Operational/Managerial Control · Individual
Baer, Douglas
Corporate Director · Individual
Derienzo, Victor
Corporate Officer · Individual
Lei, Marc
Operational/Managerial Control · Individual
Mann, Eric
Corporate Director · Individual
Tabor, James
Corporate Officer · Individual
Xie, Chonglun
Operational/Managerial Control · Individual
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