Cycle 1
Health 2025-04-17 · Fire 2025-04-17
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Jacksonville, FL
Cypress Village
5-star overall rating with 5-star inspections with $18,324 in total fines with 8 fire-safety deficiencies in the latest cycle
4600 Middleton Park Cir E, Jacksonville, FL
(904) 223-6100
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
1991-10-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 4 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
1.07
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.96
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.08
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
4.81
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,249
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0049
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.10
Baseline 23.00% · Performance 20.85% · Measure score 3.10 · Achievement 1.26 · Improvement 3.10
Healthcare-associated infections
8.91
Baseline 5.49% · Performance 5.17% · Measure score 8.91 · Achievement 8.91 · Improvement 5.97
Total nurse turnover
2.98
Baseline 70.16% · Performance 54.40% · Measure score 2.98 · Achievement 2.27 · Improvement 2.98
Adjusted total nurse staffing
5.28
Baseline 5.10 hours · Performance 4.58 hours · Measure score 5.28 · Achievement 5.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.26% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 822 · Observed rate 12.04% · Lower 95% interval 10.44% |
| Discharge to community | 67.7% |
50.57%
17.1 pts better
|
Better than the National Rate · Eligible stays 791 · Observed rate 61.82% · Lower 95% interval 64.58% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.18% |
95.27%
3.9 pts better
|
Numerator 481 · Denominator 485 |
| Falls with major injury | 1.24% |
0.77%
0.5 pts worse
|
Numerator 6 · Denominator 484 |
| Discharge self-care score | 61.13% |
53.69%
7.4 pts better
|
Numerator 195 · Denominator 319 |
| Discharge mobility score | 47.34% |
50.94%
3.6 pts worse
|
Numerator 151 · Denominator 319 |
| Pressure ulcers or injuries, new or worsened | 1.86% |
2.29%
0.4 pts better
|
Numerator 9 · Denominator 484 · Adjusted rate 1.92% |
| Healthcare-associated infections requiring hospitalization | 5.17% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 432 · Observed rate 4.17% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 3.23% |
8.2%
5 pts worse
|
Numerator 3 · Denominator 93 |
| Staff flu vaccination coverage | 2.78% |
42%
39.2 pts worse
|
Numerator 2 · Denominator 72 |
| Discharge function score | 60.5% |
56.45%
4 pts better
|
Numerator 193 · Denominator 319 |
| Transfer of health information to provider | 91.7% |
95.95%
4.2 pts worse
|
Numerator 221 · Denominator 241 |
| Transfer of health information to patient | 99.49% |
96.28%
3.2 pts better
|
Numerator 195 · Denominator 196 |
| Resident COVID-19 vaccinations up to date | 1.21% |
25.2%
24 pts worse
|
Numerator 3 · Denominator 248 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
97.8%
1.2 pts worse
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 86.5% · 4Q avg 96.6% |
| 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 | 3.4% |
2.6%
0.8 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 5.6% · Q4 2.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
3.7%
1.5 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 2.9% · Q4 2.9% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
5.9%
3.1 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 12.0% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
15.7%
3.7 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 14.3% · Q3 14.3% · Q4 33.3% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
9.8%
1.9 pts worse
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 9.5% · 4Q avg 11.7% · 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 need for help with daily activities has increased | 18.8% |
9.8%
9 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 16.7% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
0.8%
1.4 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 5.9% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.6% |
12.5%
1.9 pts better
|
19.8%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 0.0% · Q3 15.7% · Q4 10.0% · 4Q avg 10.6% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.1%
1.1 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.9% · Q3 5.5% · Q4 7.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
94.3%
0.1 pts worse
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 97.4% · Q3 92.5% · Q4 88.1% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
9.3%
1.4 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.2% · Q3 0.9% · Q4 0.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
94.7%
1.2 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
26.2%
1.4 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 22.7% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-09-10 · Fire 2021-09-10
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 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
2025-04-17
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 2025-05-17
E · Potential for more than minimal harm
2025-04-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-17
E · Potential for more than minimal harm
2025-04-17
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 2025-05-17
D · Potential for more than minimal harm
2025-04-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-17
D · Potential for more than minimal harm
2023-05-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-08-23
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-09-23
F · Potential for more than minimal harm
2023-05-25
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 2023-06-25
D · Potential for more than minimal harm
2023-05-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-25
F · Potential for more than minimal harm
2021-09-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-10-15
D · Potential for more than minimal harm
2021-09-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-10-15
D · Potential for more than minimal harm
2021-09-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-15
D · Potential for more than minimal harm
2021-09-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-10-15
Penalties and ownership
What sits behind the stars
$9,527
2023-10-10
Fine
Fine · fine $9,527
Fine
$2,447
2023-08-14
Fine
Fine · fine $2,447
Fine
$2,117
2023-08-07
Fine
Fine · fine $2,117
Fine
$4,233
2023-07-17
Fine
Fine · fine $4,233
Fine
Ownership
Ccrc Opco Ventures LLC
5% Or Greater Direct Ownership Interest · Organization
Browning, Arthur
Operational/Managerial Control · Individual
Ccrc Opco - Cypress Village, LLC
5% Or Greater Security Interest · Organization
Ccrc Propco Ventures, LLC
5% Or Greater Security Interest · Organization
Hcp S-H 2014 Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services LLC
Operational/Managerial Control · Organization
Markoski, Stephanie
Operational/Managerial Control · Individual
Morgan, Ty
Operational/Managerial Control · Individual
S-H 2014 Opco Trs Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Avante Villa At Jacksonville Beach Inc
Jacksonville Beach, FL
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Vicar's Landing Nursing Home
Ponte Vedra Beach, FL
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Regents Park Of Jacksonville
Jacksonville, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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