Cycle 1
Health 2024-02-15 · Fire 2024-02-15
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Jacksonville, FL
Dolphin Pointe Health Care Center
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5355 Dolphin Point Blvd, Jacksonville, FL
(937) 434-8820
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
146
Certified beds
Average residents
140
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-03-31
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
0.45
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,056
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9944
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.14
Baseline 22.93% · Performance 20.78% · Measure score 3.14 · Achievement 1.40 · Improvement 3.14
Healthcare-associated infections
6.55
Baseline 7.94% · Performance 5.88% · Measure score 6.55 · Achievement 6.55 · Improvement 6.51
Total nurse turnover
2.93
Baseline 83.41% · Performance 63.35% · Measure score 2.93 · Achievement 0 · Improvement 2.93
Adjusted total nurse staffing
3.97
Baseline 4.43 hours · Performance 4.21 hours · Measure score 3.97 · Achievement 3.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.78% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 562 · Observed rate 11.21% · Lower 95% interval 8.91% |
| Discharge to community | 57.3% |
50.57%
6.7 pts better
|
Better than the National Rate · Eligible stays 497 · Observed rate 49.7% · Lower 95% interval 53.26% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.28% |
95.27%
About the same
|
Numerator 424 · Denominator 445 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 5 · Denominator 445 |
| Discharge self-care score | 45.77% |
53.69%
7.9 pts worse
|
Numerator 130 · Denominator 284 |
| Discharge mobility score | 35.21% |
50.94%
15.7 pts worse
|
Numerator 100 · Denominator 284 |
| Pressure ulcers or injuries, new or worsened | 2.02% |
2.29%
0.3 pts better
|
Numerator 9 · Denominator 445 · Adjusted rate 1.84% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 366 · Observed rate 5.74% · Lower 95% interval 4.21% |
| Staff COVID-19 vaccination coverage | 9.38% |
8.2%
1.2 pts better
|
Numerator 24 · Denominator 256 |
| Staff flu vaccination coverage | 19.44% |
42%
22.6 pts worse
|
Numerator 42 · Denominator 216 |
| Discharge function score | 38.73% |
56.45%
17.7 pts worse
|
Numerator 110 · Denominator 284 |
| Transfer of health information to provider | 93.2% |
95.95%
2.8 pts worse
|
Numerator 137 · Denominator 147 |
| Transfer of health information to patient | 99.04% |
96.28%
2.8 pts better
|
Numerator 206 · Denominator 208 |
| Resident COVID-19 vaccinations up to date | 3.43% |
25.2%
21.8 pts worse
|
Numerator 8 · Denominator 233 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.2
0.9 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
97.8%
3.9 pts worse
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 92.2% · Q3 94.3% · Q4 92.8% · 4Q avg 93.9% |
| 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 | 3.3% |
2.6%
0.7 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.9% · Q3 3.8% · Q4 3.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
3.7%
2.4 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.1% · Q3 8.3% · Q4 7.1% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.9%
1.5 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.8% · Q3 3.6% · Q4 3.8% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
15.7%
1.6 pts worse
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 15.4% · Q3 16.5% · Q4 13.1% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
9.8%
3 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.1% · Q3 6.8% · Q4 6.8% · 4Q avg 6.8% · 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 | 11.5% |
11.7%
0.2 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 12.4% · Q3 6.6% · Q4 10.8% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
9.8%
2.3 pts worse
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 11.6% · Q3 4.6% · Q4 16.0% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.8%
0.5 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.1% · Q3 1.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
12.5%
3.5 pts worse
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 16.1% · Q3 9.6% · Q4 17.6% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.1%
2.8 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.0% · Q3 7.5% · Q4 5.8% · 4Q avg 7.9% · 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 90.3% · Q2 93.7% · Q3 97.2% · Q4 95.6% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
9.3%
0.2 pts worse
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 10.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.7%
4.1 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
26.2%
3.7 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 24.2% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-24 · Fire 2022-03-24
5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-03-31 · Fire 2020-03-31
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2024-02-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-15
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-02-15
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 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
F · Potential for more than minimal harm
2022-03-24
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 2022-05-03
F · Potential for more than minimal harm
2022-03-24
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-03-24
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 2022-05-03
D · Potential for more than minimal harm
2022-03-24
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 2022-05-03
Penalties and ownership
What sits behind the stars
Ownership
Olt Ii, Inc
5% Or Greater Direct Ownership Interest · Organization
Cleveland, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Dolphin Pointe Medical Investors, LLC I
5% Or Greater Direct Ownership Interest · Organization
Dolphin Pointe Medical Investors, LLC Ii
5% Or Greater Direct Ownership Interest · Organization
Dolphin Pointe Medical Investors, LLC Iii
5% Or Greater Direct Ownership Interest · Organization
Fraser, Geoffrey
5% Or Greater Indirect Ownership Interest · Individual
Nelson, Sean
5% Or Greater Indirect Ownership Interest · Individual
Fifth Third Bank
5% Or Greater Mortgage Interest · Organization
Fraser, Geoffrey
Operational/Managerial Control · Individual
Fraser, Geoffrey
Corporate Director · Individual
Fraser, Geoffrey
Corporate Officer · Individual
Nelson, Denise
Corporate Director · Individual
Nelson, Denise
Corporate Officer · Individual
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