Cycle 1
Health 2024-02-29 · Fire 2024-02-29
4 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
11 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Jacksonville, FL
First Coast Health And Rehabilitation Center
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
7723 Jasper Avenue, Jacksonville, FL
(904) 725-8044
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
100
Certified beds
Average residents
89
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Senior Health South
Operator or chain grouping
Approved since
1983-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 2 health / 3 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
0.73
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,682
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.10% · Performance 21.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.78% · Performance 8.56% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.69
Baseline 45.75% · Performance 56.79% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Adjusted total nurse staffing
2.74
Baseline 4.22 hours · Performance 3.86 hours · Measure score 2.74 · Achievement 2.74 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 12.5% · Lower 95% interval 7.59% |
| Discharge to community | 32.51% |
50.57%
18.1 pts worse
|
Worse than the National Rate · Eligible stays 35 · Observed rate 14.29% · Lower 95% interval 17.52% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 71 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 38.64% |
53.69%
15 pts worse
|
Numerator 17 · Denominator 44 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 11 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 72 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.56% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 18.18% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | 10.1% |
8.2%
1.9 pts better
|
Numerator 10 · Denominator 99 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 150 |
| Discharge function score | 40.91% |
56.45%
15.5 pts worse
|
Numerator 18 · Denominator 44 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| 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 | 2.56% |
25.2%
22.6 pts worse
|
Numerator 1 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.1 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · 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 | 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 | 1.2% |
2.6%
1.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 1.2% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 4.4% |
5.9%
1.5 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.9% · Q3 4.1% · Q4 6.5% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.6% |
15.7%
9.9 pts worse
|
19.6%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 27.8% · Q3 25.0% · Q4 25.3% · 4Q avg 25.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.9% |
9.8%
16.1 pts worse
|
16.7%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 19.2% · Q3 29.4% · Q4 30.4% · 4Q avg 25.9% · 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 | 6.7% |
11.7%
5 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 0.0% · Q3 6.9% · Q4 0.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
9.8%
2.2 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.3% · Q3 12.2% · Q4 4.3% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · 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 | 3.9% |
12.5%
8.6 pts better
|
19.8%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 4.7% · Q3 5.9% · Q4 3.6% · 4Q avg 3.9% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.1%
2.5 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.6% · Q3 7.5% · Q4 6.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.3%
5.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.5% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
9.3%
5.1 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 5.5% · Expected 14.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.8% · Q3 0.0% · Q4 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
26.2%
2.1 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 36.4% · Expected 30.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-17 · Fire 2022-03-17
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-03-12 · Fire 2020-03-12
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
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 2024-03-29
E · Potential for more than minimal harm
2024-02-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
K400 · Miscellaneous Deficiencies
Fire Safety
Meet fire sprinkler requirement for tall buildings.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-29
F · Potential for more than minimal harm
2020-03-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-04-12
D · Potential for more than minimal harm
2020-03-12
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2020-04-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-06
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-02-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-03-29
F · Potential for more than minimal harm
2024-02-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-29
D · Potential for more than minimal harm
2023-12-04
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 2024-01-04
F · Potential for more than minimal harm
2022-03-17
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 2022-04-17
D · Potential for more than minimal harm
2022-03-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-17
D · Potential for more than minimal harm
2022-03-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-04-17
D · Potential for more than minimal harm
2022-03-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-04-17
D · Potential for more than minimal harm
2020-03-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-04-12
Penalties and ownership
What sits behind the stars
Ownership
Senior Health South Ex LLC
5% Or Greater Indirect Ownership Interest · Organization
Senior Health-First Coast LLC
5% Or Greater Direct Ownership Interest · Organization
Depiano, Rich
Corporate Officer · Individual
Jaffe, Howard
Corporate Officer · Individual
Lewis, Joseph
W-2 Managing Employee · Individual
Mullen, Ann
Corporate Officer · Individual
Richmond, Penny
Corporate Officer · Individual
Stevens, Corey
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Dolphin Pointe Health Care Center
Jacksonville, FL
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Fountains Rehabilitation At Mill Cove
Jacksonville, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
University Crossing
Jacksonville, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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