Cycle 1
Health 2024-05-30 · Fire 2024-05-30
1 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Naples, FL
Gardens At Terracina Health & Rehabilitation
5-star overall rating with 4-star inspections with $10,881 in total fines with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
6869 Davis Boulevard, Naples, FL
(239) 348-6000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Goodman Group
Operator or chain grouping
Approved since
2019-10-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.85
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.88
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.38
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.38
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.62
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
710
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.04
Composite VBP score used to determine payment impact.
Payment multiplier
1.0194
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.32
Baseline 24.53% · Performance 17.92% · Measure score 8.32 · Achievement 7.58 · Improvement 8.32
Healthcare-associated infections
6.66
Baseline 5.70% · Performance 5.84% · Measure score 6.66 · Achievement 6.66 · Improvement 0
Total nurse turnover
7.28
Baseline 67.44% · Performance 34.29% · Measure score 7.28 · Achievement 7.19 · Improvement 7.28
Adjusted total nurse staffing
3.75
Performance 4.15 hours · Measure score 3.75 · Achievement 3.75 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 619 · Observed rate 9.85% · Lower 95% interval 9.35% |
| Discharge to community | 55.36% |
50.57%
4.8 pts better
|
Better than the National Rate · Eligible stays 603 · Observed rate 54.73% · Lower 95% interval 51.35% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.65% |
95.27%
3.4 pts better
|
Numerator 365 · Denominator 370 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 370 |
| Discharge self-care score | 75.78% |
53.69%
22.1 pts better
|
Numerator 219 · Denominator 289 |
| Discharge mobility score | 72.32% |
50.94%
21.4 pts better
|
Numerator 209 · Denominator 289 |
| Pressure ulcers or injuries, new or worsened | 0.81% |
2.29%
1.5 pts better
|
Numerator 3 · Denominator 369 · Adjusted rate 1.07% |
| Healthcare-associated infections requiring hospitalization | 5.84% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 357 · Observed rate 3.92% · Lower 95% interval 4.26% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 80.28% |
56.45%
23.8 pts better
|
Numerator 232 · Denominator 289 |
| Transfer of health information to provider | 99.6% |
95.95%
3.6 pts better
|
Numerator 249 · Denominator 250 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 116 · Denominator 116 |
| Resident COVID-19 vaccinations up to date | 1.56% |
25.2%
23.6 pts worse
|
Numerator 3 · Denominator 192 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 96.8% · Q3 98.2% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
9.3%
2.5 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.5% |
94.7%
8.2 pts worse
|
79.7%
6.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.5% |
| 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 19.9% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-16 · Fire 2023-02-16
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2021-06-17 · Fire 2021-06-17
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-02
F · Potential for more than minimal harm
2024-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-30
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-30
F · Potential for more than minimal harm
2023-02-16
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-16
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 2023-03-13
F · Potential for more than minimal harm
2023-02-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-16
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-13
F · Potential for more than minimal harm
2021-06-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-17
F · Potential for more than minimal harm
2021-06-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-17
F · Potential for more than minimal harm
2021-06-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-07-17
F · Potential for more than minimal harm
2021-06-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-07-17
F · Potential for more than minimal harm
2021-06-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-06-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-06-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-05-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-30
D · Potential for more than minimal harm
2023-02-16
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-16
Penalties and ownership
What sits behind the stars
$4,085
2024-05-30
Fine
Fine · fine $4,085
Fine
$6,796
2024-05-30
Fine
Fine · fine $6,796
Fine
Ownership
John B. Goodman 2006 Irrv Grantor Tr
5% Or Greater Direct Ownership Interest · Organization
Weichert, James
5% Or Greater Indirect Ownership Interest · Individual
2012 Goodman Family Gst
5% Or Greater Direct Ownership Interest · Organization
Benson, Randall
5% Or Greater Indirect Ownership Interest · Individual
Salmen, Thomas
5% Or Greater Indirect Ownership Interest · Individual
South Dakota Trust Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wilson, Mark
5% Or Greater Indirect Ownership Interest · Individual
Benson, Randall
Corporate Officer · Individual
Edinger, Craig
Corporate Officer · Individual
Huisman, Henry
W-2 Managing Employee · Individual
Knacke, Clinton
Corporate Officer · Individual
Olson, Denise
Corporate Officer · Individual
Weichert, James
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Solaris Healthcare Lely Palms
Naples, FL
1-star overall rating with 1-star inspections with abuse icon flag with $114,714 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Woodside Health And Rehabilitation Center
Naples, FL
1-star overall rating with 1-star inspections with abuse icon flag with $56,166 in total fines with 14 recent health deficiencies
#3
Oakton Place Health And Rehabilitation At The Arli
Naples, FL
2-star overall rating with 1-star inspections with $173,963 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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