Cycle 1
Health 2025-05-01 · Fire 2025-05-01
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Jacksonville, FL
Jacksonville Nursing And Rehab Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4134 Dunn Avenue, Jacksonville, FL
(904) 766-2297
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
163
Certified beds
Average residents
146
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1990-10-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 overall / 3 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
0.54
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,254
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.63
Baseline 18.82% · Performance 21.14% · Measure score 0.63 · Achievement 0.63 · Improvement 0
Healthcare-associated infections
0
Baseline 6.59% · Performance 9.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.38
Baseline 39.62% · Performance 53.96% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Adjusted total nurse staffing
2.27
Baseline 4.13 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.64% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 12.12% · Lower 95% interval 8.22% |
| Discharge to community | 46.49% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 37.23% · Lower 95% interval 38.05% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.35% |
95.27%
3.1 pts better
|
Numerator 179 · Denominator 182 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 182 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 74 · Denominator 111 |
| Discharge mobility score | 44.14% |
50.94%
6.8 pts worse
|
Numerator 49 · Denominator 111 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 182 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.11% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 15.58% · Lower 95% interval 6.01% |
| Staff COVID-19 vaccination coverage | 3.94% |
8.2%
4.3 pts worse
|
Numerator 8 · Denominator 203 |
| Staff flu vaccination coverage | 25% |
42%
17 pts worse
|
Numerator 64 · Denominator 256 |
| Discharge function score | 62.16% |
56.45%
5.7 pts better
|
Numerator 69 · Denominator 111 |
| Transfer of health information to provider | 86.6% |
95.95%
9.4 pts worse
|
Numerator 84 · Denominator 97 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.66% |
25.2%
12.5 pts worse
|
Numerator 10 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.9 · 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 | 1.3% |
2.6%
1.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.5% · Q3 0.8% · Q4 2.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 29.4% |
3.7%
25.7 pts worse
|
11.4%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 15.6% · Q3 25.6% · Q4 56.1% · 4Q avg 29.4% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.9%
3.2 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.5% · Q3 2.7% · Q4 3.9% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
15.7%
4.3 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.0% · Q3 8.5% · Q4 9.9% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.6% |
9.8%
3.8 pts worse
|
16.7%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 14.7% · Q3 16.0% · Q4 8.6% · 4Q avg 13.6% · 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 | 5.2% |
11.7%
6.5 pts better
|
16.3%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.4% · Q3 4.1% · Q4 6.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
9.8%
4 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.1% · Q3 5.3% · Q4 7.5% · 4Q avg 5.8% · 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 | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.5% |
12.5%
8 pts better
|
19.8%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.6% · Q3 3.5% · Q4 7.3% · 4Q avg 4.5% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
5.1%
3.5 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.8% · Q3 1.7% · Q4 0.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
9.3%
2.4 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 8.1% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.2% · 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 | 19.8% |
26.2%
6.4 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 24.4% · Expected 29.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-09-23 · Fire 2021-09-23
2 health deficiencies
Top issue: Quality of Life and Care (2 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
2025-05-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-05-01
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-06-01
D · Potential for more than minimal harm
2023-06-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-06-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
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 2025-06-01
D · Potential for more than minimal harm
2025-05-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-01
D · Potential for more than minimal harm
2023-06-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-06-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-06-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-06-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-29
D · Potential for more than minimal harm
2021-09-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-29
D · Potential for more than minimal harm
2021-09-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-10-29
Penalties and ownership
What sits behind the stars
Ownership
Berkadia Commercial Mortgage LLC
5% Or Greater Security Interest · Organization
Covington, Raelyn
Operational/Managerial Control · Individual
Cronquist, Royce
Operational/Managerial Control · Individual
Fl Jacksonville Holdings, LLC
5% Or Greater Security Interest · Organization
Health Services Properties LLC
5% Or Greater Security Interest · Organization
Mangine, John
Operational/Managerial Control · Individual
Melton, Donald
Operational/Managerial Control · Individual
Notermann, William
Operational/Managerial Control · Individual
Singh, Harpreet
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Lakeside Center For Rehabilitation And Healing
Jacksonville, FL
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Aviata At Harts Harbor
Jacksonville, FL
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Pavilion At Jacksonville, The
Jacksonville, FL
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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