10 health deficiencies
Top issue: Environmental (3 deficiencies)
25 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (7 deficiencies)
Jacksonville, FL
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 25 fire-safety deficiencies in the latest cycle
5377 Moncrief Road, Jacksonville, FL
(904) 768-1506
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.30
Registered nurse staffing
LPN hours / resident day
0.84
Licensed practical nurse staffing
Aide hours / resident day
2.06
Nurse aide staffing
Weekend hours
3.05
Weekend nurse staffing
RN turnover
57%
Annual RN turnover
Total nurse turnover
69%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
3.7%
2.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 12.8% |
5.9%
6.9 pts worse
|
5.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.0% |
15.7%
12.3 pts worse
|
19.6%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 33.7% |
9.8%
23.9 pts worse
|
16.7%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.5% |
11.7%
3.8 pts worse
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
9.8%
0.4 pts worse
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.4%
0.4 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.2% |
12.5%
3.3 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.1%
1.4 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
94.3%
5.2 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
9.3%
1.8 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Environmental (3 deficiencies)
25 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (7 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-25
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-25
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 2024-08-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-25
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-25
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-25
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-08-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-25
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-25
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-25
Fire Safety
Develop a communication plan.
Corrected 2024-08-25
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-08-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-25
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2024-08-25
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-08-25
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-25
Fire Safety
Meet fire sprinkler requirement for tall buildings.
Corrected 2024-08-25
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-25
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-25
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-08-25
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-02-10
Inspection history
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-06-19
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-08-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-25
Health
Keep all essential equipment working safely.
Corrected 2024-08-25
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-25
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-08-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-25
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-25
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-19
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-08-19
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-08-19
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-02-10
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 2021-02-10
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2021-02-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-02-10
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 2021-02-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-02-10
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
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