Cycle 1
Health 2024-07-25 · Fire 2024-07-25
10 health deficiencies
Top issue: Environmental (3 deficiencies)
25 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (7 deficiencies)
Jacksonville, FL
Jacksonville Nursing And Rehabilation
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
Facility snapshot
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
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
0.30
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.14
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
0.31
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,030
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 64.66% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.33
Baseline 4.29 hours · Performance 4.31 hours · Measure score 4.33 · Achievement 4.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.6 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| 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 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · 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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.2% |
3.7%
2.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 3.1% · 4Q avg 1.2% |
| 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 · Q1 9.4% · Q2 10.8% · Q3 14.7% · Q4 16.3% · 4Q avg 12.8% |
| 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 · Q1 29.0% · Q2 28.3% · Q3 27.2% · Q4 27.4% · 4Q avg 28.0% |
| 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 · Q1 37.9% · Q2 30.9% · Q3 34.3% · Q4 31.7% · 4Q avg 33.7% · 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 | 15.5% |
11.7%
3.8 pts worse
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.0% · Q3 16.7% · Q4 19.0% · 4Q avg 15.5% · Used in QM five-star |
| 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 · Q1 7.1% · Q2 10.1% · Q3 8.2% · Q4 15.2% · 4Q avg 10.2% · Used in QM five-star |
| 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 · Q1 1.0% · Q2 0.0% · Q3 0.8% · Q4 1.3% · 4Q avg 0.8% · 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 | 9.2% |
12.5%
3.3 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 5.7% · Q3 7.1% · Q4 7.0% · 4Q avg 9.2% |
| 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 · Q1 4.1% · Q2 0.0% · Q3 4.7% · Q4 5.8% · 4Q avg 3.7% · Used in QM five-star |
| 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 · Q1 97.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 · Adjusted 7.5% · Observed 8.3% · Expected 12.4% · 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 · 4Q avg 0.0% · 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 | 24.8% |
26.2%
1.4 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 25.0% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-14 · Fire 2022-07-14
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2021-01-14 · Fire 2021-01-14
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
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 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
K400 · Miscellaneous Deficiencies
Fire Safety
Meet fire sprinkler requirement for tall buildings.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-08-25
E · Potential for more than minimal harm
2022-07-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-19
D · Potential for more than minimal harm
2021-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-02-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-08
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 2025-06-19
F · Potential for more than minimal harm
2024-07-25
F801 · Nutrition and Dietary Deficiencies
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
F · Potential for more than minimal harm
2024-07-25
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 2024-08-25
F · Potential for more than minimal harm
2024-07-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-08-25
E · Potential for more than minimal harm
2024-07-25
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 2024-08-25
D · Potential for more than minimal harm
2024-07-25
F622 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-07-25
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 2024-08-25
D · Potential for more than minimal harm
2024-07-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-25
F755 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-07-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-25
F · Potential for more than minimal harm
2022-07-14
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 2022-08-19
E · Potential for more than minimal harm
2022-07-14
F693 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2022-07-14
F803 · Nutrition and Dietary Deficiencies
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
D · Potential for more than minimal harm
2022-07-14
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 2022-08-19
D · Potential for more than minimal harm
2021-01-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-02-10
D · Potential for more than minimal harm
2021-01-14
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 2021-02-10
D · Potential for more than minimal harm
2021-01-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2021-02-10
D · Potential for more than minimal harm
2021-01-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-02-10
D · Potential for more than minimal harm
2021-01-14
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 2021-02-10
D · Potential for more than minimal harm
2021-01-14
F755 · Pharmacy Service Deficiencies
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
What sits behind the stars
Ownership
Kraus, Abraham
5% Or Greater Indirect Ownership Interest · Individual
Sb Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Furtado, Susana
W-2 Managing Employee · Individual
Kraus, Abraham
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
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
#2
Shands Jacksonville Medical Center
Jacksonville, FL
5-star overall rating with 5-star inspections
#3
North Bank Center For Rehabilitation And Healing
Jacksonville, FL
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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