Jacksonville, FL

Lanier Rehabilitation Center

2-star overall rating with 2-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

12740 Lanier Road, Jacksonville, FL

(904) 757-0600

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

120

Certified beds

Average residents

100

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Sovereign Healthcare Holdings

Operator or chain grouping

Approved since

1989-10-01

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

0.73

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.71

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.20

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.64

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.26

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.45

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

0.78

CMS adjusted RN staffing hours

Adjusted total hours

3.85

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

58%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

60%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,381

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29.9

Composite VBP score used to determine payment impact.

Payment multiplier

0.9857

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

5.19

Baseline 7.73% · Performance 6.29% · Measure score 5.19 · Achievement 5.19 · Improvement 4.78

Total nurse turnover

1.91

Baseline 64.76% · Performance 55.88% · Measure score 1.91 · Achievement 1.91 · Improvement 1.72

Adjusted total nurse staffing

1.88

Baseline 4.06 hours · Performance 3.61 hours · Measure score 1.88 · Achievement 1.88 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.61%	10.72% 1.9 pts worse	No Different than the National Rate · Eligible stays 62 · Observed rate 24.19% · Lower 95% interval 9.13%
Discharge to community	40.17%	50.57% 10.4 pts worse	No Different than the National Rate · Eligible stays 50 · Observed rate 24% · Lower 95% interval 26.58%
Medicare spending per beneficiary	0.97	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 87 · Denominator 87
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 87
Discharge self-care score	47.5%	53.69% 6.2 pts worse	Numerator 19 · Denominator 40
Discharge mobility score	45%	50.94% 5.9 pts worse	Numerator 18 · Denominator 40
Pressure ulcers or injuries, new or worsened	4.6%	2.29% 2.3 pts worse	Numerator 4 · Denominator 87 · Adjusted rate 3.93%
Healthcare-associated infections requiring hospitalization	6.29%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 2.94%
Staff COVID-19 vaccination coverage	1.28%	8.2% 6.9 pts worse	Numerator 2 · Denominator 156
Staff flu vaccination coverage	27.37%	42% 14.6 pts worse	Numerator 49 · Denominator 179
Discharge function score	52.5%	56.45% 4 pts worse	Numerator 21 · Denominator 40
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 48 · Denominator 48
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	21.05%	25.2% 4.1 pts worse	Numerator 12 · Denominator 57

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.1	2.1 About the same	1.9 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	1.2 0.3 pts worse	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · 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	3.8%	2.6% 1.2 pts worse	3.3% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.3% · Q3 3.2% · Q4 3.3% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.5%	3.7% 1.2 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 4.7% · Q4 1.2% · 4Q avg 2.5%
Percentage of long-stay residents who lose too much weight	1.3%	5.9% 4.6 pts better	5.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	2.0%	15.7% 13.7 pts better	19.6% 17.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 5.6% · Q4 0.0% · 4Q avg 2.0%
Percentage of long-stay residents who received an antipsychotic medication	14.1%	9.8% 4.3 pts worse	16.7% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 15.5% · Q3 10.8% · Q4 11.8% · 4Q avg 14.1% · 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	1.6%	11.7% 10.1 pts better	16.3% 14.7 pts better	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	0.7%	9.8% 9.1 pts better	14.9% 14.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · 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	1.4%	12.5% 11.1 pts better	19.8% 18.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.3% · Q3 0.0% · Q4 1.0% · 4Q avg 1.4%
Percentage of long-stay residents with pressure ulcers	2.9%	5.1% 2.2 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.1% · Q3 1.4% · Q4 1.2% · 4Q avg 2.9% · 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	12.5%	9.3% 3.2 pts worse	12.0% 0.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.1% · Expected 10.8% · 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	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	37.7%	26.2% 11.5 pts worse	23.9% 13.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 37.7% · Observed 39.4% · Expected 24.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-20 · Fire 2025-02-20

6 health deficiencies

Top issue: Administration (1 deficiency)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-04-06 · Fire 2023-04-06

2 health deficiencies

Top issue: Resident Rights (2 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2021-08-12 · Fire 2021-08-12

3 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-20

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

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 2025-03-20

D · Potential for more than minimal harm 2023-04-06

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-05-06

D · Potential for more than minimal harm 2023-04-06

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-05-06

D · Potential for more than minimal harm 2023-04-06

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-05-06

F · Potential for more than minimal harm 2021-08-12

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2021-09-11

F · Potential for more than minimal harm 2021-08-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2021-09-11

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-02-20

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 2025-03-20

F · Potential for more than minimal harm 2025-02-20

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-03-20

F · Potential for more than minimal harm 2025-02-20

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-03-20

E · Potential for more than minimal harm 2025-02-20

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

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 2025-03-20

D · Potential for more than minimal harm 2025-02-20

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 2025-03-20

E · Potential for more than minimal harm 2023-04-06

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2023-05-06

E · Potential for more than minimal harm 2023-04-06

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 2023-05-06

D · Potential for more than minimal harm 2021-08-12

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-09-11

D · Potential for more than minimal harm 2021-08-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2021-09-11

D · Potential for more than minimal harm 2021-08-12

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2021-09-11

Penalties and ownership