Cycle 1
Health 2025-06-19 · Fire 2025-06-19
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Macclenny, FL
Macclenny Nursing And Rehab Center
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
755 S 5th St, Macclenny, FL
(904) 259-4873
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
120
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1991-07-11
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
0.52
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,198
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9903
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.58
Baseline 21.76% · Performance 17.94% · Measure score 7.58 · Achievement 7.54 · Improvement 7.58
Healthcare-associated infections
0
Baseline 7.61% · Performance 7.84% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.54
Baseline 71.53% · Performance 52.68% · Measure score 3.54 · Achievement 2.69 · Improvement 3.54
Adjusted total nurse staffing
3.70
Baseline 4.35 hours · Performance 4.13 hours · Measure score 3.70 · Achievement 3.70 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.25% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 11.83% · Lower 95% interval 8.36% |
| Discharge to community | 54.02% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 47.1% · Lower 95% interval 44.06% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 157 · Denominator 157 |
| Falls with major injury | 0.64% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 157 |
| Discharge self-care score | 69.16% |
53.69%
15.5 pts better
|
Numerator 74 · Denominator 107 |
| Discharge mobility score | 50.47% |
50.94%
0.5 pts worse
|
Numerator 54 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 0.64% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 157 · Adjusted rate 0.66% |
| Healthcare-associated infections requiring hospitalization | 7.84% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 8.33% · Lower 95% interval 5% |
| Staff COVID-19 vaccination coverage | 8.53% |
8.2%
0.3 pts better
|
Numerator 11 · Denominator 129 |
| Staff flu vaccination coverage | 37.11% |
42%
4.9 pts worse
|
Numerator 59 · Denominator 159 |
| Discharge function score | 69.16% |
56.45%
12.7 pts better
|
Numerator 74 · Denominator 107 |
| Transfer of health information to provider | 98.04% |
95.95%
2.1 pts better
|
Numerator 100 · Denominator 102 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.46% |
25.2%
15.7 pts worse
|
Numerator 7 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.4 · 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 | 2.7% |
2.6%
0.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.3% · Q3 2.2% · Q4 3.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
3.7%
1.8 pts worse
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.5% · Q3 7.7% · Q4 7.3% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.9%
2.9 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 4.0% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.2% |
15.7%
9.5 pts better
|
19.6%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.1% · Q3 9.1% · Q4 0.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
9.8%
2.9 pts worse
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 13.3% · Q3 12.8% · Q4 12.2% · 4Q avg 12.7% · 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 | 0.7% |
11.7%
11 pts better
|
16.3%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
9.8%
6.3 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.8% · Q3 3.8% · Q4 4.9% · 4Q avg 3.5% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.5% |
12.5%
2 pts better
|
19.8%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 12.8% · Q3 7.3% · Q4 2.1% · 4Q avg 10.5% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.1%
3.2 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 6.2% · 4Q avg 1.9% · 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 | 11.8% |
9.3%
2.5 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 13.0% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · 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 | 27.1% |
26.2%
0.9 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 28.0% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-10-21 · Fire 2021-10-21
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-19
E · Potential for more than minimal harm
2025-06-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-19
E · Potential for more than minimal harm
2025-06-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-19
D · Potential for more than minimal harm
2025-06-19
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 2025-07-19
D · Potential for more than minimal harm
2025-06-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-19
D · Potential for more than minimal harm
2023-08-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-10-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-11-26
D · Potential for more than minimal harm
2021-10-21
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 2021-11-26
D · Potential for more than minimal harm
2021-10-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-26
D · Potential for more than minimal harm
2021-10-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-11-26
D · Potential for more than minimal harm
2021-10-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-11-26
D · Potential for more than minimal harm
2021-10-21
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-11-26
Penalties and ownership
What sits behind the stars
Ownership
Berkadia Commercial Mortgage LLC
5% Or Greater Security Interest · Organization
Cronquist, Royce
Operational/Managerial Control · Individual
Fl Macclenny Holdings, LLC
5% Or Greater Security Interest · Organization
Health Services Properties LLC
5% Or Greater Security Interest · Organization
Kalmus, Gregory
Operational/Managerial Control · Individual
Mangine, John
Operational/Managerial Control · Individual
Melton, Donald
Operational/Managerial Control · Individual
Notermann, William
Operational/Managerial Control · Individual
Sharpe, Michael
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
W Frank Wells Nursing Home
Macclenny, FL
1-star overall rating with 1-star inspections with $26,320 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Vivo Healthcare Normandy
Jacksonville, FL
5-star overall rating with 4-star inspections with 9 fire-safety deficiencies in the latest cycle
#3
Fouraker Hills Rehab And Nursing Center
Jacksonville, FL
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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