Cycle 1
Health 2024-12-05 · Fire 2024-12-05
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gainesville, FL
Magnolia Ridge Health And Rehabilitation Center
3-star overall rating with 3-star inspections with $5,678 in total fines with 6 recent health deficiencies
6517 Nw 39th Avenue, Gainesville, FL
(678) 592-3396
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
223
Certified beds
Average residents
197
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2022-03-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing
LPN hours / resident day
0.96
Licensed practical nurse staffing
Aide hours / resident day
2.00
Nurse aide staffing
Weekend hours
3.34
Weekend nurse staffing
RN turnover
59%
Annual RN turnover
Total nurse turnover
67%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.8%
1.8 pts better
|
93.4%
6.2 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 | 4.9% |
2.6%
2.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
3.7%
2.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.4% |
5.9%
2.5 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
15.7%
5.7 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
9.8%
6.1 pts better
|
16.7%
13 pts better
|
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 | 20.7% |
11.7%
9 pts worse
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
9.8%
7.8 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.4%
1.8 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
0.8%
0.7 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
12.5%
9.2 pts worse
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.1%
0.4 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
9.3%
0.8 pts worse
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.7% |
94.7%
About the same
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
26.2%
1.8 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-03-18 · Fire 2022-03-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-24
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 2023-09-22
E · Potential for more than minimal harm
2023-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-24
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 2023-09-22
D · Potential for more than minimal harm
2023-08-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-01
E · Potential for more than minimal harm
2024-12-05
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 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
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 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
F · Potential for more than minimal harm
2023-08-24
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 2023-10-02
E · Potential for more than minimal harm
2023-08-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
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 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
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 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
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 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-02
Penalties and ownership
What sits behind the stars
$5,678
2023-08-24
Fine
Fine · fine $5,678
Fine
Ownership
Charlotte R. Kellett Gst Trust
5% Or Greater Indirect Ownership Interest · Organization
Jnk Sbk Iii Gst Trust
5% Or Greater Indirect Ownership Interest · Organization
Margaret V Smith Gst Trust
5% Or Greater Indirect Ownership Interest · Organization
Andy Wilkes Retirement Trust
5% Or Greater Indirect Ownership Interest · Organization
Alachua 223, LLC
5% Or Greater Direct Ownership Interest · Organization
Alachua County Hrc, LLC
5% Or Greater Direct Ownership Interest · Organization
Awrt Alachua LLC
5% Or Greater Direct Ownership Interest · Organization
Branch Banking And Trust Company
5% Or Greater Mortgage Interest · Organization
Clear Choice Health Care LLC
Operational/Managerial Control · Organization
Crk Alachua LLC
5% Or Greater Direct Ownership Interest · Organization
Jnk Sbk Iii Alachua, LLC
5% Or Greater Direct Ownership Interest · Organization
Lp Designs LLC
5% Or Greater Direct Ownership Interest · Organization
Mvs Alachua, LLC
5% Or Greater Direct Ownership Interest · Organization
Partee, Leslie
Operational/Managerial Control · Individual
Partee, Leslie
Corporate Officer · Individual
Sbk LLC
Operational/Managerial Control · Organization
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