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
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
0.62
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.55
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,159
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.34% · Performance 23.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.08
Baseline 7.68% · Performance 6.02% · Measure score 6.08 · Achievement 6.08 · Improvement 5.69
Total nurse turnover
0
Performance 65.12% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.76
Baseline 5.18 hours · Performance 4.15 hours · Measure score 3.76 · Achievement 3.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 1004 · Observed rate 9.56% · Lower 95% interval 9.01% |
| Discharge to community | 57.37% |
50.57%
6.8 pts better
|
Better than the National Rate · Eligible stays 987 · Observed rate 52.08% · Lower 95% interval 53.88% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.24% |
95.27%
2 pts better
|
Numerator 600 · Denominator 617 |
| Falls with major injury | 1.13% |
0.77%
0.4 pts worse
|
Numerator 7 · Denominator 617 |
| Discharge self-care score | 58.29% |
53.69%
4.6 pts better
|
Numerator 232 · Denominator 398 |
| Discharge mobility score | 48.74% |
50.94%
2.2 pts worse
|
Numerator 194 · Denominator 398 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 6 · Denominator 617 · Adjusted rate 1% |
| Healthcare-associated infections requiring hospitalization | 6.02% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 625 · Observed rate 5.28% · Lower 95% interval 4.35% |
| Staff COVID-19 vaccination coverage | 20% |
8.2%
11.8 pts better
|
Numerator 53 · Denominator 265 |
| Staff flu vaccination coverage | 13.06% |
42%
28.9 pts worse
|
Numerator 35 · Denominator 268 |
| Discharge function score | 53.02% |
56.45%
3.4 pts worse
|
Numerator 211 · Denominator 398 |
| Transfer of health information to provider | 93.14% |
95.95%
2.8 pts worse
|
Numerator 326 · Denominator 350 |
| Transfer of health information to patient | 93.98% |
96.28%
2.3 pts worse
|
Numerator 156 · Denominator 166 |
| Resident COVID-19 vaccinations up to date | 1% |
25.2%
24.2 pts worse
|
Numerator 3 · Denominator 300 |
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 · Adjusted 1.9 · Observed 2.3 · Expected 2.4 · Used in QM five-star |
| 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 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| 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 · Q1 99.2% · Q2 99.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 4.9% |
2.6%
2.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.8% · Q3 4.1% · Q4 3.5% · 4Q avg 4.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.9% · Q3 1.7% · Q4 1.6% · 4Q avg 1.1% |
| 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 · Q1 2.8% · Q2 10.0% · Q3 14.8% · Q4 5.4% · 4Q avg 8.4% |
| 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 · Q1 10.1% · Q2 6.1% · Q3 13.3% · Q4 10.4% · 4Q avg 10.0% |
| 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 · Q1 5.5% · Q2 5.8% · Q3 2.5% · Q4 1.2% · 4Q avg 3.7% · 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 | 20.7% |
11.7%
9 pts worse
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 31.4% · Q3 6.5% · Q4 17.0% · 4Q avg 20.7% · Used in QM five-star |
| 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 · Q1 25.2% · Q2 21.4% · Q3 13.7% · Q4 10.7% · 4Q avg 17.6% · Used in QM five-star |
| 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 · Q1 3.3% · Q2 3.9% · Q3 1.1% · Q4 0.6% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 2.4% · Q2 1.5% · Q3 1.4% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| 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 · Q1 28.4% · Q2 33.3% · Q3 12.5% · Q4 14.7% · 4Q avg 21.7% |
| 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 · Q1 4.3% · Q2 7.1% · Q3 4.4% · Q4 3.2% · 4Q avg 4.7% · Used in QM five-star |
| 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 · Q1 98.7% · Q2 96.3% · Q3 98.2% · Q4 100.0% · 4Q avg 98.3% |
| 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 · Adjusted 10.1% · Observed 9.4% · Expected 10.5% · Used in QM five-star |
| 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 · Q1 2.4% · Q2 3.1% · Q3 1.6% · Q4 0.5% · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 94.7% |
| 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 · Adjusted 28.0% · Observed 26.0% · Expected 22.1% · Used in QM five-star |
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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