Cycle 1
Health 2024-08-29 · Fire 2024-08-29
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orange Park, FL
Moosehaven
5-star overall rating with 5-star inspections
1701 Park Avenue, Orange Park, FL
(904) 278-1200
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-06-24
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
1.04
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.80
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.92
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
5.17
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
7.15
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1,123
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0148
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.80
Baseline 17.88% · Performance 18.74% · Measure score 5.80 · Achievement 5.80 · Improvement 0
Healthcare-associated infections
2.09
Baseline 5.69% · Performance 7.21% · Measure score 2.09 · Achievement 2.09 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Baseline 6.64 hours · Performance 6.47 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.03% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 3.49% · Lower 95% interval 5.42% |
| Discharge to community | 54.82% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 55.84% · Lower 95% interval 44.66% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 2.9% |
0.77%
2.1 pts worse
|
Numerator 2 · Denominator 69 |
| Discharge self-care score | 82.98% |
53.69%
29.3 pts better
|
Numerator 39 · Denominator 47 |
| Discharge mobility score | 74.47% |
50.94%
23.5 pts better
|
Numerator 35 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.74% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 6.25% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 6.13% |
8.2%
2.1 pts worse
|
Numerator 10 · Denominator 163 |
| Staff flu vaccination coverage | 38.64% |
42%
3.4 pts worse
|
Numerator 68 · Denominator 176 |
| Discharge function score | 78.72% |
56.45%
22.3 pts better
|
Numerator 37 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 12 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.8%
1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.5% · 4Q avg 98.8% |
| 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 | 7.0% |
2.6%
4.4 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.1% · Q3 9.5% · Q4 0.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
5.9%
4.7 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
15.7%
1.7 pts worse
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
9.8%
1.2 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · 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 | 12.3% |
11.7%
0.6 pts worse
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
9.8%
2.1 pts worse
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
0.4%
3.2 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 3.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.9% |
12.5%
2.4 pts worse
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 17.6% · Q4 17.0% · 4Q avg 14.9% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.1%
2.3 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.3% · Q3 5.1% · Q4 4.0% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.8% |
94.3%
17.5 pts worse
|
81.7%
4.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 88.6% · Q3 71.4% · Q4 51.4% · 4Q avg 76.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
9.3%
2.8 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 6.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.3% |
1.5%
3.8 pts worse
|
1.6%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.3% |
94.7%
20.4 pts worse
|
79.7%
5.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.7% |
26.2%
4.5 pts worse
|
23.9%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 28.4% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-01 · Fire 2022-09-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-02-25 · Fire 2021-02-25
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-02-25
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-03-25
D · Potential for more than minimal harm
2021-02-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-03-25
D · Potential for more than minimal harm
2021-02-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-03-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-01
F · Potential for more than minimal harm
2021-02-25
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-03-25
D · Potential for more than minimal harm
2021-02-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-03-25
D · Potential for more than minimal harm
2021-02-25
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 2021-03-25
D · Potential for more than minimal harm
2021-02-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2021-03-25
Penalties and ownership
What sits behind the stars
Ownership
Carroll, Tracy
Operational/Managerial Control · Individual
Emrey, Barbara
Operational/Managerial Control · Individual
Grooms, Susan
Operational/Managerial Control · Individual
Grooms, Susan
Corporate Director · Individual
Hamilton, Paul
Operational/Managerial Control · Individual
Hart, Scott
Operational/Managerial Control · Individual
Hart, Scott
Corporate Director · Individual
Jewell, Brenda
Operational/Managerial Control · Individual
Johnson, Karyn
Operational/Managerial Control · Individual
Johnson, Karyn
Corporate Director · Individual
Kern, Scott
Operational/Managerial Control · Individual
Kern, Scott
Corporate Director · Individual
Keyser, Lurty
Operational/Managerial Control · Individual
Masopost, Bruce
Operational/Managerial Control · Individual
Masopost, Bruce
Corporate Director · Individual
Mclaughlin, Susan
Operational/Managerial Control · Individual
Oneal, Dan
Operational/Managerial Control · Individual
Oneal, Dan
Corporate Director · Individual
Peterson, Kristin
Operational/Managerial Control · Individual
Peterson, Kristin
Corporate Director · Individual
Reiter, John
Operational/Managerial Control · Individual
Reiter, John
Corporate Director · Individual
Richards, Lee
Operational/Managerial Control · Individual
Seaton, Cristina
Operational/Managerial Control · Individual
Stephens, Michael
Operational/Managerial Control · Individual
Taylor, Helen
Operational/Managerial Control · Individual
Taylor, Helen
Corporate Director · Individual
Thomas, Kevin
Operational/Managerial Control · Individual
Thompson, William
Operational/Managerial Control · Individual
Thompson, William
Corporate Director · Individual
Tippins, William
Operational/Managerial Control · Individual
Treadwell, Terry
Operational/Managerial Control · Individual
Treadwell, Terry
Corporate Director · Individual
Nearby options
Other facilities in reach
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Oak View Health And Rehabilitation Center
Orange Park, FL
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Aviata At Orange Park
Orange Park, FL
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Vivo Healthcare Orange Park
Orange Park, FL
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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