3 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Pensacola, FL
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
8325 University Parkway, Pensacola, FL
(850) 898-8000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
90
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-03-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.99
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.89
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.20
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.78
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
7,096
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.56
Baseline 22.30% · Performance 21.21% · Measure score 1.56 · Achievement 0 · Improvement 1.56
Healthcare-associated infections
4.57
Baseline 5.40% · Performance 6.47% · Measure score 4.57 · Achievement 4.57 · Improvement 0
Total nurse turnover
4.68
Performance 44.55% · Measure score 4.68 · Achievement 4.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.50
Baseline 4.69 hours · Performance 3.50 hours · Measure score 1.50 · Achievement 1.50 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.4% |
10.72%
1.7 pts worse
|
Worse than the National Rate · Eligible stays 843 · Observed rate 12.22% · Lower 95% interval 10.81% |
| Discharge to community | 69.3% |
50.57%
18.7 pts better
|
Better than the National Rate · Eligible stays 840 · Observed rate 64.64% · Lower 95% interval 65.44% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.36% |
95.27%
4.1 pts better
|
Numerator 624 · Denominator 628 |
| Falls with major injury | 0.16% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 628 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 290 · Denominator 464 |
| Discharge mobility score | 51.72% |
50.94%
0.8 pts better
|
Numerator 240 · Denominator 464 |
| Pressure ulcers or injuries, new or worsened | 0.96% |
2.29%
1.3 pts better
|
Numerator 6 · Denominator 627 · Adjusted rate 1.06% |
| Healthcare-associated infections requiring hospitalization | 6.47% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 527 · Observed rate 5.69% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 213 |
| Staff flu vaccination coverage | 16.18% |
42%
25.8 pts worse
|
Numerator 50 · Denominator 309 |
| Discharge function score | 52.59% |
56.45%
3.9 pts worse
|
Numerator 244 · Denominator 464 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 203 · Denominator 203 |
| Transfer of health information to patient | 99.27% |
96.28%
3 pts better
|
Numerator 407 · Denominator 410 |
| Resident COVID-19 vaccinations up to date | 2.57% |
25.2%
22.6 pts worse
|
Numerator 8 · Denominator 311 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.3%
5.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.8% · Q2 99.6% · Q3 99.4% · Q4 99.4% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
9.3%
4.5 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.4% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.0% · Q3 1.7% · Q4 1.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
94.7%
4.9 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
26.2%
0.4 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 24.6% · Expected 22.1% · Used in QM five-star |
Survey summary
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-05-22
Fire Safety
Ensure that periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established.
Corrected 2022-09-25
Inspection history
Health
Post nurse staffing information every day.
Corrected 2025-04-11
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
Health
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Corrected 2025-04-18
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-24
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-25
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-09-25
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-25
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-09-25
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-09-25
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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