Jacksonville, FL

Pavilion At Jacksonville, The

5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

1771 Edgewood Ave W, Jacksonville, FL

(904) 766-7436

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

57

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Pavilion Group

Operator or chain grouping

Approved since

1993-08-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.56

Registered nurse staffing

LPN hours / resident day

0.68

Licensed practical nurse staffing

Aide hours / resident day

2.12

Nurse aide staffing

Weekend hours

3.15

Weekend nurse staffing

RN turnover

43%

Annual RN turnover

Total nurse turnover

56%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	2.1 0.6 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	1.2 0.8 pts worse	1.8 0.2 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.6%	97.8% 0.8 pts better	93.4% 5.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.4%	99.2% 2.8 pts worse	95.5% 0.9 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	0.5%	2.6% 2.1 pts better	3.3% 2.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	1.6%	3.7% 2.1 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	5.1%	5.9% 0.8 pts better	5.4% 0.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.1%	15.7% 9.6 pts better	19.6% 13.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	10.7%	9.8% 0.9 pts worse	16.7% 6 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	6.2%	11.7% 5.5 pts better	16.3% 10.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	6.8%	9.8% 3 pts better	14.9% 8.1 pts better	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	5.1%	12.5% 7.4 pts better	19.8% 14.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	3.7%	5.1% 1.4 pts better	5.1% 1.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	86.5%	94.3% 7.8 pts worse	81.7% 4.8 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	9.7%	9.3% 0.4 pts worse	12.0% 2.3 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	84.6%	94.7% 10.1 pts worse	79.7% 4.9 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.0%	26.2% 2.2 pts better	23.9% 0.1 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-02 · Fire 2024-05-02

3 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

5 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2022-05-12 · Fire 2022-05-12

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2020-10-29 · Fire 2020-10-29

0 health deficiencies

No concentrated health issue counts in this cycle.

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-05-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-31

E · Potential for more than minimal harm 2024-05-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-31

E · Potential for more than minimal harm 2024-05-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-02

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-02

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-05-31

E · Potential for more than minimal harm 2020-10-29

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2020-11-18

E · Potential for more than minimal harm 2020-10-29

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2020-11-18

E · Potential for more than minimal harm 2020-10-29

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2020-11-18

D · Potential for more than minimal harm 2020-10-29

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2020-11-18

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-05-02

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-02

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 2024-05-31

D · Potential for more than minimal harm 2024-05-02

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-02

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-05-31

F · Potential for more than minimal harm 2022-05-12

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 2022-06-05

D · Potential for more than minimal harm 2022-05-12