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

Chain footprint

6 facilities

Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars

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

0.56

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.68

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.12

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.36

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.24

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.65

CMS adjusted RN staffing hours

Adjusted total hours

3.88

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

56%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,513

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.44

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

0

Baseline 7.93% · Performance 8.42% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.39

Baseline 77.33% · Performance 51.67% · Measure score 4.39 · Achievement 2.94 · Improvement 4.39

Adjusted total nurse staffing

2.64

Baseline 4.29 hours · Performance 3.83 hours · Measure score 2.64 · Achievement 2.64 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.14%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 47 · Observed rate 14.89% · Lower 95% interval 7.73%
Discharge to community	51.86%	50.57% 1.3 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 42.86% · Lower 95% interval 36.42%
Medicare spending per beneficiary	1.19	1.02 0.2 pts worse
Drug regimen review with follow-up	97.56%	95.27% 2.3 pts better	Numerator 40 · Denominator 41
Falls with major injury	2.44%	0.77% 1.7 pts worse	Numerator 1 · Denominator 41
Discharge self-care score	37.93%	53.69% 15.8 pts worse	Numerator 11 · Denominator 29
Discharge mobility score	31.03%	50.94% 19.9 pts worse	Numerator 9 · Denominator 29
Pressure ulcers or injuries, new or worsened	4.88%	2.29% 2.6 pts worse	Numerator 2 · Denominator 41 · Adjusted rate 3.15%
Healthcare-associated infections requiring hospitalization	8.42%	7.12% 1.3 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 5.15%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 85
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 95
Discharge function score	51.72%	56.45% 4.7 pts worse	Numerator 15 · Denominator 29
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.

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 · Adjusted 1.5 · Observed 1.3 · Expected 1.6 · Used in QM five-star
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 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star
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 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 96.2% · 4Q avg 98.6%
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 · 4Q avg 96.4%
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 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
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 · Q1 4.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6%
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 · Q1 5.9% · Q2 8.5% · Q3 2.1% · Q4 3.9% · 4Q avg 5.1%
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 · Q1 9.8% · Q2 6.4% · Q3 4.2% · Q4 3.8% · 4Q avg 6.1%
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 · Q1 14.3% · Q2 10.7% · Q3 4.0% · Q4 11.8% · 4Q avg 10.7% · 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	6.2%	11.7% 5.5 pts better	16.3% 10.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.0% · 4Q avg 6.2% · Used in QM five-star
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 · Q1 6.2% · Q2 4.8% · Q3 7.7% · Q4 8.5% · 4Q avg 6.8% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 1.9% · Q2 6.3% · Q3 6.3% · Q4 6.2% · 4Q avg 5.1%
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 · Q1 1.8% · Q2 2.0% · Q3 6.7% · Q4 4.3% · 4Q avg 3.7% · Used in QM five-star
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 · Q1 60.7% · Q2 86.1% · Q3 94.3% · Q4 97.6% · 4Q avg 86.5%
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 · Adjusted 9.7% · Observed 12.5% · Expected 14.4% · Used in QM five-star
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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · 4Q avg 84.6%
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 · Adjusted 24.0% · Observed 33.3% · Expected 33.1% · Used in QM five-star

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