Cycle 1
Health 2024-06-20 · Fire 2024-06-20
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Penney Farms, FL
Pavilion For Health Care, The
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3465 Caroline Blvd, Penney Farms, FL
(904) 297-9700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-12-27
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
0.77
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.42
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.60
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.79
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
5.12
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.65
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
0.91
CMS adjusted RN staffing hours
Adjusted total hours
6.84
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
838
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.11
Composite VBP score used to determine payment impact.
Payment multiplier
1.0179
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.97% · Performance 22.10% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.58
Baseline 6.76% · Performance 5.87% · Measure score 6.58 · Achievement 6.58 · Improvement 4.56
Total nurse turnover
10
Baseline 35.29% · Performance 23.53% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
8.66
Baseline 5.82 hours · Performance 5.54 hours · Measure score 8.66 · Achievement 8.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.23% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 108 · Observed rate 12.96% · Lower 95% interval 8.63% |
| Discharge to community | 58.81% |
50.57%
8.2 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 56.63% · Lower 95% interval 50.02% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.15% |
95.27%
2.9 pts better
|
Numerator 53 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 24 · Denominator 45 |
| Discharge mobility score | 51.11% |
50.94%
0.2 pts better
|
Numerator 23 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.87% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 1.67% · Lower 95% interval 2.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 25.3% |
42%
16.7 pts worse
|
Numerator 21 · Denominator 83 |
| Discharge function score | 57.78% |
56.45%
1.3 pts better
|
Numerator 26 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.32% |
96.28%
6 pts worse
|
Numerator 28 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 39.29% |
25.2%
14.1 pts better
|
Numerator 11 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
99.2%
1.7 pts worse
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
2.6%
0.2 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 2.9% · Q4 2.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
3.7%
1.5 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.9% · Q3 0.0% · Q4 3.3% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.9%
5.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
15.7%
7.1 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 11.5% · Q4 4.3% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
9.8%
1.8 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · 4Q avg 8.0% · 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 | 12.5% |
11.7%
0.8 pts worse
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
9.8%
6.3 pts worse
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.1% · Q4 13.0% · 4Q avg 16.1% · 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 | 2.3% |
0.8%
1.5 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 2.9% · Q4 3.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.6% |
12.5%
5.9 pts better
|
19.8%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 9.4% · Q3 11.1% · Q4 3.2% · 4Q avg 6.6% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.1%
0.8 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.6% · Q3 4.0% · Q4 3.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
94.3%
4.3 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
9.3%
3.8 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 11.1% · Expected 9.5% · 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 · Q1 0.0% · 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 | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
26.2%
2.4 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 20.0% · Expected 16.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-15 · Fire 2022-09-15
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-07 · Fire 2021-04-07
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-06-20
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 2024-07-10
D · Potential for more than minimal harm
2022-09-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-01
E · Potential for more than minimal harm
2021-04-07
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 2021-05-08
Penalties and ownership
What sits behind the stars
Ownership
Issa, Hani
Operational/Managerial Control · Individual
Mcgurer, Christie
Operational/Managerial Control · Individual
Scott, Teresa
Operational/Managerial Control · Individual
Scott, Teresa
Corporate Director · Individual
Scott, Teresa
Corporate Officer · Individual
Standley, Jamie
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
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3-star overall rating with 2-star inspections with $43,664 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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