Cycle 1
Health 2024-10-08 · Fire 2024-10-08
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fleming Island, FL
Pruitthealth - Fleming Island
1-star overall rating with 1-star inspections with $16,153 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2040 Town Center Blvd, Fleming Island, FL
(904) 293-1311
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pruitthealth
Operator or chain grouping
Approved since
2019-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
95 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.85
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.13
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
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
48%
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
6,942
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.61
Baseline 22.71% · Performance 20.94% · Measure score 2.61 · Achievement 1.05 · Improvement 2.61
Healthcare-associated infections
2.57
Baseline 6.11% · Performance 7.07% · Measure score 2.57 · Achievement 2.57 · Improvement 0
Total nurse turnover
4.39
Baseline 58.33% · Performance 45.75% · Measure score 4.39 · Achievement 4.39 · Improvement 3.26
Adjusted total nurse staffing
2.94
Baseline 4.56 hours · Performance 3.92 hours · Measure score 2.94 · Achievement 2.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 16.47% |
10.72%
5.7 pts worse
|
Worse than the National Rate · Eligible stays 469 · Observed rate 18.76% · Lower 95% interval 13.4% |
| Discharge to community | 66.45% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 383 · Observed rate 61.62% · Lower 95% interval 61.34% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.36% |
95.27%
4.1 pts better
|
Numerator 309 · Denominator 311 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 3 · Denominator 311 |
| Discharge self-care score | 52.59% |
53.69%
1.1 pts worse
|
Numerator 122 · Denominator 232 |
| Discharge mobility score | 42.24% |
50.94%
8.7 pts worse
|
Numerator 98 · Denominator 232 |
| Pressure ulcers or injuries, new or worsened | 1.29% |
2.29%
1 pts better
|
Numerator 4 · Denominator 310 · Adjusted rate 1.18% |
| Healthcare-associated infections requiring hospitalization | 7.07% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 270 · Observed rate 6.67% · Lower 95% interval 4.79% |
| Staff COVID-19 vaccination coverage | 6.92% |
8.2%
1.3 pts worse
|
Numerator 9 · Denominator 130 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 55.17% |
56.45%
1.3 pts worse
|
Numerator 128 · Denominator 232 |
| Transfer of health information to provider | 99.54% |
95.95%
3.6 pts better
|
Numerator 218 · Denominator 219 |
| Transfer of health information to patient | 86% |
96.28%
10.3 pts worse
|
Numerator 43 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 12.09% |
25.2%
13.1 pts worse
|
Numerator 22 · Denominator 182 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
97.8%
1.3 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
99.2%
2.5 pts worse
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
2.6%
3.8 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.3% · Q3 5.7% · Q4 3.7% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.2% |
3.7%
10.5 pts worse
|
11.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 8.5% · Q3 21.7% · Q4 19.1% · 4Q avg 14.2% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.9%
2.1 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.2% · Q3 0.0% · Q4 4.8% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.8% |
15.7%
14.1 pts worse
|
19.6%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 29.2% · Q3 28.3% · Q4 32.6% · 4Q avg 29.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
9.8%
3.2 pts worse
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 12.5% · Q3 17.6% · Q4 15.2% · 4Q avg 13.0% · 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 | 14.4% |
11.7%
2.7 pts worse
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
9.8%
7.7 pts worse
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 10.9% · Q3 20.0% · Q4 12.5% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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 1.8% · Q2 3.6% · Q3 1.9% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
12.5%
9.8 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 24.1% · Q3 29.2% · Q4 11.1% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.1%
1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 2.1% · Q3 3.4% · Q4 3.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
94.3%
1.7 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 94.0% · Q3 96.0% · Q4 96.8% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
9.3%
2.4 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 11.2% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.2% · Q3 0.6% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
94.7%
2.8 pts worse
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
26.2%
0.9 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 25.2% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-14 · Fire 2022-12-14
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-05-13 · Fire 2021-05-13
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-08
F · Potential for more than minimal harm
2021-05-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-06-13
F · Potential for more than minimal harm
2021-05-13
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-06-13
F · Potential for more than minimal harm
2021-05-13
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-06-13
F · Potential for more than minimal harm
2021-05-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-06-13
Inspection history
Recent health citations
J · Immediate jeopardy
2025-06-13
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-07-17
J · Immediate jeopardy
2025-06-13
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-07-10
J · Immediate jeopardy
2025-06-13
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-10
D · Potential for more than minimal harm
2024-10-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-08
F · Potential for more than minimal harm
2021-05-13
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 2021-06-13
F · Potential for more than minimal harm
2021-05-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-06-13
D · Potential for more than minimal harm
2021-05-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-13
D · Potential for more than minimal harm
2021-05-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-06-13
D · Potential for more than minimal harm
2021-05-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-06-13
D · Potential for more than minimal harm
2021-05-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-06-13
Penalties and ownership
What sits behind the stars
$5,384
2025-06-13
Fine
Fine · fine $5,384
Fine
$5,384
2025-06-13
Fine
Fine · fine $5,384
Fine
$5,385
2025-06-13
Fine
Fine · fine $5,385
Fine
Ownership
United Health Services Of Florida, Inc
5% Or Greater Direct Ownership Interest · Organization
Clay Healthcare Properties, Inc
5% Or Greater Indirect Ownership Interest · Organization
J Paige Pruitt Trust
5% Or Greater Indirect Ownership Interest · Organization
Lisa P Hamby Trust
5% Or Greater Indirect Ownership Interest · Organization
Neil L Pruitt Jr Trust
5% Or Greater Indirect Ownership Interest · Organization
Nwp 2020 Chile Trust Fbo Neil L Pruitt Jr
5% Or Greater Indirect Ownership Interest · Organization
Odonnell, Connie
Operational/Managerial Control · Individual
Pruitt, Nancy
Corporate Officer · Individual
Pruitt, Neil
Corporate Officer · Individual
Samara, David
Operational/Managerial Control · Individual
Small, Philip
Corporate Director · Individual
Uhs-Pruitt Holdings, Inc.
5% Or Greater Indirect Ownership Interest · Organization
United Health Services Inc
5% Or Greater Indirect Ownership Interest · Organization
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#3
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