Cycle 1
Health 2024-10-31 · Fire 2024-10-31
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Jacksonville, FL
River Garden Hebrew Home For The Aged
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
11401 Old Saint Augustine Rd, Jacksonville, FL
(904) 260-1818
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
162
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
0.92
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.96
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.75
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.29
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.62
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
1.05
CMS adjusted RN staffing hours
Adjusted total hours
5.39
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,997
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9999
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.89% · Performance 25.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.02
Baseline 5.69% · Performance 6.93% · Measure score 3.02 · Achievement 3.02 · Improvement 0
Total nurse turnover
7.67
Baseline 42.05% · Performance 32.32% · Measure score 7.67 · Achievement 7.67 · Improvement 5.15
Adjusted total nurse staffing
7.91
Baseline 5.33 hours · Performance 5.33 hours · Measure score 7.91 · Achievement 7.91 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.87% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 973 · Observed rate 9.76% · Lower 95% interval 9.11% |
| Discharge to community | 59.44% |
50.57%
8.9 pts better
|
Better than the National Rate · Eligible stays 951 · Observed rate 56.36% · Lower 95% interval 56.64% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 520 · Denominator 530 |
| Falls with major injury | 0.19% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 530 |
| Discharge self-care score | 42.23% |
53.69%
11.5 pts worse
|
Numerator 182 · Denominator 431 |
| Discharge mobility score | 31.55% |
50.94%
19.4 pts worse
|
Numerator 136 · Denominator 431 |
| Pressure ulcers or injuries, new or worsened | 1.7% |
2.29%
0.6 pts better
|
Numerator 9 · Denominator 530 · Adjusted rate 1.92% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 547 · Observed rate 6.03% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 428 |
| Staff flu vaccination coverage | 90.43% |
42%
48.4 pts better
|
Numerator 340 · Denominator 376 |
| Discharge function score | 44.55% |
56.45%
11.9 pts worse
|
Numerator 192 · Denominator 431 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 351 · Denominator 351 |
| Transfer of health information to patient | 99.18% |
96.28%
2.9 pts better
|
Numerator 121 · Denominator 122 |
| Resident COVID-19 vaccinations up to date | 21.35% |
25.2%
3.8 pts worse
|
Numerator 57 · Denominator 267 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.8%
1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 98.5% · Q3 100.0% · Q4 99.3% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
2.6%
2 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.6% · Q3 4.9% · Q4 5.2% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
3.7%
2.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.9%
3.2 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 4.6% · Q3 3.9% · Q4 1.7% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
15.7%
0.8 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 19.3% · Q3 14.5% · Q4 13.9% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
9.8%
8.4 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 23.9% · Q3 15.7% · Q4 10.9% · 4Q avg 18.2% · 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 | 11.1% |
11.7%
0.6 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 18.1% · Q3 11.9% · Q4 4.5% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
9.8%
3.2 pts worse
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 19.6% · Q3 12.1% · Q4 8.9% · 4Q avg 13.0% · 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 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.9% |
12.5%
5.6 pts better
|
19.8%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 6.7% · Q3 10.7% · Q4 7.6% · 4Q avg 6.9% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.1%
1.9 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.1% · Q3 5.0% · Q4 1.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
94.3%
About the same
|
81.7%
12.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 92.0% · Q3 98.0% · Q4 100.0% · 4Q avg 94.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
9.3%
1.9 pts worse
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.4% · Q3 0.4% · Q4 0.4% · 4Q avg 0.5% · 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 | 29.9% |
26.2%
3.7 pts worse
|
23.9%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 26.3% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-07 · Fire 2022-12-07
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 2021-04-29 · Fire 2021-04-29
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-31
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-25
B · Minimal harm
2021-04-29
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-05-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-04-29
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 2021-05-29
D · Potential for more than minimal harm
2021-04-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-29
Penalties and ownership
What sits behind the stars
Ownership
Mentz, Bobbie Jo
Operational/Managerial Control · Individual
Mizrahi, Mauri
Corporate Officer · Individual
Mizrahi, Mauri
Contracted Managing Employee · Individual
River Garden Hebrew Home For The Aged
5% Or Greater Direct Ownership Interest · Organization
River Garden Hebrew Home For The Aged
Operational/Managerial Control · Organization
Sorna, Betty
Operational/Managerial Control · Individual
Sorna, Betty
Corporate Officer · Individual
Truist
5% Or Greater Mortgage Interest · Organization
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