1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Jacksonville, FL
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
6535 Chester Avenue, Jacksonville, FL
(904) 731-8230
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
81
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-07-01
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
RN hours / resident day
0.56
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
6,445
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.84% · Performance 22.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.11
Baseline 9.00% · Performance 6.75% · Measure score 5.11 · Achievement 3.61 · Improvement 5.11
Total nurse turnover
4.40
Performance 45.68% · Measure score 4.40 · Achievement 4.40 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.62
Baseline 4.08 hours · Performance 4.11 hours · Measure score 3.62 · Achievement 3.62 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 9.28% · Lower 95% interval 7.13% |
| Discharge to community | 32.02% |
50.57%
18.5 pts worse
|
Worse than the National Rate · Eligible stays 66 · Observed rate 22.73% · Lower 95% interval 25.44% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 60.47% |
53.69%
6.8 pts better
|
Numerator 26 · Denominator 43 |
| Discharge mobility score | 37.21% |
50.94%
13.7 pts worse
|
Numerator 16 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 59 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 5.88% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 4.63% |
8.2%
3.6 pts worse
|
Numerator 5 · Denominator 108 |
| Staff flu vaccination coverage | 17.04% |
42%
25 pts worse
|
Numerator 23 · Denominator 135 |
| Discharge function score | 62.79% |
56.45%
6.3 pts better
|
Numerator 27 · Denominator 43 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.79% |
25.2%
11.4 pts worse
|
Numerator 4 · Denominator 29 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
97.8%
0.2 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 98.3% · Q3 100.0% · Q4 96.8% · 4Q avg 98.0% |
| 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 | 3.1% |
2.6%
0.5 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 5.0% · Q3 4.5% · Q4 1.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 5.5% |
5.9%
0.4 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.7% · Q3 6.4% · Q4 6.5% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.0% |
15.7%
23.3 pts worse
|
19.6%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 40.0% · Q3 39.6% · Q4 39.1% · 4Q avg 39.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
9.8%
9.8 pts worse
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 29.0% · Q3 16.2% · Q4 11.1% · 4Q avg 19.6% · 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 | 8.8% |
11.7%
2.9 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 7.9% · Q4 10.7% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
9.8%
1 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 6.8% · Q3 8.9% · Q4 2.2% · 4Q avg 8.8% · 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 | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.5% |
12.5%
2 pts better
|
19.8%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.4% · Q3 12.5% · Q4 9.6% · 4Q avg 10.5% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.1%
4 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
94.3%
1.5 pts worse
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 95.9% · Q3 89.8% · Q4 90.9% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
9.3%
3 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 12.0% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 | 23.2% |
26.2%
3 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 26.0% · Expected 26.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-31
Inspection history
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-31
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-23
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-23
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-16
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-01-16
Penalties and ownership
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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