Cycle 1
Health 2024-10-04 · Fire 2024-10-04
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gainesville, FL
Terrace Healthcare & Rehabilitation Center
5-star overall rating with 4-star inspections with $13,674 in total fines with 4 recent health deficiencies
7207 Sw 24th Ave, Gainesville, FL
(352) 333-0600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
138
Certified beds
Average residents
131
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
2002-06-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
46 facilities
Chain averages 3 overall / 3 health / 3 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
0.36
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,466
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.53% · Performance 21.85% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.77% · Performance 10.52% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 71.35% · Performance 75.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.95
Baseline 3.65 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 13.74% · Lower 95% interval 8.54% |
| Discharge to community | 44.28% |
50.57%
6.3 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 36.05% · Lower 95% interval 36.97% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.54% |
95.27%
2.3 pts better
|
Numerator 317 · Denominator 325 |
| Falls with major injury | 0.62% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 325 |
| Discharge self-care score | 63.45% |
53.69%
9.8 pts better
|
Numerator 125 · Denominator 197 |
| Discharge mobility score | 64.97% |
50.94%
14 pts better
|
Numerator 128 · Denominator 197 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 13 · Denominator 325 · Adjusted rate 4.35% |
| Healthcare-associated infections requiring hospitalization | 10.52% |
7.12%
3.4 pts worse
|
Worse than the National Rate · Eligible stays 121 · Observed rate 14.88% · Lower 95% interval 7.18% |
| Staff COVID-19 vaccination coverage | 14.77% |
8.2%
6.6 pts better
|
Numerator 35 · Denominator 237 |
| Staff flu vaccination coverage | 13.66% |
42%
28.3 pts worse
|
Numerator 25 · Denominator 183 |
| Discharge function score | 59.9% |
56.45%
3.4 pts better
|
Numerator 118 · Denominator 197 |
| Transfer of health information to provider | 97.71% |
95.95%
1.8 pts better
|
Numerator 213 · Denominator 218 |
| Transfer of health information to patient | 83.33% |
96.28%
13 pts worse
|
Numerator 20 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 0.56% |
25.2%
24.6 pts worse
|
Numerator 1 · Denominator 177 |
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 2.5 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
97.8%
0.2 pts worse
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 95.5% · Q3 97.9% · Q4 99.0% · 4Q avg 97.6% |
| 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 3.4% · Q2 5.7% · Q3 6.3% · Q4 3.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.5% |
3.7%
7.8 pts worse
|
11.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 16.4% · Q3 13.3% · Q4 12.4% · 4Q avg 11.5% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.9%
3.4 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 2.4% · Q4 3.5% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.0% |
15.7%
12.7 pts better
|
19.6%
16.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.5% · Q3 1.2% · Q4 1.1% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.9% |
9.8%
4.9 pts better
|
16.7%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.3% · Q3 4.5% · Q4 5.6% · 4Q avg 4.9% · 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 | 5.0% |
11.7%
6.7 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.3% · Q3 6.4% · Q4 2.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
9.8%
5.5 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.6% · Q3 6.0% · Q4 1.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 | 1.1% |
12.5%
11.4 pts better
|
19.8%
18.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.0% · Q4 1.0% · 4Q avg 1.1% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.1%
0.6 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.7% · Q3 7.8% · Q4 4.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
94.3%
8.9 pts worse
|
81.7%
3.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.0% · Q2 85.6% · Q3 89.4% · Q4 85.2% · 4Q avg 85.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.5% |
9.3%
6.8 pts better
|
12.0%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.5% · Observed 2.9% · Expected 12.8% · 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 | 95.9% |
94.7%
1.2 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
26.2%
6.9 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 23.7% · Expected 29.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-07 · Fire 2023-06-07
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-01-21 · Fire 2022-01-21
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-06-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-04
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 2024-11-07
D · Potential for more than minimal harm
2024-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-04-26
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-05-27
E · Potential for more than minimal harm
2023-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-07
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 2023-07-25
E · Potential for more than minimal harm
2023-06-07
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 2023-07-25
D · Potential for more than minimal harm
2023-06-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-25
C · Minimal harm
2023-03-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-27
F · Potential for more than minimal harm
2022-01-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-02-25
F · Potential for more than minimal harm
2022-01-21
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 2022-02-25
D · Potential for more than minimal harm
2022-01-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-25
Penalties and ownership
What sits behind the stars
$13,674
2024-01-22
Fine
Fine · fine $13,674
Fine
Ownership
Terrace SNF Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Copper Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Fl Master Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Gold Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Mathurin, Lisena
W-2 Managing Employee · Individual
Shelby, Jack
Corporate Officer · Individual
Silver Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Palm Garden Of Gainesville
Gainesville, FL
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Aviata At North Florida
Gainesville, FL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $160,499 in total fines with 17 recent health deficiencies
#3
Plaza Health And Rehab
Gainesville, FL
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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