Cycle 1
Health 2024-08-15 · Fire 2024-08-15
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Jacksonville, FL
Terrace Of Jacksonville, The
5-star overall rating with 5-star inspections with 1 recent health deficiencies
10680 Old St Augustine Rd, Jacksonville, FL
(904) 268-4953
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
175
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-12-07
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
0.36
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.20
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
0.39
CMS adjusted RN staffing hours
Adjusted total hours
4.09
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,116
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.63
Baseline 21.55% · Performance 19.29% · Measure score 4.63 · Achievement 4.63 · Improvement 4.51
Healthcare-associated infections
4.91
Baseline 7.46% · Performance 6.37% · Measure score 4.91 · Achievement 4.91 · Improvement 3.95
Total nurse turnover
2.96
Baseline 70.71% · Performance 54.82% · Measure score 2.96 · Achievement 2.17 · Improvement 2.96
Adjusted total nurse staffing
2.43
Baseline 3.66 hours · Performance 3.77 hours · Measure score 2.43 · Achievement 2.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.97% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 12.88% · Lower 95% interval 8.61% |
| Discharge to community | 42.76% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 34.07% · Lower 95% interval 32.48% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.73% |
95.27%
3.5 pts better
|
Numerator 155 · Denominator 157 |
| Falls with major injury | 0.64% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 157 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 55 · Denominator 110 |
| Discharge mobility score | 53.64% |
50.94%
2.7 pts better
|
Numerator 59 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 3.18% |
2.29%
0.9 pts worse
|
Numerator 5 · Denominator 157 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 254 |
| Staff flu vaccination coverage | 44.44% |
42%
2.4 pts better
|
Numerator 208 · Denominator 468 |
| Discharge function score | 55.45% |
56.45%
1 pts worse
|
Numerator 61 · Denominator 110 |
| Transfer of health information to provider | 98.39% |
95.95%
2.4 pts better
|
Numerator 61 · Denominator 62 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 62.37% |
25.2%
37.2 pts better
|
Numerator 58 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · 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 | 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 | 1.0% |
2.6%
1.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.6% · Q3 0.6% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
3.7%
3.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 0.7% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.9%
3.3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.1% · Q3 2.4% · Q4 0.8% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.9% |
15.7%
22.2 pts worse
|
19.6%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.1% · Q2 41.5% · Q3 42.1% · Q4 25.8% · 4Q avg 37.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
9.8%
7.6 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 22.6% · Q3 11.7% · Q4 7.5% · 4Q avg 17.4% · 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 | 3.7% |
11.7%
8 pts better
|
16.3%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 1.8% · Q3 1.3% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.6% |
9.8%
7.2 pts better
|
14.9%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.6% · Q3 2.4% · Q4 1.7% · 4Q avg 2.6% · 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 | 0.0% |
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 | 6.6% |
12.5%
5.9 pts better
|
19.8%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 5.5% · Q3 4.6% · Q4 1.2% · 4Q avg 6.6% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.1%
2.2 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.5% · Q3 2.9% · Q4 1.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
94.3%
2.8 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 96.6% · Q3 99.2% · Q4 99.1% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
9.3%
3.4 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 6.8% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 1.9% · Q3 1.4% · Q4 1.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.7%
2.1 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
26.2%
5.6 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 23.9% · Expected 27.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-11 · Fire 2022-08-11
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-02-18 · Fire 2021-02-18
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-08
D · Potential for more than minimal harm
2024-05-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-06-14
D · Potential for more than minimal harm
2022-08-11
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 2022-08-15
D · Potential for more than minimal harm
2022-08-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-15
G · Actual harm
2021-02-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-03-18
G · Actual harm
2021-02-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-03-18
G · Actual harm
2021-02-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-03-18
F · Potential for more than minimal harm
2021-02-18
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 2021-03-18
F · Potential for more than minimal harm
2021-02-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-03-18
E · Potential for more than minimal harm
2021-02-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-03-18
D · Potential for more than minimal harm
2021-02-18
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 2021-03-18
D · Potential for more than minimal harm
2021-02-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-03-18
D · Potential for more than minimal harm
2021-02-18
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 2021-03-18
D · Potential for more than minimal harm
2021-02-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-03-18
D · Potential for more than minimal harm
2021-02-18
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 2021-03-18
D · Potential for more than minimal harm
2021-02-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-03-18
Penalties and ownership
What sits behind the stars
Ownership
Jv Ltc Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Wirtenberg, David
5% Or Greater Indirect Ownership Interest · Individual
Botanical Trust
5% Or Greater Direct Ownership Interest · Organization
Jv Ltc Holdings LLC
Operational/Managerial Control · Organization
Roth, Daniel
Operational/Managerial Control · Individual
Roth, Daniel
Corporate Officer · Individual
Wirtenberg, David
Operational/Managerial Control · Individual
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