Cycle 1
Health 2024-12-19 · Fire 2024-12-19
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Jacksonville, FL
University Crossing
4-star overall rating with 4-star inspections with 2 recent health deficiencies
6210 Beach Blvd, Jacksonville, FL
(904) 345-8100
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
99
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
Hours and turnover
RN hours / resident day
1.08
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.52
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.13
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.73
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.60
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
5.31
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
5.86
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,202
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.04
Baseline 19.10% · Performance 20.48% · Measure score 2.04 · Achievement 2.04 · Improvement 0
Healthcare-associated infections
8.6
Baseline 2.81% · Performance 5.27% · Measure score 8.6 · Achievement 8.6 · Improvement 0
Total nurse turnover
5.01
Baseline 44.44% · Performance 43.18% · Measure score 5.01 · Achievement 5.01 · Improvement 0.14
Adjusted total nurse staffing
2.55
Baseline 4.10 hours · Performance 3.80 hours · Measure score 2.55 · Achievement 2.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.33% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 1230 · Observed rate 9.92% · Lower 95% interval 9.54% |
| Discharge to community | 64.95% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 1252 · Observed rate 63.82% · Lower 95% interval 62.47% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.83% |
95.27%
3.6 pts better
|
Numerator 505 · Denominator 511 |
| Falls with major injury | 0.59% |
0.77%
0.2 pts better
|
Numerator 3 · Denominator 511 |
| Discharge self-care score | 55.16% |
53.69%
1.5 pts better
|
Numerator 230 · Denominator 417 |
| Discharge mobility score | 61.39% |
50.94%
10.5 pts better
|
Numerator 256 · Denominator 417 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 12 · Denominator 511 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 5.26% |
7.12%
1.9 pts better
|
Better than the National Rate · Eligible stays 628 · Observed rate 3.82% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 0.6% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 166 |
| Staff flu vaccination coverage | 69.8% |
42%
27.8 pts better
|
Numerator 171 · Denominator 245 |
| Discharge function score | 55.88% |
56.45%
0.6 pts worse
|
Numerator 233 · Denominator 417 |
| Transfer of health information to provider | 92.81% |
95.95%
3.1 pts worse
|
Numerator 426 · Denominator 459 |
| Transfer of health information to patient | 91.89% |
96.28%
4.4 pts worse
|
Numerator 34 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 81.96% |
25.2%
56.8 pts better
|
Numerator 159 · Denominator 194 |
Quality measures
Resident outcomes and process scores
| 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 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
97.8%
8.9 pts worse
|
93.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 81.6% · Q3 89.4% · Q4 91.8% · 4Q avg 88.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.6% |
99.2%
14.6 pts worse
|
95.5%
10.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.6%
1 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 2.1% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
3.7%
3.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.9%
0.8 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 8.5% · Q3 9.1% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
15.7%
4.1 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 21.3% · Q3 21.7% · Q4 19.1% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
9.8%
2 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.1% · Q3 12.1% · Q4 9.7% · 4Q avg 7.8% · 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 | 27.3% |
11.7%
15.6 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.9% |
9.8%
10.1 pts worse
|
14.9%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 19.5% · Q3 22.2% · Q4 13.2% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.4%
0.9 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 1.6% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
0.8%
2.5 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.0% · Q3 2.2% · Q4 4.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
12.5%
13.2 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 17.8% · Q3 16.9% · Q4 43.6% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.1%
0.5 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.3% · Q3 7.1% · Q4 6.9% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
94.3%
5.1 pts worse
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.5% · Q2 88.8% · Q3 93.4% · Q4 91.0% · 4Q avg 89.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
9.3%
1.2 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 8.1% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.3% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.1% |
94.7%
19.6 pts worse
|
79.7%
4.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
26.2%
1.3 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 22.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-20 · Fire 2023-01-20
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-06-10 · Fire 2021-06-10
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2024-12-19
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 2025-01-17
D · Potential for more than minimal harm
2024-12-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-17
F · Potential for more than minimal harm
2023-01-20
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 2023-04-05
D · Potential for more than minimal harm
2021-06-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-06-10
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 2021-06-30
Penalties and ownership
What sits behind the stars
Ownership
Brooks Skilled Nursing, Inc.
5% Or Greater Direct Ownership Interest · Organization
Genesis Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Allen, Jennifer
Operational/Managerial Control · Individual
Baer, Douglas
Corporate Officer · Individual
Becht, Taylor
Operational/Managerial Control · Individual
Derienzo, Victor
Corporate Officer · Individual
Mann, Eric
Corporate Officer · Individual
Tabor, James
Corporate Officer · Individual
Xie, Chonglun
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Vivo Healthcare University
Jacksonville, FL
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Riverwood Center
Jacksonville, FL
2-star overall rating with 2-star inspections with $34,778 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Palm Garden Of Jacksonville
Jacksonville, FL
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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