Cycle 1
Health 2024-11-07 · Fire 2024-11-07
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Jacksonville, FL
Vivo Healthcare University
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
3648 University Blvd S, Jacksonville, FL
(904) 733-7440
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
117
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vivo Healthcare
Operator or chain grouping
Approved since
1980-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 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
0.41
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
2.10
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
79%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,347
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.16
Baseline 22.08% · Performance 20.23% · Measure score 3.16 · Achievement 2.59 · Improvement 3.16
Healthcare-associated infections
2.31
Baseline 6.43% · Performance 7.14% · Measure score 2.31 · Achievement 2.31 · Improvement 0
Total nurse turnover
0
Performance 72.63% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.38
Baseline 4.18 hours · Performance 3.47 hours · Measure score 1.38 · Achievement 1.38 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 14.1% · Lower 95% interval 7.93% |
| Discharge to community | 44.8% |
50.57%
5.8 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 31.91% · Lower 95% interval 30.68% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 84.95% |
95.27%
10.3 pts worse
|
Numerator 79 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 42.37% |
53.69%
11.3 pts worse
|
Numerator 25 · Denominator 59 |
| Discharge mobility score | 45.76% |
50.94%
5.2 pts worse
|
Numerator 27 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 1.08% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 93 · Adjusted rate 0.89% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 2.38% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 126 |
| Staff flu vaccination coverage | 4.58% |
42%
37.4 pts worse
|
Numerator 6 · Denominator 131 |
| Discharge function score | 55.93% |
56.45%
0.5 pts worse
|
Numerator 33 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.92% |
25.2%
23.3 pts worse
|
Numerator 1 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
97.8%
6.3 pts worse
|
93.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 90.0% · Q3 92.4% · Q4 94.3% · 4Q avg 91.5% |
| 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 | 1.2% |
2.6%
1.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.3% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
3.7%
0.7 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.1% · Q3 1.4% · Q4 3.9% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.9%
0.2 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 2.7% · Q3 7.1% · Q4 5.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
15.7%
2.2 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 9.5% · Q3 13.9% · Q4 18.5% · 4Q avg 13.5% |
| 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 9.8% · Q2 10.0% · Q3 7.1% · Q4 4.5% · 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 | 4.7% |
11.7%
7 pts better
|
16.3%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.8% · Q3 6.0% · Q4 2.6% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.8% |
9.8%
7 pts better
|
14.9%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.4% · Q3 1.4% · Q4 3.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.9% · 4Q avg 0.5% · 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 | 6.8% |
12.5%
5.7 pts better
|
19.8%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.5% · Q3 1.2% · Q4 12.1% · 4Q avg 6.8% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.1%
1.1 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.8% · Q3 3.9% · Q4 2.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
94.3%
0.1 pts worse
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 93.7% · Q3 93.6% · Q4 97.9% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
9.3%
2.3 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 7.5% · Expected 12.0% · 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 1.0% · Q2 1.1% · Q3 1.2% · 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 | 96.6% |
94.7%
1.9 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
26.2%
10.6 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 17.0% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-22 · Fire 2022-12-22
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-05-20 · Fire 2021-05-20
10 health deficiencies
Top issue: Quality of Life and Care (4 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
2024-11-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-11-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-01
D · Potential for more than minimal harm
2022-12-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-11-07
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 2024-12-10
D · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-08-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-14
E · Potential for more than minimal harm
2023-09-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-03-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-04-14
D · Potential for more than minimal harm
2022-12-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-27
E · Potential for more than minimal harm
2021-05-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-20
D · Potential for more than minimal harm
2021-05-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-20
D · Potential for more than minimal harm
2021-05-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-06-20
D · Potential for more than minimal harm
2021-05-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-06-20
D · Potential for more than minimal harm
2021-05-20
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 2021-06-20
D · Potential for more than minimal harm
2021-05-20
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 2021-06-20
Penalties and ownership
What sits behind the stars
Ownership
Jacksonville 3 University Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Jek Irrv Tr Ii
5% Or Greater Indirect Ownership Interest · Organization
Nmj Irrv Tr Ii
5% Or Greater Indirect Ownership Interest · Organization
Cukier, Brocha
5% Or Greater Indirect Ownership Interest · Individual
Cukier, Josef
5% Or Greater Indirect Ownership Interest · Individual
Ab Marbec Realty Group
5% Or Greater Indirect Ownership Interest · Organization
Gluck, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Jacobowitz, Judah
5% Or Greater Indirect Ownership Interest · Individual
Cukier, Brocha
5% Or Greater Mortgage Interest · Individual
Cukier, Josef
Operational/Managerial Control · Individual
Cukier, Josef
Corporate Officer · Individual
Friedland, Shalom
Operational/Managerial Control · Individual
Gluck, Benjamin
Operational/Managerial Control · Individual
Gluck, Benjamin
5% Or Greater Mortgage Interest · Individual
Jacksonville 3 Propco Holdings LLC
5% Or Greater Mortgage Interest · Organization
University Propco LLC
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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4-star overall rating with 4-star inspections with 2 recent health deficiencies
#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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