Cycle 1
Health 2024-11-15 · Fire 2024-11-15
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Jacksonville, FL
Westminster Woods On Julington Creek
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
25 State Road 13, Jacksonville, FL
(904) 287-7300
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Westminster Communities Of Florida
Operator or chain grouping
Approved since
1996-03-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 5 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
0.87
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,271
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.18
Composite VBP score used to determine payment impact.
Payment multiplier
1.0134
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.56
Baseline 19.40% · Performance 18.39% · Measure score 6.56 · Achievement 6.56 · Improvement 3.76
Healthcare-associated infections
3.93
Baseline 6.36% · Performance 6.66% · Measure score 3.93 · Achievement 3.93 · Improvement 0
Total nurse turnover
9.27
Baseline 57.81% · Performance 25.81% · Measure score 9.27 · Achievement 9.27 · Improvement 9
Adjusted total nurse staffing
3.52
Baseline 4.07 hours · Performance 4.08 hours · Measure score 3.52 · Achievement 3.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 7.6% · Lower 95% interval 7.1% |
| Discharge to community | 68.75% |
50.57%
18.2 pts better
|
Better than the National Rate · Eligible stays 156 · Observed rate 67.95% · Lower 95% interval 61.12% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.64% |
95.27%
1.6 pts worse
|
Numerator 103 · Denominator 110 |
| Falls with major injury | 0.91% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 110 |
| Discharge self-care score | 63.95% |
53.69%
10.3 pts better
|
Numerator 55 · Denominator 86 |
| Discharge mobility score | 61.63% |
50.94%
10.7 pts better
|
Numerator 53 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 110 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 4.72% · Lower 95% interval 3.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 96.6% |
42%
54.6 pts better
|
Numerator 227 · Denominator 235 |
| Discharge function score | 65.12% |
56.45%
8.7 pts better
|
Numerator 56 · Denominator 86 |
| Transfer of health information to provider | 97.14% |
95.95%
1.2 pts better
|
Numerator 34 · Denominator 35 |
| Transfer of health information to patient | 91.07% |
96.28%
5.2 pts worse
|
Numerator 51 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 17.86% |
25.2%
7.3 pts worse
|
Numerator 10 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.7 · Expected 1.1 · 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 | 4.0% |
2.6%
1.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.8% · Q3 4.7% · Q4 2.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
3.7%
0.4 pts worse
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.5% · Q3 4.9% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.9%
0.3 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 3.7% · Q3 10.3% · Q4 0.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
15.7%
1.8 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 14.3% · Q3 17.2% · Q4 10.3% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
9.8%
2.6 pts worse
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 13.6% · Q3 9.5% · Q4 8.7% · 4Q avg 12.4% · 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 | 18.4% |
11.7%
6.7 pts worse
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.9% |
9.8%
8.9 pts better
|
14.9%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.3% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.0% |
12.5%
5.5 pts better
|
19.8%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 12.2% · Q3 8.2% · Q4 0.0% · 4Q avg 7.0% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
5.1%
4.5 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
94.3%
1.9 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 97.6% · Q3 93.7% · Q4 98.8% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
9.3%
0.9 pts worse
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 8.8% · Expected 9.7% · 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 | 95.2% |
94.7%
0.5 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
26.2%
10 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 12.1% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-29 · Fire 2022-12-29
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-07-01 · Fire 2021-07-01
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2024-11-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-10
D · Potential for more than minimal harm
2022-12-29
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-01-25
D · Potential for more than minimal harm
2022-12-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-25
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Andre, Andy
Operational/Managerial Control · Individual
Doddridge, Donald
Corporate Director · Individual
Elramady, Dalia
Operational/Managerial Control · Individual
Faubel, Megan
Corporate Officer · Individual
Hennis, Garry
Corporate Officer · Individual
Keith, Henry
5% Or Greater Indirect Ownership Interest · Individual
Keith, Henry
Corporate Officer · Individual
Westminster Services Inc
5% Or Greater Indirect Ownership Interest · Organization
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