Cycle 1
Health 2025-01-30 · Fire 2025-01-30
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Jacksonville, FL
Woodland Grove Healthcare & Rehabilitation Center
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
4325 Southpoint Boulevard, Jacksonville, FL
(904) 245-7620
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
120
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
2004-02-20
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
0.68
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.63
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,626
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.80% · Performance 21.85% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.98
Baseline 7.29% · Performance 6.94% · Measure score 2.98 · Achievement 2.98 · Improvement 1
Total nurse turnover
3.46
Baseline 53.92% · Performance 49.53% · Measure score 3.46 · Achievement 3.46 · Improvement 1.01
Adjusted total nurse staffing
1.45
Baseline 3.62 hours · Performance 3.49 hours · Measure score 1.45 · Achievement 1.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 11.63% · Lower 95% interval 7.04% |
| Discharge to community | 49.42% |
50.57%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 37.7% · Lower 95% interval 36.98% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.48% |
95.27%
0.2 pts better
|
Numerator 169 · Denominator 177 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 177 |
| Discharge self-care score | 33.61% |
53.69%
20.1 pts worse
|
Numerator 41 · Denominator 122 |
| Discharge mobility score | 40.98% |
50.94%
10 pts worse
|
Numerator 50 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 3.39% |
2.29%
1.1 pts worse
|
Numerator 6 · Denominator 177 · Adjusted rate 2.93% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 9.09% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 1.47% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 136 |
| Staff flu vaccination coverage | 36.3% |
42%
5.7 pts worse
|
Numerator 53 · Denominator 146 |
| Discharge function score | 40.16% |
56.45%
16.3 pts worse
|
Numerator 49 · Denominator 122 |
| Transfer of health information to provider | 98.04% |
95.95%
2.1 pts better
|
Numerator 50 · Denominator 51 |
| Transfer of health information to patient | 98.36% |
96.28%
2.1 pts better
|
Numerator 60 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 13.04% |
25.2%
12.2 pts worse
|
Numerator 12 · Denominator 92 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · 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 | 0.9% |
2.6%
1.7 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
3.7%
2.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.8% · Q4 1.2% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.9%
0.2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.6% · Q3 5.4% · Q4 8.1% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
15.7%
3.9 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 12.2% · Q3 12.0% · Q4 5.3% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
9.8%
3.6 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.9% · Q3 5.2% · Q4 4.5% · 4Q avg 6.2% · 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 | 8.7% |
11.7%
3 pts better
|
16.3%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 16.5% · Q3 12.9% · Q4 3.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
9.8%
5.6 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.1% · Q3 2.9% · Q4 1.5% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 4.1% |
12.5%
8.4 pts better
|
19.8%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.2% · Q3 2.4% · Q4 4.7% · 4Q avg 4.1% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.1%
0.6 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 5.5% · Q3 6.0% · Q4 4.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
94.3%
3.3 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 96.8% · Q3 97.5% · Q4 97.9% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
9.3%
4.4 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 5.3% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.6% · Q3 3.5% · Q4 2.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.7%
3.8 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
26.2%
6.1 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 23.7% · Expected 28.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
D · Potential for more than minimal harm
2023-03-16
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-03-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-16
E · Potential for more than minimal harm
2021-07-22
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 2021-08-20
D · Potential for more than minimal harm
2021-07-22
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 2021-08-20
Penalties and ownership
What sits behind the stars
Ownership
Woodland Grove 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
Shelby, Jack
Corporate Officer · Individual
Silver Fl Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Stover, Patricia
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Aviata At Jacksonville
Jacksonville, FL
3-star overall rating with 3-star inspections with $4,778 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Jacksonville
Jacksonville, FL
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#3
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
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