Vivo Healthcare University
3648 University Blvd S, Jacksonville, FL 32216 · For profit - Corporation · 117 certified beds · (904) 733-7440 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- nursing-staff turnover (69%) runs well above the national median (45%)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.0% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.5% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.4% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.2% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.0% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.2% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.1% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.6% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.3% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.7% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.44 | 2.13 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.28 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 69 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.8%CMS range 30.7–57.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.9–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 47.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 4.0–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 117 beds and averages 108.1 residents a day — about 92% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.34 on weekdays — 7% thinner on weekends. RN hours go from 0.56 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 69% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · F2024-11-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen. The facility failed to 1) Date mark open packages of croutons and tea bags, 2) Clean grease build-up inside and around the door area of the convection oven, 3) Clean grease and food substances from the inside door area and oven floor, 4) Clean grease and food debris from the oven tray, 5) Clean food debris stuck on and around the safety guard of the mixer, 6) Clean food debris stuck on the meat slicer, 7) Clean one of two microwaves located in the east unit nourishment room, 8) Clean the ice machine dispenser tray located in the west unit nourishment room, and 9) Address condensation build-up in the walk-in freezer. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good grooming and personal hygiene for two (Residents #48 and #19) of three residents reviewed for ADL care from a total survey sample of 46 residents. The findings include: 1. A review of Resident #48's medical record revealed an admission date of 09/01/23 with diagnoses including Type 2 diabetes mellitus (T2DM), acute chronic diastolic (congestive) hear failure, muscle weakness (generalized), pleural effusion, legal blindness, end stage renal disease (ESRD), hyperthyroidism, arteriosclerotic heart disease of native coronary artery, major depressive disorder, generalized anxiety disorder, and hypertension. On 11/05/24 at 10:20 AM, an observation was made of Resident #48's fingernails which were long with brown matter underneath. (photographic evidence obtained) On 11/07/24 at 8:56 AM, an observation was made of Resident #48's fingernails which remained long with brown matter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, interviews, and a review of facility policy, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #72) of one resident reviewed for accident hazards out of 46 residents in the total survey sample. Medicated ointments in plastic medication cups were left at the resident's bedside. Resident #72 had not been assessed for capability of self-administering/applying medicated ointments. No self-administration assessment was found in the record or provided by the facility during the survey. No care plan was located in the record indicating that the resident was capable of safely self-administering medications/medicated ointments. The findings include: On 11/04/24 at 10:43 AM, two medication cups were observed on the resident's bedside table. (photographic evidence obtained) An interview was conducted with the resident at the time of this observation, who reported that the cups contained her medications, which were the two creams she applied to both her hands for psoriasis.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, for one (Resident #34) of one resident reviewed for respiratory care, from a total survey sample of 46 residents. Resident #34 was not receiving oxygen at the flow rate ordered by her physician. The findings include: On 11/04/24 at 11:20 AM, Resident #34 was observed fully dressed sitting in her wheelchair inside her room wearing a nasal cannula with an oxygen tank on the back of her wheelchair. She reported receiving oxygen at a flow rate of 1.5 liters per minute (L/min) when she was in her wheelchair and 3.0 L/min when in bed and sleeping. Resident #34's oxygen concentrator located at bedside was observed to be set at 3.0 L/min. On 11/07/24 at 10:11 AM, Resident #34 was observed fully dressed in the main dining room sitting in her wheelchair wearing her nasal cannula with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, by failing to provide dermatology consults as ordered for one (Resident #4) of four sampled residents. The findings include: On 8/26/2024 at 11:44 am, Resident #4 was observed in her room with several areas of blotches (dark red in color) and scaly skin on the palm of her left hand. A blue plastic glove was covering her right hand. When questioned about her hands, Resident #4 stated, she had an unknown skin condition which affected both her hands. She stated that it was present upon her admission into the facility. She was getting a topical cream for it; however, she hadn't received it in some time. She did not know if it had been discontinued nor did she know the proper diagnosis. Resident #4 explained that the facility nurses had advised her that she needed to see a dermatologist,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-19 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, record review, and facility policy and procedure review, the facility failed to ensure the privacy and confidentiality of protected health information (PHI) for 15 of 15 residents receiving skilled therapy services, by posting a list of residents on the counter top of the East and [NAME] wing nurses' station, visible to other residents and guests. The findings include: On 09/19/2023 at 10:00 am, an observation of the nurse's station on the East Wing revealed a list of fifteen (15) resident names receiving therapy with their appointment times, wing, room, type, duration, and therapy provider taped down to the top of the counter. This information could be seen by residents and guests who were observed passing along the hallway. (Photographic evidence obtained) On 09/19/2023 at 10:23 AM, an observation of the nurse's station on the [NAME] Wing revealed a list of fifteen (15) resident names receiving therapy with their appointment times, wing, room, type, duration, and therapy provider taped down to the top of the counter. This information could be seen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to maintain and implement an infection prevention control program to provide a safe, sanitary and comfortable environment. The facility staff failed to ensure the proper use of protective equipment (PPE) in transmission base precaution (TBP)/COVID-19 isolation room for three (Residents #3, #7, and #6) of four sampled residents; and the facility failed to ensure all staff used proper hand hygiene in a TBP room/COVID-19 isolation room (rooms [ROOM NUMBERS]). Failure to adhere to infection control and prevention protocol increase the risk of transmitting communicable diseases and infection. The findings include: During a tour of the facility on 09/19/2023 at 12:30 PM, room [ROOM NUMBER] was observed to have a sign posted for droplet precautions and isolation instructing staff to cover their eyes, nose and mouth completely. (Photographic evidence obtained) The storage cart for PPE next to the room door in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #47) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, specifically, failure to apply physician-ordered, medicated cream/ointment to an ongoing rash. The findings include: On 12/19/22 at 11:50 a.m., Resident #47 was observed lying in bed, awake. She was scratching at her upper chest and both upper extremities. Her upper chest and both upper extremities were observed with a patchy, red rash. The rash was comprised of small red circles, some raised slightly and some flat. Some areas were observed open with scratch marks and some were intact. The resident stated the rash was related to nerves from her last roommate. She stated, It gets itchy and I think I'm supposed to have some kind of antibiotic cream but no one has put it on. On 12/20/22 at 9:15 a.m., Resident #47 was observed lying in bed, awake. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, medical record review, staff interviews, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. There were four errors and 33 opportunities for error, resulting in an error rate of 12.12% and involving two errors for Resident #50, one error for Resident #69, and one error for Resident #28. The findings include: On 12/21/22 at 4:20 p.m., Licensed Practical Nurse (LPN) F was observed preparing medications for Resident #50. One of the tablets (Bumex 2 mg (milligrams) was observed to fall onto the medication cart when popped out of the blister pack. LPN F was observed picking up the tablet with an ungloved hand and placing it in the medication cup with another tablet (Coreg 25 mg). LPN F was observed picking up the medication cup and then proceeded to walk toward the resident's room. He was stopped and asked if he was going to give the medication he had dropped and picked up with his ungloved hand to the resident. He stated, Yes, the cart is clean. If I dropped the pill on the floor, I would throw it away and get a new…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-05-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that two of 33 sampled residents, Residents #187 and #73, who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The findings include: 1. On 5/17/2021 at 1:44 pm, Resident #187 was observed in her room with nasal cannula present and an oxygen concentrator administering oxygen at .5 liters per minute. On 5/18/2021 at 10:45 am, Resident #187 was observed in her room sitting in a wheelchair with nasal cannula present. The the oxygen concentrator was administering oxygen at 1 liter per minute. Record review for Resident # 187 revealed that she was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus; dysphagia; unspecified dementia without behavioral disturbance; acute respiratory failure with hypoxia; essential hypertension; anxiety disorder; arteriosclerotic heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · Dcited before2021-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and medical record review, it was determined that the facility failed to ensure one of 33 sampled residents (Resident #59) received treatment and care in accordance with professional standards of practice for her skin rash and itching. The findings include: On 5/16/2021 at 3:10 pm, Resident #59 was observed in her room, rubbing under her chin and her arms. She voiced a complaint of constant itching. She stated staff tell her it is anxiety, but she doesn't think it is anxiety. A tube of Cortisone 10 cream which was observed to be almost empty was seen next to her bed. She lifted her shirt several times and it appeared red under her shirt area. She stated it itched on her arms, neck, and chest. On 05/18/21 at 8:30 AM, Resident #59 was observed sitting up in bed. She was lightly scratching her bilateral upper arms, not causing any scratches to appear. No rash was observed on her arms. She was asked if her skin was itchy. She replied, Yes, my arms, my chest, my…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure that residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections (UTI) for one resident (Resident #63) out of 3 residents with a Foley catheter in a total sample of 33 residents. The findings include: During the initial tour on 05/16/21 at 02:33 PM, Resident #63 was observed lying on the bed. The Foley catheter tubing had cloudy drainage. Another observation on 5/17/21 at 9:00 AM, revealed the resident lying on the bed facing the door. The catheter bag was in a privacy bag, but cloudy drainage was flowing through the tubing. Record review indicated that Resident #63 was admitted to the facility on [DATE]. Diagnoses included pneumonia, disease of stomach and duodenum, encounter for surgical aftercare following surgery on the digestive system, obstructive reflux uropathy, methicillin resistant staphylococcus aureus (MRSA), history of malignant neoplasm of prostate, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to ensure Pharmacist recommendations of gradual dose reductions were reviewed and acted upon by the resident's physician in a timely manner for one of five residents (Resident #54) reviewed for unnecessary medications from a sample of 33 residents. The findings include: During a record review of Resident #54's chart, the physician orders showed he was ordered Paxil for depression and Seroquel for a psychotic disorder. Resident #54's electronic record contained an assessment titled Medication Regimen Review dated 08/03/2020 which contained pharmacy recommendations for the Paxil. The Pharmacist recommended a change from 20 mg to 10 mg at that time. The associated progress note contained the same information, but neither included information that these recommendations were sent to a physician for review. A paper note from the resident's psychiatric APRN showed that on 09/01/2020, Resident #54 was on 25 mg of Seroquel twice a day and 20 mg of Paxil once a day. Page 3 of this note stated he was on a trial dose reduction of both…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Gradual Dose Reduction (GDR) recommendation was enacted in a timely manner for one of five residents reviewed for unnecessary medications (Resident #54) from a sample of 33 residents. The findings include: Record review for Resident #54 revealed physician orders for Paxil for depression and Seroquel for a psychotic disorder. On 5/19/2021 at 10:01 am Employee A, LPN, stated his Paxil was just adjusted on 5/18/2021 from 20 mg to 10 mg. Review of the physician orders in the electronic medical record confirmed the Paxil was changed from 20 mg to 10 mg on 5/18/2021. Until this change, he had been on Paxil 20mg since 02/14/2020. (Photographic evidence obtained) During a review of the assessment dated [DATE] within the electronic record titled Medication Regimen Review (MRR) for Resident #54, the Pharmacist recommended the Paxil be reduced to 10 mg (from 20 mg) as a trial gradual dose reduction (GDR). The facility also had paper recommendation forms…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure Schedule II-V medications were stored in a separately locked compartment, permitting only authorized personnel to have access. The findings include: On May 20, 2021 at 10:00 am, Employee E was asked to show the medication room where their Omni Cell Automated Medication Dispensing System (AMDS) was located. Employee E asked Employee D to show the surveyor where the AMDS was kept. Both Employees D and E escorted the surveyor to a room across from the Med-Bridge nurses station area which had a sign next to the door that said Doctors Lounge. The door to this room was open. It was observed that the door handle had a 5 digit push lock system. It was observed that the door latch was taped down with paper surgical tape in such a fashion that the latch would not engage with the door frame if closed. The AMDS was observed inside this room. Employee D was asked if this door was always kept open. She replied, To be honest, I've never seen this door closed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to VIVO HEALTHCARE — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.4 | +1.6 vs chain |
| Health inspection | 3 of 5 | 1.9 | +1.1 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 11 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| JACKSONVILLE 3 UNIVERSITY OPCO HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/09/2022 |
| KAGAN, JEFFREY | Individual | DIRECT OWNERSHIP INTEREST | — | since 09/09/2022 |
| AB MARBEC REALTY GROUP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 9% | since 09/09/2022 |
| JEK IRRV TR II | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 13% | since 09/09/2022 |
| NMJ IRRV TR II | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 13% | since 09/09/2022 |
| CUKIER, BROCHA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | 10% | since 09/09/2022 |
| GLUCK, BENJAMIN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 5% | since 09/09/2022 |
| JACOBOWITZ, JUDAH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 5% | since 09/09/2022 |
| JEK HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/09/2022 |
| NMJ HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/09/2022 |
| SF IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/09/2022 |
| JACKSONVILLE 3 PROPCO HOLDINGS LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 09/09/2022 |
| UNIVERSITY PROPCO LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 09/09/2022 |
| CUKIER, JOSEF | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/09/2022 |
| FRIEDLAND, SHALOM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/09/2022 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | — | since 09/09/2022 |
| PEASE BELL CPAS LLC | Organization | ADP OF THE SNF | — | since 09/09/2022 |
| SUMMATION FINANCIAL SERVICES LLC | Organization | ADP OF THE SNF | — | since 09/09/2022 |
| VIVO HEALTHCARE CONSULTING LLC | Organization | ADP OF THE SNF | — | since 09/09/2022 |
| BLATT, MARC | Individual | ADP OF THE SNF | — | since 12/02/2022 |
| MOORE, JAYNA | Individual | ADP OF THE SNF | — | since 09/03/2024 |
CMS files one row per role, so the 34 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.
13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105366. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.