Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

VIVO HEALTHCARE UNIVERSITY

JACKSONVILLE, FL · 117 certified beds · Last Life Safety survey November 7, 2024

CMS Certification Number 105366 · first certified July 1980

Ownership

Operated by VIVO HEALTHCARE · For profit - Corporation

  • Ownership changed September 9, 2022 (change of ownership)from SOUTH JACKSONVILLE FL OPCO LLC
15
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
6
Inspection & testing records
Of the citations on file

Position within FL

15 citations — more than 88% of the 694 certified nursing homes in FL. Compared within FL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 14 citations; the earlier surveys in the window averaged 0.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (February 2026 to September 2026). Most FL facilities have been surveyed by December 2026. This facility’s last Life Safety survey was November 2024. Facilities in FL are typically surveyed 15–23 months after the last one (median 17), measured over 729 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Emergency preparedness

5 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in FL, and nationally. Surveyors differ markedly between states, so the FL figure is the meaningful one.

This facility15FL median7National median11
Citations on file over three years, compared
MeasureCitations
This facility15
Median facility in FL7
Median facility nationally11

Survey history

Citations at each Life Safety survey
02021-0512022-12142024-11
Citations at each Life Safety survey
Survey dateCitations
May 20, 20210
December 22, 20221
November 7, 202414

Most-cited tags

Most-cited tags at this facility
E-00061K-05211E-00421K-03241E-00391K-02311K-02111K-09211
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
E-0006Conduct risk assessment and an All-Hazards approach.12024-11-07
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.12024-11-07
E-0042Meet the requirements of an integrated health system.12024-11-07
K-0324Provide properly protected cooking facilities.12024-11-07
E-0039Conduct testing and exercise requirements.12024-11-07
K-0231Provide large enough exits.12024-11-07
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12024-11-07
K-0921Ensure that testing and maintenance of electrical equipment is performed.12022-12-22

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 5
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Egress Deficiencies 3
  • Smoke Deficiencies 2
  • Other 2
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies5
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies3
Smoke Deficiencies2
Miscellaneous Deficiencies1
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 7, 2024 — 14 citations

Citations issued on November 7, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (December 1, 2024)
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (December 1, 2024)
E-0025Create arrangements with other facilities to receive patients.Deficient, Provider has date of correction (December 1, 2024)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (December 1, 2024)
E-0042Meet the requirements of an integrated health system.Deficient, Provider has date of correction (December 1, 2024)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (December 1, 2024)
K-0222Add 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.Deficient, Provider has date of correction (December 1, 2024)
K-0231Provide large enough exits.Deficient, Provider has date of correction (December 1, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (December 1, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (December 1, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (December 1, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (December 1, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 1, 2024)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (December 1, 2024)

December 22, 2022 — 1 citation

Citations issued on December 22, 2022
TagWhat the surveyor checksStatus
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (January 27, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.