Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avante Villa At Jacksonville Beach Inc during CMS and state inspections, most recent first.
Failure to Notify LTC Ombudsman of Transfers/Discharges: The facility did not document or provide required LTC Ombudsman notification for multiple residents who were discharged or transferred, including planned SNF discharges, a discharge home with skilled services, and hospital transfers. Records lacked CMS Form 3120 documentation or showed incomplete forms, and one LTC Ombudsman confirmed no transfer notice was received.
Failure to Provide Adequate Fingernail Care: Four residents were observed with elongated or jagged fingernails and brown matter under the nails, and several confirmed they had not received nail care and wanted it. Records showed cognitive impairment, dependence for personal hygiene, and diagnoses including ESRD, TBI, seizures, schizophrenia, bipolar disorder, and dementia. Staff interviews showed inconsistent timing for nail care, while the facility policy required residents unable to perform ADLs to receive necessary grooming and personal hygiene services.
Unsecured razors and hair shears were repeatedly found in a shared bathroom next to the sink in the room of two residents, including one with moderate cognitive impairment and one with severe cognitive impairment and wandering risk. Staff said sharp grooming items were not to be kept in resident rooms or shared bathrooms and should be stored in a locked supply closet or disposed of after use, while the DON stated the facility had no specific policy for handling or storing razors for independent residents.
Medication administration errors exceeded the allowed rate, with three errors in 26 opportunities. An LPN gave a resident one tablet of Divalproex Sodium 500 mg instead of the ordered two tablets, and another LPN gave a second resident one tablet of Trazadone HCL 50 mg instead of the ordered two tablets. The DON stated staff were expected to verify the right resident, medication, dose, time, frequency, and route, and the LTC pharmacy manual required verification of the correct medication, dose, route, date, time, and resident before administration.
Surveyors identified that several residents with feeding tubes had enteral feeding bags and water flush bags that were either undated or outdated, despite staff stating that the night shift was responsible for changing and dating all tube feeding equipment. Residents affected had complex medical conditions and physician orders for specific feeding and flush regimens, but the facility did not consistently follow protocols for equipment management.
A resident was found with over-the-counter medications, including Zyrtec and a nasal spray, left unsecured on the bedside table for over 21 hours after being brought in by a family member. The medications were accessible to other residents, and there were no physician orders, assessments, or care plan updates permitting self-administration. Facility staff confirmed that required protocols for self-medication were not followed.
The facility failed to administer respiratory services according to physician orders for five residents. Observations showed discrepancies in oxygen flow rates compared to orders, with some residents lacking documented orders. Staff interviews revealed a lack of training and awareness regarding correct oxygen settings, contributing to the issue.
The facility failed to maintain the dignity and privacy of two residents. One resident's catheter bag was left uncovered and visible, compromising his dignity. Another resident's personal medical information was displayed openly in her room, violating her privacy. Staff interviews revealed a lack of proactive measures to address these issues.
A resident was found with dirty, elongated nails, indicating a failure in the facility's care plan to maintain nail care. Despite the resident's need for assistance, there was no recent documentation of podiatry care or staff intervention. The facility's policy on maintaining residents' abilities in ADLs was not followed, leading to this deficiency.
The facility failed to maintain accurate clinical records for two residents. One resident with a tracheostomy had outdated documentation for oxygen equipment changes, while another resident's death notification was inconsistently documented. Attempts to clarify with the Medical Director were unsuccessful.
Failure to Notify LTC Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide transfer/discharge notification to the LTC Ombudsman's office prior to or as soon as was practicable for five residents reviewed for transfer or discharge. Resident #22 was admitted on 05/05/2026 and discharged on 05/07/2026 to another SNF, but the medical record contained no Nursing Home Transfer/Discharge Form (CMS Form 3120) and no evidence that the LTC Ombudsman was notified. Resident #90 was admitted on 04/27/2026 and discharged on 05/26/2026 to home with skilled home care services, but there was no evidence of CMS Form 3120 or LTC Ombudsman notification. Resident #156 was admitted on 01/20/2026 and discharged on 02/03/2026 to another SNF; a progress note documented that Social Services called the resident's wife and left a message, but there was no evidence of CMS Form 3120 or notification of the LTC Ombudsman. Resident #148 was admitted on 02/25/2026 and discharged on 03/22/2026 after transfer to the hospital, and the CMS Form 3120 provided was incomplete, with no explanation for the transfer and no indication of when the LTC Ombudsman was notified. There was also no evidence in the record that the Ombudsman's office received the form. Resident #16 was admitted on 2/18/2026 and had an unplanned transfer to an acute care hospital on 5/7/2026, with the CMS Form 3120 documenting transfer for evaluation, but the record contained no evidence that the LTC Ombudsman was notified or received a copy of the form; the LTC Ombudsman later confirmed no transfer notification had been received. The facility's policy stated that a copy of the notice must be sent to the local ombudsman council within 5 business days after signature, but the records reviewed did not show that this occurred for these residents.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for four residents who were observed with elongated fingernails, jagged edges, and brown matter under the nails. Resident #57 was seen resting in bed with elongated fingernails on the right hand and brown matter underneath them, and later the same day the condition remained unchanged. The resident confirmed he had not received fingernail care, desired it, and would not refuse it if offered. His record showed diagnoses including ESRD, epilepsy, and hospice services, with moderate cognitive impairment and substantial/maximal assistance needed for personal hygiene. Resident #72 was observed lying in bed with elongated fingernails on both hands and later confirmed he had not received fingernail care during the shift and wanted his nails trimmed. His record showed traumatic brain injury, severe cognitive impairment, and dependence on staff for personal hygiene. Resident #118 was observed with elongated fingernails and brown matter under them, and later the same findings were still present; he confirmed he had not received fingernail care during the shift. His record showed seizures, generalized muscle weakness, severe cognitive impairment, and no documented refusal of care. Resident #140 was observed resting in bed with jagged fingernails and brown matter under both hands. Her record showed diagnoses including schizophrenia, bipolar disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and she required substantial/maximal assistance with personal hygiene. Staff interviews indicated CNAs and licensed nurses were responsible for fingernail care, with one CNA stating it was provided weekly and an LPN stating it was provided every 15 days, while the facility policy required residents unable to perform ADLs to receive necessary grooming and personal hygiene services.
Unsecured razors and hair shears left in shared resident bathroom
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for two residents who shared a room. Resident #89 had a Quarterly MDS with a BIMS score of 12, indicating moderate cognitive impairment, and was independent with self-care, used a walker, and had no upper or lower extremity impairments. Resident #103 had diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety, and a Quarterly MDS BIMS score of 3, indicating severe cognitive impairment. Resident #103 was care planned for elopement risk/wandering and had a history of impaired safety awareness. During multiple observations, razors and hair shears were found in the shared bathroom in a lidless bin next to the sink in the room occupied by both residents. A razor and hair shears were observed on one occasion, and razors were observed again on later occasions in the same unsecured location. Staff interviews indicated that sharp items such as razors were not to be kept in resident rooms, especially not in bathrooms shared by roommates, and that hazardous grooming supplies were to be stored in a locked supply closet or disposed of after use. The DON stated the facility did not have a specific policy addressing how razors or sharps should be handled and stored for independent residents who did their own grooming.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5.0%, with 26 opportunities for error and three identified medication errors for an error rate of 11.0%. The errors involved two of nine residents observed during medication administration, including Resident #59 and Resident #135. On 5/28/2026 at 9:44 AM, an LPN prepared and administered Divalproex Sodium 500 mg, one tablet, to Resident #59, then confirmed in the eMAR that the resident should have received two tablets for a total of 1000 mg and also should have received Voltaren External Gel 1% topically twice daily. The LPN acknowledged responsibility for ensuring the right resident received the right medication, dose, time, frequency, and route. Later that day at 4:25 PM, another LPN prepared and administered Trazadone HCL 50 mg, one tablet, to Resident #135. After administration, the active physician's orders were reviewed in the eMAR, and the LPN confirmed the resident should have received two tablets of Trazadone HCL for a total of 100 mg. During an interview at 5:30 PM, the DON stated her expectation that nursing staff ensure medications are given to the right person at the right time, via the right route, at the right frequency, and for the right medication and dosage. The facility's LTC Pharmacy Services and Procedures Manual stated staff should verify each time a medication is administered that it is the correct medication, dose, route, date, time, and resident.
Failure to Properly Change and Date Enteral Feeding Equipment
Penalty
Summary
Surveyors found that the facility failed to adhere to professional standards of practice regarding the changing and dating of enteral feeding equipment for five out of eight residents reviewed for tube feeding. Observations revealed that several residents had enteral feeding bags and water flush bags that were either undated or outdated. For example, one resident's water flush bag was dated two days prior to the observation, and several other residents had undated water bags or feeding bags. Photographic evidence was obtained to document these findings. Medical records confirmed that these residents had physician orders for specific enteral feeding regimens and water flushes, but the required dating and timely changing of equipment was not consistently performed. Interviews with facility staff, including an LPN, RN, and the DON, indicated that the night shift was responsible for changing out all tube feedings, bags, and syringes, and that these items should be dated when placed. However, the presence of undated or outdated equipment during the survey indicated that this protocol was not being reliably followed. The residents involved had complex medical histories, including conditions such as hemiplegia, gastrostomy status, amyotrophic lateral sclerosis, and severe malnutrition, making adherence to enteral feeding protocols especially important.
Failure to Prevent Accident Hazards Due to Unsecured Medications at Bedside
Penalty
Summary
Facility staff failed to ensure a resident's environment was free from accident hazards when over-the-counter medications, specifically a bottle of Zyrtec and a nasal spray, were found on a resident's bedside table. The medications were brought in by the resident's son and remained accessible for approximately 21 hours across three shifts before being removed by staff. During this period, other residents could have accessed the medications. The resident, who was cognitively intact with a BIMS score of 15/15, acknowledged receiving the medications from her son and stated she was aware she was not supposed to have them. Record review revealed there were no physician orders for the nasal spray, no orders permitting self-administration of medications, and no assessment for self-administration documented in the resident's record. The resident's care plan did not address self-administration of medications. Interviews with LPNs confirmed that the facility's process requires physician approval, a nursing assessment, and care plan updates before a resident may self-administer medications, none of which were completed in this case. Staff also indicated that both the resident and her son had previously been educated not to bring medications into the facility.
Failure to Administer Respiratory Services According to Physician Orders
Penalty
Summary
The facility failed to ensure that respiratory services were administered according to physician orders for five residents receiving respiratory care. Observations and record reviews revealed discrepancies in the oxygen flow rates set on the concentrators compared to the physician's orders. For instance, Resident #96's oxygen concentrator was set at 2 liters per minute, but there was no documented physician order for oxygen in the resident's medical record. Similarly, Resident #106's oxygen was set at 2.5 liters per minute, while the physician's order specified 2 liters via trach collar. Resident #59's oxygen concentrator was also set at 2.5 liters per minute, but there was no current physician order for oxygen in the resident's medical record. The resident's care plan indicated the need for oxygen settings according to the medical doctor's order, but the facility failed to maintain accurate documentation. Additionally, Resident #105's oxygen concentrator was consistently set at 2 liters per minute, despite the physician's order for 3 liters per minute via nasal cannula for shortness of breath. Resident #90 was observed with varying oxygen flow rates between 1.5 and 3 liters per minute, while the physician's order specified a continuous flow of 2 liters per minute. Interviews with staff members revealed a lack of training and awareness regarding the correct oxygen settings, contributing to the discrepancies. The facility's policy on respiratory care was not adhered to, resulting in the failure to provide necessary respiratory care and services as ordered by physicians.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to protect the dignity of Resident #53 by not properly managing the visibility of his suprapubic catheter urine collection bag. Observations on multiple occasions revealed the urine collection bag was hanging on the bedrail and on the floor without a cover, in plain view from the room door. This lack of privacy was noted despite the resident having no cognitive impairment and being dependent on staff for mobility and toileting. Interviews with a CNA indicated that while he had received training on catheter care, he typically deferred the cleaning and dressing application to an LPN. For Resident #38, the facility did not ensure the confidentiality of personal medical information. Signage containing sensitive medical details was posted above the resident's bed, visible from the room door. This signage had been in place for at least two months, and staff interviews revealed uncertainty about who placed it there. The LPN interviewed suggested the family might have put up the signs and admitted to not addressing the issue with the family or seeking alternative communication methods. The signage was visible to anyone entering the room, compromising the resident's privacy.
Failure to Maintain Resident's Nail Care
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident did not experience a decline in their ability to maintain clean and neat fingernails and toenails. During an initial tour, a resident was observed with dirty, elongated, and thickened nails, despite expressing a need for assistance with nail care. The resident had previously communicated this need to a staff member, but could not recall the name of the staff member. The resident's care plan included interventions for nail care, such as checking nail length and trimming them on bath days, but these interventions were not documented as being followed. The resident's medical record indicated a history of chronic obstructive pulmonary disease, muscle weakness, and other conditions, with a moderately impaired mental status. Despite being independent in mobility, the resident required assistance with nail care, particularly for toenails, which were to be managed by podiatry. However, the last documented podiatry consult was dated several months prior, and there was no recent documentation of podiatry care or nursing notes related to nail care. Interviews with staff revealed a lack of awareness and documentation regarding the resident's nail care needs, with conflicting accounts of the resident's ability to perform self-care. The facility's policy on maintaining residents' abilities in activities of daily living was not adhered to, as evidenced by the lack of documentation and follow-up on the resident's nail care needs. The facility's procedures required daily assessments and appropriate treatment to maintain or improve residents' abilities in activities of daily living, including grooming. However, the resident's overgrown nails and the absence of recent podiatry consultations indicated that the care plan was not being effectively implemented, leading to the deficiency.
Deficiencies in Clinical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in documentation. For Resident 103, who has a tracheostomy and requires humidified oxygen, the facility did not properly document the timely change of the oxygen tubing and humidification bottle. Observations revealed that the date on the humidification bottle was outdated, and the Treatment Administration Record (TAR) showed incomplete documentation for the required weekly changes. This oversight occurred despite the resident's complex medical conditions, including Huntington's disease and dependence on supplemental oxygen. In the case of Resident 124, the facility's documentation was inconsistent regarding the notification of the resident's death. Although the Director of Nursing stated that the medical doctor was notified on the day of the resident's death, a witness statement indicated that the MD was notified immediately of the change in condition. Additionally, a progress note by the Medical Director, dated after the resident's death, inaccurately stated that the care plan was reviewed with the patient. Attempts to clarify this discrepancy with the Medical Director were unsuccessful, as phone calls were not answered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jacksonville Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Village | 3.4 mi | ★★★★★ | 0 | 0 |
| Vicar's Landing Nursing Home | 4.7 mi | ★★★★★ | 0 | 0 |
| Fleet Landing | 9.1 mi | ★★★★★ | 0 | 0 |
| Fountains Rehabilitation At Mill Cove | 9.4 mi | ★★★★★ | 23 | 0 |
| Regents Park Of Jacksonville | 9.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.