Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At San Jose during CMS and state inspections, most recent first.
A resident with HF, CAD, cardiomyopathy, arrhythmia, and an implantable defibrillator had physician orders for Carvedilol and Isosorbide Dinitrate that included specific SBP hold parameters. Review of the MAR and orders showed that multiple nurses administered these medications several times when the resident’s SBP was below the ordered threshold, despite care plan directions to monitor vital signs and the facility policy requiring review and clarification of physician orders when uncertain. The DON confirmed that these doses were given outside the ordered parameters and that staff are expected to follow the 6 rights of medication administration and adhere to provider orders.
The facility did not ensure that residents with mental disorders or intellectual disabilities received complete and timely PASRR assessments, resulting in incomplete, missing, or unsigned documentation for several individuals with significant psychiatric diagnoses and treatment histories.
A resident with multiple chronic health issues and incontinence reported a significant delay in staff response and inadequate care during a bowel movement. Despite expressing her intent to file a grievance to the SSA, no grievance was documented or investigated, and the resident received no updates, in violation of facility policy requiring prompt grievance handling and communication.
Surveyors found that two residents were exposed to accident hazards: one had multiple medications, including narcotics, left unattended at the bedside without a physician order or care plan for self-administration, while another resident with severe cognitive impairment and on anticoagulants had several razors stored in their room. Staff interviews confirmed that these practices were not in line with facility procedures, and there was a lack of specific policy guidance or implementation regarding the safe storage of medications and razors.
A resident receiving enteral nutrition was administered tube feeding at a rate lower than the physician-ordered 45 ml/hour, with the feeding bottle also lacking proper resident identification and being incorrectly labeled. Staff interviews and policy review confirmed that the facility's procedures were not followed, resulting in a failure to provide care as ordered for a resident with a history of malnutrition and feeding difficulties.
Two residents with respiratory conditions did not receive oxygen therapy at the flow rates ordered by their physicians, with one receiving 3.5 L/min instead of 5 L/min and another receiving 3 L/min instead of 4 L/min. Staff interviews revealed uncertainty about monitoring responsibilities, and facility policy required adherence to physician-specified flow rates.
Two residents experienced significant delays in receiving assistance with daily care needs, including transfers and incontinence care, due to insufficient nursing staff and inconsistent response to call lights. One resident, dependent on staff for all mobility and care, was left in bed for hours despite repeated requests for help, while another waited over an hour for a brief change. Staff and administrative interviews, along with payroll records, confirmed ongoing staffing shortages and low weekend coverage, impacting the facility's ability to meet resident needs.
The facility did not ensure that monthly medication regimen reviews were completed by a licensed pharmacist for two residents, and failed to implement a pharmacist's recommendation for medication changes that was agreed upon by a physician. One resident's medication review recommendations were not acted upon, while another resident did not have evidence of monthly reviews for several months, contrary to facility policy.
Failure to Follow BP Hold Parameters for Heart Failure Medications
Penalty
Summary
Surveyors identified a deficiency in medication management when nursing staff failed to follow physician-ordered parameters for heart failure medications for Resident #1. The resident was admitted with diagnoses including unspecified systolic (congestive) heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified cardiac arrhythmia, other cardiomyopathies, and the presence of an automatic implantable cardiac defibrillator. A 5-day MDS showed the resident was cognitively intact with a BIMS score of 14/15 and required substantial assistance with toileting/transfers, as well as dialysis and IV access. The care plan included a focus on altered cardiovascular status related to hypertension, coronary artery disease, heart failure, and history of pulmonary embolism, with an intervention to monitor vital signs as ordered and notify the MD of significant abnormalities. Review of physician orders and the January MAR revealed multiple instances where ordered blood pressure (BP) hold parameters were not followed. For Carvedilol 6.25 mg twice daily, ordered to be held for SBP less than 115 and/or heart rate less than 60, staff administered doses when the resident’s SBP was below 115 on four occasions (114/58, 102/72, 110/60, and 112/70). For Isosorbide Dinitrate 20 mg three times daily, ordered to be held for SBP less than 115, staff administered the medication five times when SBP was below 115 (110/71, 114/58, 102/72, 110/60, and 114/72), and once under a revised schedule (three times daily on specified days) when SBP was 112/70. On one occasion, a BP of 92/54 was documented and the medication was held. During interview, the DON confirmed that these administrations were outside the physician-ordered parameters and stated her expectation that licensed nurses adhere to the six rights of medication administration and follow physician orders, consistent with the facility’s oral medication administration policy requiring review of physician orders and verification of the MAR/EMAR when there are uncertainties.
Failure to Complete and Document PASRR Screenings for Residents with Mental Disorders or Intellectual Disabilities
Penalty
Summary
The facility failed to ensure that residents with mental disorders or intellectual disabilities were appropriately assessed through the Preadmission Screening and Resident Review (PASRR) process upon admission or as needed. Specifically, five residents with significant psychiatric or developmental diagnoses did not have complete or properly executed PASRR documentation. In several cases, residents were admitted under provisional or hospital discharge exemptions, but the required follow-up screenings were not conducted when the exemption period ended. For example, one resident was admitted under a 30-day provisional exemption but was not re-screened after the period expired, as confirmed by the Regional Nurse Consultant. Other residents had incomplete or unsigned PASRR Level I forms, or had sections of the form left blank despite having diagnoses and histories that clearly indicated the need for further assessment. In one case, a resident's PASRR Level I did not document any psychiatric diagnoses, even though the resident had a history of schizophrenia, depression, and anxiety, and was receiving multiple psychotropic medications. Another resident's PASRR Level I was not signed or dated by a physician, despite the presence of multiple psychiatric diagnoses and ongoing treatment with antipsychotic and anxiolytic medications. The facility's policy required that all residents with serious mental illness or intellectual disability receive appropriate preadmission screenings and that documentation be maintained in the medical record. The policy also specified that exemptions must be properly documented and that follow-up screenings be conducted as required. However, interviews with staff and review of records revealed that these procedures were not consistently followed, resulting in incomplete or missing PASRR documentation for residents with significant mental health needs.
Failure to Assist Resident in Filing and Resolving Grievance
Penalty
Summary
A resident with multiple chronic conditions, including chronic atrial fibrillation, heart failure, morbid obesity, and bowel and bladder incontinence, reported that she pressed her call light for assistance during a bowel movement and waited over two hours for staff to respond. When a CNA eventually arrived, the staff member refused to clean her because she was still having a bowel movement, leaving her in an unclean state until a nurse later provided care. The resident communicated her dissatisfaction and intent to file a grievance to the Social Services Assistant (SSA) during morning rounds, but did not receive any updates or follow-up regarding her complaint. A review of the facility's grievance log showed no record of a grievance filed by or on behalf of the resident for the incident in question. Interviews with facility staff, including the Social Services Director (SSD) and the Administrator, confirmed that the grievance process was not initiated as required by facility policy. The staff member who received the complaint did not complete a grievance form or ensure the concern was formally documented and investigated, resulting in a lack of prompt action and communication with the resident about the status of her grievance. Facility policy mandates that all grievances be documented, investigated within a specified timeframe, and that residents be kept informed of progress and outcomes. In this case, the failure to file and investigate the grievance promptly, as well as the lack of communication with the resident, constituted a violation of the resident's right to voice grievances without discrimination or reprisal and to receive timely resolution and updates regarding her concerns.
Failure to Prevent Accident Hazards: Unsecured Medications and Razors
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe environment free from accident hazards for two residents. In the first instance, a resident was observed with multiple medications, including narcotics and other prescription drugs, left unattended at the bedside on two separate occasions. The resident reported retrieving medications from the medication cart due to perceived delays and keeping some pills to take later or not at all. There was no physician order or care plan in place permitting self-administration of medications, nor was there an assessment for the resident's ability to self-administer. Facility staff interviews confirmed that medications should not be stored at the bedside without proper orders and care planning, and that nurses are responsible for ensuring medications are taken as prescribed and not left with the resident unless authorized. In the second instance, another resident with severe cognitive impairment and on anticoagulant therapy was found with several razors stored in a plastic bag on the dresser in their room. The resident required significant assistance with activities of daily living and had a history of impaired cognitive function. Staff interviews revealed that razors are typically stored in locked supply closets and are only provided to residents deemed safe to use them, with supervision recommended. There was no policy provided regarding the safe handling or storage of razors in resident rooms during the survey. A review of facility policies indicated requirements for medication administration and general safety precautions, but there was a lack of specific guidance or implementation regarding the safe storage of medications and razors in resident rooms. The facility's failure to follow its own procedures and ensure proper assessment and authorization for self-administration of medications, as well as the improper storage of potentially hazardous items like razors, contributed to an environment that was not as free from accident hazards as possible for the affected residents.
Failure to Administer Enteral Nutrition per Physician Order and Label Feeding Bottle Correctly
Penalty
Summary
The facility failed to provide enteral nutrition according to the physician's order for one resident receiving tube feeding. Observations on two consecutive days showed that the resident's enteral nutrition was being administered at 40 ml/hour, while the physician's order specified Jevity 1.5 at 45 ml/hour for 20 hours daily. Additionally, the nutrition bottle was not properly labeled with the resident's identifier and was incorrectly labeled with the flow rate. The resident's medical record indicated a history of severe protein-calorie malnutrition, failure to thrive, and feeding difficulties, and the resident was dependent on staff for eating and other activities of daily living. Interviews with staff revealed that CNAs did not adjust the feeding pump and that LPNs were responsible for confirming physician orders and monitoring tube placement. The Director of Nursing stated that facility policy required the resident's name, room number, time the bottle was hung, flow rate, and flush rate to be written on the enteral nutrition container. A review of the facility's policy confirmed that nurses are to administer enteral feedings as ordered by the physician and according to pump manufacturer guidelines. Despite these protocols, the observed discrepancies in administration rate and labeling constituted a failure to follow physician orders and facility policy for enteral nutrition.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide oxygen therapy according to physician orders for two residents who required respiratory care. In the first case, a resident with multiple diagnoses including COPD, morbid obesity, and diabetes was observed receiving oxygen at 3.5 L/min via nasal cannula on two separate occasions, despite an active physician order specifying continuous oxygen at 5 L/min. The resident was cognitively intact and aware of his oxygen needs. Documentation confirmed the physician's order for 5 L/min, and the care plan included interventions to administer oxygen as ordered. Interviews with nursing staff revealed that LPNs were trained to set the oxygen flow rate per order and were expected to check the flow rate each time they entered the room, while CNAs were responsible only for ensuring the oxygen was running and properly placed. The DON was unable to provide details on the facility's policy for monitoring oxygen flow rates during the survey. In the second case, another resident with chronic respiratory failure, COPD, and dependence on supplemental oxygen was observed receiving oxygen at 3 L/min via nasal cannula on two occasions, while the physician's order specified continuous oxygen at 4 L/min. This resident had severe cognitive impairment and required significant assistance with daily activities. The care plan addressed the resident's oxygen dependence and risk for impaired gas exchange, and the physician's orders included specific instructions for oxygen therapy and monitoring. No oxygen signage was present on the resident's door during observations. A review of the facility's oxygen therapy policy confirmed that oxygen administration should follow the physician's specified flow rate. The policy also required a "No Smoking" sign as part of the equipment for oxygen therapy. The survey found that the facility did not ensure oxygen was administered at the ordered flow rates for both residents, and staff interviews indicated a lack of clarity regarding the frequency and responsibility for monitoring oxygen flow rates.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of all residents, as evidenced by multiple instances where residents' requests for assistance were not met in a timely manner. One resident, who was totally dependent on staff for bed mobility, toileting, dressing, and transfers due to hemiplegia, hemiparesis, and moderate cognitive impairment, reported that he had asked several staff members to help him get out of bed after breakfast but remained unattended for several hours. Despite activating his call light and repeated requests, he was not assisted until much later in the day, and his call light was turned off by staff and administration without his needs being met. The resident expressed concern that his requests were not being addressed and that staff were not responsive to his needs. Another resident was observed with her call light on, requesting pain medication and a brief change. While she received her pain medication, her request for a brief change was not addressed for an extended period, and she reported not seeing her assigned CNA since the morning. The call light remained on for over an hour before her needs were met, and she refused her lunch tray until she was cleaned up. Staff interviews confirmed that call lights should remain on until resident needs are met, but this protocol was not consistently followed. A review of facility records and interviews with staff revealed ongoing staffing issues, particularly on weekends, with the facility experiencing low staffing levels on approximately three days each week. Payroll records confirmed excessively low weekend staffing and a one-star rating. The facility's staffing coordinator and administration acknowledged these issues, and the facility's assessment tools indicated a high number of residents with behavioral health needs and high acuity, further emphasizing the need for adequate staffing to meet resident care requirements.
Failure to Complete and Implement Monthly Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's medication regimen review recommendations were maintained and followed for one resident, and also failed to ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for another resident. For one resident with a history of encephalopathy, bipolar disorder, major depressive disorder, long-term use of anticoagulants and insulin, chronic pain, and heart failure, the consultant pharmacist made a recommendation on 3/31/2025 to either discontinue Apixaban or reduce the dose of Eliquis, which was agreed upon by the physician. However, this recommendation was not carried out by the facility, and there was no evidence in the medical record that the physician's response was acted upon in a timely manner. Additionally, for another resident with multiple diagnoses including atherosclerotic heart disease, polyneuropathies, diabetes mellitus, chronic pain, anxiety disorder, insomnia, and substance abuse, the facility was unable to provide evidence that monthly medication regimen reviews were completed by the consultant pharmacist for several months. Only three reviews were available for a period spanning from August 2024 through April 2025, indicating that the required monthly reviews were not consistently performed for this resident. The facility's policy requires that the Director of Nursing or designee ensure monthly drug regimen reviews are completed and that any outstanding recommendations are followed up with physicians or the Medical Director as needed. Despite this policy, the records reviewed showed lapses in both the completion of monthly reviews and the implementation of pharmacist recommendations, as evidenced by missing documentation and unaddressed recommendations in the residents' records.
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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
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terrace Of Jacksonville, The | 1.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Jacksonville | 3 mi | ★★★★★ | 0 | 0 |
| River Garden Hebrew Home For The Aged | 3.1 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Taylor | 3.4 mi | ★★★★★ | 2 | 0 |
| Woodland Grove Healthcare & Rehabilitation Center | 3.5 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 July 2026) and official state health department websites.