Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Fernandina Beach Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to Notify LTC Ombudsman of Resident Transfers and Discharges: The facility did not provide transfer/discharge notices or copies of the actual forms to the LTC Ombudsman for three residents reviewed. One resident was discharged to another facility, one was transferred to an acute care hospital and later discharged home, and one was discharged from the facility; in each case, the EMR lacked the required discharge/transfer form and there was no documented proof that the Ombudsman was notified. The DON/ADON and SSD were unable to verify the process, and the Administrator could not produce fax confirmations showing the notices were sent.
A resident reported verbal abuse by a CNA, who threatened not to respond to the resident's call light after a derogatory exchange. The resident, with intact cognition, had previously filed grievances about missing items and delayed call light responses, which were not properly addressed. The facility's policy on abuse prevention was not followed, and the Administrator was unaware of the incident until informed by surveyors.
The facility failed to notify a resident's representative and the Ombudsman of a hospital transfer. The resident was hospitalized for right foot pain, fever, and nausea, and later readmitted with cellulitis. The Administrator confirmed the absence of written notification and lacked documentation or policy for such notifications.
Two residents experienced significant weight loss due to the facility's failure to provide timely nutritional interventions. One resident lost 21.57% of her body weight, and another lost 26.24% over six months. Despite being prescribed Ensure supplements, they were not consistently provided, and meal consumption was poor. Staff interviews revealed confusion about supplement distribution responsibilities, contributing to the deficiency.
A facility failed to provide meals for a resident undergoing dialysis and did not complete necessary communication forms for multiple residents. A resident reported not receiving meals for dialysis appointments, confirmed by her sister. Observations showed her lunch was served in her room while she was away. Additionally, communication forms for three residents were incomplete, indicating lapses in documentation. Staff interviews revealed confusion about handling these forms, contrary to facility policy.
The facility failed to maintain a clean and homelike environment in four resident rooms, with issues such as bubbled paint, dust and debris on air conditioner vents, detached air conditioner units, and broken furniture. These deficiencies were observed during a survey, highlighting the facility's failure to provide a safe and comfortable environment for residents.
A resident reported an incident involving a CNA who allegedly refused assistance after being called a derogatory name. The facility failed to document and investigate the grievance promptly, and the Administrator was unaware of the details until informed by surveyors. The facility's policy requires immediate reporting of such allegations, which was not followed, leading to a deficiency.
A facility failed to issue a Bed Hold notice to a resident transferred to a hospital, as required by its policy. The resident's medical record lacked the notice, and the Administrator confirmed it was not provided. The facility's policy mandates informing residents or their representatives about the Bed Hold Policy upon admission and during transfers, which was not adhered to in this case.
The facility failed to properly store medications, with instances of medications left unattended at residents' bedsides and at a nurses' station. One resident had Vitamin C tablets left on her table, while another had an inhaler without a self-administration assessment. A third resident had outdated assessments for self-administration of medications. Additionally, personal items were found in a medication room, and expired medications were discovered in a cart, indicating lapses in adherence to storage protocols.
A facility failed to accurately document medication administration for a resident, resulting in discrepancies between the eMAR and narcotic sign-out sheet for oxycodone. The resident reported delays in receiving pain medication, contrary to the facility's policy that emphasizes administration based on resident need and preference.
An LPN failed to perform hand hygiene during medication administration for two residents, violating the facility's infection control policy. The LPN accessed the medication cart and administered medications without washing hands, contrary to established procedures.
The facility failed to assess the pneumococcal vaccination status of two residents within the required timeframe. Despite a policy mandating assessments within five working days of admission, the vaccination status for these residents was not reviewed. The DON, acting as the Infection Preventionist, confirmed the oversight and had not yet begun a planned audit to address the issue.
The facility failed to provide CMS-10055 forms to two residents receiving Medicare Part A Skilled services. The Social Services Department, responsible for these forms, was unaware of the requirement, leading to the deficiency.
Failure to Notify LTC Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide a notice of transfer/discharge and a copy of the actual transfer/discharge form to the Long-Term Care Ombudsman’s Office for three residents reviewed for transfer/discharge. Resident #7 was admitted with a diagnosis including a fracture of the upper end of the left humerus, had a care plan focus area for discharge to the community, and was discharged to another facility with supportive services. The medical record contained a discharge planning summary and physician orders for discharge, but no discharge/transfer form was found in the EMR. An interview with the ADON confirmed the form should be in the EMR, but it was not located. Resident #71 was admitted, transferred to an acute care hospital, re-entered the facility the next day, and later discharged home. The EMR did not contain a transfer/discharge notification to the LTC Ombudsman or evidence that such notice had been sent for either the hospital transfer or the later discharge, and no discharge/transfer form was present. Resident #125 was admitted and later discharged from the facility, but the EMR also lacked evidence of notification to the LTC Ombudsman and did not contain a discharge/transfer form. The Administrator stated the Ombudsman was notified monthly by fax, but could not provide fax confirmations, and the binder of monthly logs and fax cover sheets did not verify that the required information was sent to or received by the Ombudsman. The facility policy stated that a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. The incident involved a resident who reported feeling ignored by staff and experiencing verbal abuse from a Certified Nursing Assistant (CNA). The resident stated that after a therapy session, she was in pain and requested to go back to bed, but the CNA refused and did not provide pain medication. In frustration, the resident called the CNA a derogatory name, to which the CNA responded by threatening not to answer the resident's call light in the future. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), reported the incident to the Social Services Director (SSD). However, the SSD did not document the grievance properly or initiate an investigation. The SSD claimed to have a separate book for unresolved grievances but failed to produce it when requested. Additionally, the facility's grievance log showed previous unresolved grievances from the resident, including issues with missing personal items and delayed call light responses. The Administrator was unaware of the details of the grievance until it was brought to her attention by the surveyors. The facility's policy on abuse prevention and response was not followed, as the incident was not reported or investigated promptly. The lack of consistent nursing leadership, as mentioned by the SSD, contributed to the failure to address the resident's grievances and provide necessary staff education on abuse prevention.
Failure to Notify Resident Representative and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide the appropriate transfer/discharge notice to a resident and their responsible party, as well as notify the Office of the State Long-Term Care Ombudsman in writing of a resident's transfer to the hospital. This deficiency was identified for one resident out of a sample of 42. The resident was transported to the hospital for right foot pain, fever, and nausea, and later readmitted to the facility with a diagnosis of cellulitis in the right lower extremity. During an interview, the Administrator confirmed that there was no written notification to the resident's representative or the local Ombudsman regarding the transfer. A review of emails sent to the Ombudsman showed no record of notification for the month in which the transfer occurred, and the Administrator admitted to having no additional documentation or facility policy regarding such notifications.
Failure to Provide Adequate Nutritional Interventions
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, leading to significant weight loss. Resident #57 experienced a 21.57% weight loss over six months, dropping from 108 pounds to 84.7 pounds. Despite being ordered Ensure chocolate nutritional supplements three times a day, observations revealed that these supplements were not consistently provided. The resident's meal consumption was poor, with records showing she consumed 50% or less of her meals in the past 30 days. Interviews with staff indicated a lack of awareness and responsibility regarding the provision of Ensure supplements, contributing to the resident's continued weight loss. Resident #34 also suffered significant weight loss, losing 26.24% of her body weight over six months, from 157 pounds to 115.8 pounds. Despite being on a mechanical soft diet, her meal consumption was inadequate, with records showing she consumed 50% or less of her meals in the past 30 days. Observations confirmed that she often refused to eat her meals, and there was no documentation of specific interventions to address her weight loss. The facility's dietitian noted her significant weight loss but believed the existing interventions were sufficient, despite the resident's continued decline. The facility's failure to provide timely and appropriate nutritional interventions for these residents highlights a deficiency in maintaining their nutritional status. The lack of consistent provision of prescribed supplements and inadequate meal consumption monitoring contributed to the residents' significant weight loss. Interviews with staff revealed confusion and miscommunication regarding the responsibility for providing nutritional supplements, further exacerbating the issue.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate meals and snacks for a resident undergoing hemodialysis, as well as failed to complete necessary communication forms for multiple residents receiving dialysis. Resident #23, who regularly attends dialysis appointments, reported not receiving a lunch or snack to take with her to her appointments, resulting in her going without food from breakfast until dinner. This issue was corroborated by her sister, who stated that the facility had not provided a lunch since the resident's admission, requiring her to purchase snacks and meals for the resident. Observations confirmed that the resident's lunch was served in her room while she was away at dialysis, and interviews with staff revealed inconsistencies in the process of providing meals for residents with appointments. Additionally, the facility did not maintain proper documentation for residents receiving dialysis. Communication forms, which are essential for conveying important information between the facility and the dialysis center, were found to be incomplete for three residents. These forms are supposed to include details such as lab work, vital signs, and any concerns or recommendations from the dialysis center. However, upon review, it was discovered that sections of these forms were not filled out by the nursing facility staff either before or after the dialysis appointments, indicating a lapse in communication and documentation practices. Interviews with various staff members, including the Director of Nursing and a Licensed Practical Nurse, revealed confusion and lack of awareness regarding the handling and storage of these communication forms. The forms were supposed to be kept in a binder at the nurses' station and later uploaded into the computer system, but this process was not consistently followed. The facility's policy on dialysis care emphasizes the importance of communication and providing meals to residents, yet these standards were not met, leading to deficiencies in care for the residents involved.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in four of the 62 occupied rooms, as observed during a survey conducted on June 25, 2024. Specific deficiencies included bubbled paint around the air conditioner unit, built-up dust and debris on the air conditioner vent, and the air conditioner unit being detached from the wall in two rooms. Additionally, one room had black-colored markings on the air conditioner unit's front panel, resembling biological growth. Another room had trim falling off the wall behind the bed's headboard, and a broken top drawer of the dresser. These environmental concerns were identified through observations and interviews with facility staff. The Environmental Director/Plant Operation Director acknowledged the issues during a follow-up tour on June 27, 2024, and noted the need for repairs and cleaning. The report highlights the facility's failure to uphold the residents' right to a safe, clean, comfortable, and homelike environment, as required by regulations.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required two-hour timeframe. The incident involved a Certified Nursing Assistant (CNA) who allegedly refused to assist a resident after being called a derogatory name by the resident. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), reported the incident to the Social Services Director (SSD) but the grievance was not documented or investigated promptly. The resident expressed distress over the situation, stating that her call light was being ignored by staff, which exacerbated her pain and discomfort. The facility's grievance handling was inadequate, as evidenced by the SSD's inability to produce documentation of the grievance or any follow-up actions. The SSD admitted to having unresolved grievances and a lack of consistent nursing management to address staff education. Additionally, the Administrator was unaware of the details of the grievance until it was brought to her attention by the surveyors, indicating a breakdown in communication and reporting procedures within the facility. The facility's policy on abuse, neglect, and misappropriation requires immediate reporting of any allegations to the Administrator and other designated officials. However, this protocol was not followed in the case of the resident's complaint. The Administrator only became aware of the grievance after the surveyors' inquiry, and an investigation was initiated belatedly. The facility's failure to adhere to its own policy and federal regulations resulted in a deficiency related to the timely reporting and investigation of alleged abuse incidents.
Failure to Provide Bed Hold Notice for Hospital Transfer
Penalty
Summary
The facility failed to provide a Bed Hold notice to a resident who was transferred to an acute care hospital. A review of the resident's medical record showed a progress note indicating the transfer, but no Bed Hold notice was present. During an interview, the Administrator confirmed that no Bed Hold notice was issued for the resident's transfer. The facility's policy requires informing residents or their legal representatives about the Bed Hold Policy upon admission and when leaving for hospitalization, observation, or therapeutic leave, but this was not followed in this instance.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to maintain proper storage of medications for several residents and in various locations within the facility. During an initial tour, it was observed that a resident had Vitamin C tablets left unattended on her over-the-bed table, which she stated she liked to suck on after taking other medications. The LPN confirmed that the medication should not have been left at the bedside and acknowledged the expectation to remain with residents until medications are taken. Another resident was found with a Budesonide inhaler on his bedside table without an assessment for safe self-administration, despite being cognitively intact. In another instance, a resident had multiple medications, including eye drops and inhalers, left on her bedside table. Although she was cognitively intact and had previous assessments for self-administration, these assessments were outdated and did not cover the current medications. The Director of Nursing was unaware of these medications being left at the bedside and acknowledged the need for updated assessments. Additionally, at a nurses' station, medication cards containing a resident's information were left unattended, which the LPN admitted should not have been left out. Further observations revealed improper storage practices, such as personal items found in a medication room and expired medications in a medication cart. The facility's policies on medication administration and storage were reviewed, highlighting the requirement for medications to be stored in locked compartments and outdated drugs to be returned or destroyed. These findings indicate lapses in adherence to medication storage and administration protocols within the facility.
Medication Administration Documentation Discrepancy
Penalty
Summary
The facility failed to maintain accurate documentation on medication administration records for a resident, leading to discrepancies between the electronic Medication Administration Record (eMAR) and the narcotic sign-out sheet. The resident had a physician's order for oxycodone 10 mg every 4 hours as needed. However, the eMAR and the narcotic sign-out sheet showed inconsistencies in the times the medication was documented as administered. For instance, on one day, the eMAR recorded administration at 4:27 AM, 8:48 AM, and 1:53 PM, while the narcotic sign-out sheet only showed administration at 4:27 AM and 1:53 PM, with an additional undocumented administration at 8:26 PM. Similar discrepancies were noted on subsequent days, with mismatches in the recorded times of administration between the eMAR and the narcotic sign-out sheet. An interview with the Director of Nursing confirmed that the medication should be documented in the eMAR once administered, and the system would prompt the nurse to document the medication's effectiveness. The resident reported delays in receiving her pain medication, stating that on one occasion, she requested it multiple times over several hours before it was finally administered. The facility's policy on medication administration emphasizes that medication times should be based on resident need and preference, not staff convenience, highlighting a failure to adhere to these guidelines.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement proper infection control measures during medication administration, as observed with two residents. On June 27, 2024, an LPN was seen administering medications to a resident without performing hand hygiene before or after the process. The LPN accessed the medication cart, prepared the medication, and entered the resident's room without washing hands. Similarly, the LPN repeated this process with another resident, again neglecting to perform hand hygiene before or after administering the medications. This was in violation of the facility's policy, which mandates adherence to infection control procedures, including handwashing during medication administration.
Failure to Timely Assess Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to assess the pneumococcal vaccination status of two residents in a timely manner, as required by their policy. Resident #454 was admitted to the facility with an assessment due by June 10, 2024, and Resident #406 was admitted with an assessment due by June 21, 2024. However, a review conducted on June 27, 2024, revealed that the vaccination status for both residents had not been assessed within the required timeframe. The Director of Nursing, who was also the acting Infection Preventionist, confirmed the absence of vaccination status records for these residents. The facility's policy, revised in February 2024, mandates that assessments of pneumococcal vaccination status be conducted within five working days of a resident's admission. Despite this policy, the assessments for Residents #454 and #406 were not completed as required. The DON, new to the role of Infection Preventionist, acknowledged the oversight and indicated plans to conduct a comprehensive audit of the facility's residents to address the issue, but this had not yet been initiated at the time of the review.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the required CMS-10055 forms, known as Skilled Nursing Facility Advance Beneficiary Notices, to two residents who were sampled for review of beneficiary notices. Resident #55's Medicare Part A Skilled services began on January 5, 2024, and ended on February 28, 2024, but the CMS 10055 form was not provided. Similarly, Resident #456's Medicare Part A Skilled services began on March 9, 2024, and ended on April 15, 2024, without the provision of the CMS 10055 form. Interviews conducted on June 26, 2024, revealed that the Social Services Department was responsible for completing and providing these forms. However, the Regional Field Analyst stated that the forms were not completed because the Social Services Department was unaware of this requirement. The Social Services Director confirmed this lack of awareness and acknowledged that the forms had not been completed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 156 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fernandina Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Senior Care Center - St Marys | 8.3 mi | ★★★★★ | 12 | 0 |
| Lanier Rehabilitation Center | 15.3 mi | ★★★★★ | 0 | 0 |
| River City Nursing And Rehab Center | 15.7 mi | ★★★★★ | 2 | 0 |
| Aviata At Harts Harbor | 19 mi | ★★★★★ | 26 | 0 |
| Lakeside Center For Rehabilitation And Healing | 20.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Fernandina Beach Rehabilitation And Nursing Center.
100% money-back within 48 hours.
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.