Below 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 Jacksonville Rehabilitation And Nursing during CMS and state inspections, most recent first.
Dish Machine Sanitation and Temp Logging Failure: A Dietary Aide responsible for dishwashing did not verify sanitizer levels or record dish machine temps on the log, and the temp gauge stayed at 120 degrees Fahrenheit during repeated demonstrations. A Dietary Director also found the sanitizer test strip did not change colors and replaced the sanitizer bucket, but the gauge still remained at 120 degrees Fahrenheit. The dish machine log had consistently recorded 140 degrees Fahrenheit for months, despite the observed 120-degree readings.
The facility failed to notify the LTC Ombudsman’s office of multiple resident transfers and discharges, including planned discharges and acute care hospital transfers. Records for several residents with diagnoses such as dementia, metabolic encephalopathy, cerebral infarction, acute cholecystitis, and muscle wasting showed no CMS Form 3120 or Ombudsman notification in the EMR. Interviews confirmed the facility was sending only a monthly log, and the discharge planning policy did not address Ombudsman notification.
Failure to Follow Diet Orders, Portion Control, and Standardized Recipes: Surveyors found that the kitchen did not follow a resident’s pescatarian diet order and served multiple residents meal trays that did not match ordered portions or menu expectations. Staff gave inconsistent explanations about substitutions and tracking, and the DON/Dietary leadership could not initially produce a matching lunch recipe for the fried chicken item served, while one resident receiving an alternate meal was given no vegetables.
The facility failed to maintain infection control when an LPN did not perform hand hygiene before or after administering medications to two residents, and another LPN did the same for a third resident. The facility also failed to keep a resident’s urinary catheter drainage bag off the floor; both a CNA and an RN confirmed the bag should never touch the floor, and the RN observed that it was resting on the floor beside the bed.
Inoperable and Missing Resident Call Lights: Several resident call lights on the 3rd floor were found not working, including multiple rooms where the lights did not illuminate outside the room doors or at the nurses' station. One call light was disconnected from the wall socket, and another resident room had no call light present. The DORM noted prior concerns with the system, but testing showed persistent error alerts in the dome light and wireless device systems, and the LPN could not explain the missing call light.
Accessible sharps left in a resident room. A white Bible on the tray table contained scissors, and a pocketknife and razors were also observed in the room on separate observations. An LPN/Unit Manager confirmed the scissors should not have been in the resident’s possession, and the DON stated residents were not to have sharps but the facility had no policy addressing sharp objects in resident rooms. The resident had intact cognition, was independent with ADLs, and had dx including depression and anxiety.
Surveyors found that the facility failed to maintain a sanitary and safe environment, with 16 rooms exhibiting issues such as biological growth, pest presence, dirty and damaged fixtures, and unaddressed maintenance needs. These deficiencies were confirmed by staff interviews and a lack of maintenance work orders, affecting a significant number of residents.
The facility failed to employ a Certified Dietary Manager (CDM) or certified food service manager, despite not having a full-time registered dietitian (RD). The kitchen manager lacked necessary credentials, and the facility relied on a regional RD present only part-time. The administrator misunderstood regulatory requirements, leading to noncompliance with Florida Administrative Code 59A-4.110, potentially affecting all residents.
The facility failed to meet food service safety standards, using expired buns and improperly testing a malfunctioning dish machine. Refrigerators in nourishment rooms exceeded safe temperatures, and logs were incomplete. Staff lacked training and knowledge of kitchen processes, leading to potential risks for residents.
The facility's dish machine failed to reach the required sanitizing temperature of 180°F, posing a risk of foodborne illness. Kitchen staff were unaware of the machine's operational requirements, and the Maintenance Director confirmed it was not functioning correctly. Despite service attempts, the machine remained out of service, failing to meet necessary sanitizing standards.
The facility failed to maintain a safe and sanitary environment, with deteriorating door frames and a tripping hazard near the 3rd floor elevator. Additionally, a resident's enteral nutrition pump was found with dried product and was sticky, with staff unclear on cleaning responsibilities. The Administrator was unaware of these issues, despite daily rounds intended to identify such problems.
A resident with acute respiratory failure was transferred to an acute care hospital without proper documentation of the transfer's basis, unmet needs, or services available at the hospital. The facility did not provide a Nursing Home Transfer and Discharge Notice or a physician's order for the transfer. Interviews with the DON confirmed the lack of documentation, including the time of departure and mode of transportation, despite the resident's request to be sent to the ER after experiencing chest pain.
Two residents in a facility did not receive necessary care due to inadequate care planning. One resident experienced pain from long toenails that had not been clipped since admission, while another resident had an IV line without a care plan for maintenance, leading to a lack of routine flushes and dressing changes. Staff interviews revealed confusion about responsibilities and a failure to update care plans based on new needs.
The facility failed to provide necessary nail care for four residents, resulting in elongated and untrimmed fingernails and toenails. Despite care plans indicating the need for assistance, there was no documentation of nail care being provided. Interviews with staff revealed confusion about responsibilities, and the facility's policies on nail care were not followed.
A resident did not receive their prescribed Prozac 60 mg for three consecutive days due to unavailability in the medication cart and Pyxis machine. The LPN did not notify the physician about the missed doses, contrary to facility policy. This resulted in a deficiency in providing necessary pharmaceutical services.
The facility experienced an 8% medication error rate due to two incidents involving an LPN. In one case, a resident missed three doses of Prozac because it was unavailable, and the physician was not notified. In another case, the LPN failed to administer Lisinopril to a resident, as she did not verify the medications against the MAR. The facility's medication administration policy was not followed in both instances.
Dish Machine Sanitation and Temperature Logging Failure
Penalty
Summary
The facility failed to follow proper dish sanitation practices and failed to log proper temperatures for the dish machine. During an observation and interview on 04/27/2026, a Dietary Aide confirmed she was responsible for cleaning residents’ dishes and operating the low-temperature dishwasher. When she ran the dishwasher, the temperature gauge remained at 120 degrees Fahrenheit, she did not test the sanitation level, and she did not record the temperature or sanitation level on the dishwasher log. When the process was demonstrated again, the Dietary Director ran the dishwasher and the temperature gauge again remained at 120 degrees Fahrenheit. The sanitation test strip did not change colors, and the Dietary Director replaced the sanitation bucket connected to the dishwasher before running it again, with the temperature gauge still remaining at 120 degrees Fahrenheit. Review of the dish machine log for November 2025 through April 2026 showed a consistent recording of 140 degrees Fahrenheit for the rinse and wash after breakfast, lunch, and dinner. The facility then moved to serving food on paper products. A review of dishwasher in-service training dated 04/27/2026 stated aides must run the dishwasher twice, verify temperature, prime the sanitizer, and test sanitizer, and noted that if the thermostat does not move from 120, a thermometer should be used and a supervisor informed.
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 8 of 12 residents reviewed for transfer/discharge. The residents identified were #12, #115, #92, #64, #31, #25, #23, and #18. A review of the facility’s records showed no evidence in the EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification to the LTC Ombudsman’s office for these residents. Resident #12 had diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety, and was discharged from the facility with a planned discharge noted on the MDS. Resident #115 had diagnoses including syncope and collapse and transferred to an acute care hospital. Resident #92 had diagnoses including metabolic encephalopathy and transferred to an acute care hospital. Resident #64 had diagnoses including cerebral infarction and had a planned discharge home. Resident #31 had diagnoses including tinea unguium and transferred to an acute care hospital. Resident #25 had diagnoses including acute cholecystitis and transferred to an acute care hospital. Resident #23 had diagnoses including osteomyelitis of the lumbar vertebra and had a planned discharge home. Resident #18 had diagnoses including muscle wasting and atrophy of multiple sites and had an unplanned discharge to an acute care hospital. On 04/29/2026, the DON provided a list of resident transfers/discharges for February and March 2026, and the LTC Ombudsman’s office confirmed there had been no Nursing Home Transfer/Discharge notifications from the facility during those months. Interviews with the Administrator, SSD, and DON showed that notification responsibilities had shifted to nursing management when the facility lost its SSD, and that the facility had been forwarding a monthly log of transfers and discharges by email at the end of each month. The facility’s Discharges/Discharge Planning policy, effective 12/2008 and revised 08/2023, did not address notification of the LTC Ombudsman’s office upon transfer or discharge.
Failure to Follow Diet Orders, Portion Control, and Standardized Recipes
Penalty
Summary
The facility failed to provide a nourishing, palatable, and well-balanced diet that met residents’ daily nutritional and special dietary needs and preferences. Surveyors found that the kitchen did not adhere to therapeutic diet orders for a pescatarian diet and did not follow standardized recipes and portion control in accordance with professional food service standards. These issues were observed during meal service and tray line review and affected nine resident meal trays, including residents with ordered diet modifications such as no added salt, mechanical soft texture, consistent carbohydrate diet, large portions, and double portions. During a lunchtime dining observation on the 300 hallway, one resident whose meal ticket identified a no added salt, mechanical soft, pescatarian diet received two vegetable servings and one fruit serving. The resident stated the meal components received were what the kitchen provided because she was pescatarian. During a kitchen tour, the same resident’s meal ticket again identified a pescatarian diet, but she was provided one vegetable and two starch servings. Later, the lunch menu on the tray line included drumettes/wingettes, French fries, green beans, and dessert, and staff stated that a serving of protein was four drumettes/wingettes. At tray line service, several residents whose meal tickets identified regular, consistent carbohydrate, large portion, or double portion diets were each provided one protein serving of four drumettes/wingettes, one vegetable, and one starch serving. One resident who was provided an alternate meal of two sandwiches received no vegetables. Dietary aides and the dietary manager gave differing explanations about substitutions, portion sizes, and tracking practices. The dietary director stated substitutions were tracked on a substitution log, but the dietary manager stated substitutions were not tracked. The dietary director also confirmed that meal quantities were based on census reports, large and double portion diets, and recipe books, yet she could not initially produce a lunch recipe and later provided a recipe for oven fried chicken that did not match the fried drumettes/wingettes actually served. The facility did not have an applicable food and nutrition policy available for review.
Infection Control Lapses During Medication Administration and Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when nursing staff did not perform hand hygiene during medication administration for three residents. During observation, an LPN pulled medications from the cart and entered Resident #93's room without performing hand hygiene, administered medications, and exited without performing hand hygiene. The same LPN then pulled medications for Resident #70, entered the room without hand hygiene, administered medications, and again exited without performing hand hygiene. In a separate observation, another LPN pulled medications for Resident #74, entered the room without hand hygiene, administered medications, and exited without performing hand hygiene. The facility also failed to keep a urinary catheter drainage bag off the floor for Resident #107. The resident was observed lying in bed with the catheter bag resting on the floor beside the bed, and photographic evidence was obtained. During interviews, a CNA and an RN both stated that the urinary drainage bag should never touch the floor, and the RN confirmed that Resident #107's bag was on the floor while noting that low bed position can allow bags to touch the floor.
Inoperable and Missing Resident Call Lights
Penalty
Summary
The facility failed to ensure that working call systems were available in resident bathrooms, bathing areas, and at the bedside for multiple residents. During a tour of the facility, several call lights on the third floor were found to be inoperable, including rooms 301A, 301B, 302A, 302B, 303B, 303C, 304A, 304B, 307A, 307B, 307C, and 308B. The call light box for 308C was disconnected from the wall socket, and there was no call light in room C at the time of observation. Photographic evidence was obtained during these observations. During interview, the Director of Maintenance stated there had been some concerns with the facility's call lights in the past and that they may have needed to be reset. While testing the system at the nurses' station, error alerts appeared indicating a critical alert in the Dome Light system and a warning in the Wireless Devices system, with the system stating it may be partially functional. The same alerts were seen for rooms 313A, 313B, and 313C. After unplugging and reconnecting the system, the alerts remained. The Director of Maintenance could not provide evidence or documentation of previous repairs or replacements for the identified call lights. When the affected rooms were retested, the call lights in rooms 301B, 302A, 302B, 303B, 303C, 307B, 307C, and 308B remained inoperable and did not illuminate outside the room doors or at the nurses' station call box. The Unit Manager/LPN stated she was not sure what had happened to the missing call light in room C and said the resident should have had one.
Accessible sharps left in resident room
Penalty
Summary
The facility failed to ensure that one resident’s room was free from accident hazards when sharp objects were left accessible without identified safety parameters. During observation, a white Bible on the resident’s tray table contained a pair of scissors, and a multi-colored pocketknife and a pack of razors were observed on the windowsill. On a later observation, the same white Bible containing the scissors and a pack of razors were again seen on the windowsill, with photographic evidence obtained on both occasions. During interview, the LPN/Unit Manager was taken to the room and, after being directed to the Bible on the windowsill, acknowledged the scissors and confirmed the resident should not have scissors in his possession. The DON confirmed that residents were not to have sharps in their possession and stated the items were part of the resident’s art supplies. The DON also stated the facility did not have a policy addressing residents’ possession of sharp objects or identifying hazardous items prohibited in resident rooms. The resident had an admission date of 05/06/2025, diagnoses including depression and other specified persistent mood disorders, a BIMS score of 13 indicating intact cognition, and was independent with ADLs. A psychiatry/psychology note documented major depressive disorder, recurrent, moderate, and other specified anxiety disorder, with the resident reporting low interest, depressed mood, low energy, poor appetite, anxiety, uncontrolled worry, and wanting to leave the facility.
Failure to Maintain Sanitary and Safe Physical Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, functional, sanitary, and comfortable physical environment for residents, staff, and the public. During a facility tour, 16 resident rooms were found with various deficiencies, including black biological growth under toilet rims, dark stains inside toilet bowls, black biological film on window rails, dead and live cockroaches, dirty and torn floor mats, dust buildup on vents, water-damaged ceilings with biological growth, missing door thresholds with exposed screws, stained and damaged walls, holes around plumbing, broken floor tiles, and full garbage cans. Additional issues included dirty wash bins, used urinals left on floors, brown-colored scratches on toilet seats, and missing floorboards. An industrial-sized fan in a hallway was covered in dirt and dust, and a wheelchair stored in a hallway was found with food particles and damaged wheels. Interviews with staff and review of facility documentation revealed that these environmental concerns were not reported through maintenance work orders, and daily housekeeping procedures outlined in facility policy were not consistently followed. The Director of Housekeeping and the Administrator confirmed that the observed issues should have been addressed by staff as part of their daily responsibilities. The lack of adherence to cleaning and maintenance protocols resulted in unsanitary and unsafe conditions affecting 40 out of 117 residents.
Noncompliance in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skills to manage the food and nutrition services effectively. During a survey, it was discovered that the facility did not have a Certified Dietary Manager (CDM) or a certified food service manager, despite not having a registered dietitian (RD) employed on a full-time basis. The kitchen manager, identified as Kitchen Manager O, was not certified and only held a high school diploma. The facility relied on a regional RD, who was not an employee of the facility and was only present three days a week, to oversee clinical duties. However, the RD was not responsible for the budget, and the kitchen manager was tasked with ordering and purchasing food without the necessary credentials. Interviews with the facility's administrator revealed a misunderstanding of the regulatory requirements, as she believed that having a dietary director and a consulting dietitian negated the need for a CDM. The administrator confirmed that there was no specific training provided for the kitchen processes and acknowledged the facility's noncompliance with the Florida Administrative Code 59A-4.110, which outlines the requirements for food and nutrition services. The lack of a qualified CDM or certified food service manager had the potential to affect all residents in the facility.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Expired buns were used during meal service, and dietary staff were unable to properly test the dish machine, which was not functioning correctly. The dish machine's final rinse temperature was below the required level, and chemicals were not being dispensed as needed. Additionally, the dish machine test log was pre-dated with test results, indicating a lack of proper documentation and oversight. Refrigerators in the nourishment rooms on the 2nd and 3rd floors were found to have temperatures exceeding the safe limit of 41 degrees Fahrenheit. The temperature logs for these refrigerators were incomplete, and an open, unlabeled, and undated candy bar was discovered in the 3rd floor nourishment room refrigerator. These issues suggest a failure in maintaining proper food storage conditions, which could potentially affect all residents in the facility. Interviews with staff revealed a lack of knowledge and training regarding the kitchen processes and equipment. The Kitchen Manager and dietary aides were unable to identify whether the dish machine was high or low temperature, and there was confusion about the correct test strips to use for sanitation testing. The Administrator was unaware of the pre-dated sanitation log and the identity of the staff member who signed it, further highlighting the facility's inadequate oversight and management of food safety protocols.
Dish Machine Fails to Meet Sanitizing Requirements
Penalty
Summary
The facility failed to maintain its dishwashing equipment in safe operating condition, as observed during a survey. The dish machine, which was supposed to function as a high-temperature sanitizing unit, did not reach the required final rinse temperature of 180 degrees Fahrenheit. Instead, it only reached 130 degrees Fahrenheit, and there was no evidence of chemical sanitizing agents being dispensed from the buckets into the machine. The kitchen staff, including the Kitchen Manager and Dietary Aide, were unaware of the machine's operational requirements and did not know how to address the issue, indicating a lack of training or communication regarding the equipment's maintenance and operation. The Maintenance Director confirmed the machine was not functioning correctly and was unable to determine why the chemicals were not being dispensed. Despite attempts to rectify the situation, including a service visit from a dishwasher company, the machine continued to fail in reaching the necessary sanitizing temperature. The Administrator was informed that the machine was operable without chemicals if it reached the required temperature, but subsequent tests showed it consistently failed to do so. At the time of the survey exit, the dish machine remained out of service, and no technicians had returned to resolve the issue.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment in several areas, including eight resident rooms and the 3rd floor elevator area. Observations revealed that door frames in these rooms were rusted and deteriorating, with some having missing floor tiles and holes in the walls. Additionally, a floorboard near the 3rd floor elevator was raised, creating a tripping hazard. The Maintenance Director acknowledged awareness of the disrepair but had not reported it to the Administrator, citing challenges in conducting repairs due to the facility's near-capacity status and the need to relocate residents during renovations. The facility also failed to maintain a sanitary environment for a resident receiving enteral feeding. The resident's enteral nutrition pump was repeatedly observed with dried and splattered nutrition product on it, and it was sticky to the touch. Interviews with staff, including an LPN and a CNA, revealed a lack of clarity regarding responsibility for cleaning the enteral nutrition pumps. The facility's policy on cleaning and disinfection of resident-care items was reviewed, but it was undated and did not specify who was responsible for cleaning the equipment. The Administrator was unaware of the deteriorating conditions and the issues with the enteral nutrition pump. Despite the facility's practice of conducting daily Angel Rounds to identify problems, the deterioration of door frames and other issues were not documented in the checklists for the months reviewed. The Administrator acknowledged the difficulty in addressing these issues due to the facility's capacity constraints and the need for resident relocation during repairs.
Failure to Document Resident Transfer to Acute Care Hospital
Penalty
Summary
The facility failed to document the basis for a resident's transfer to an acute care hospital, including the specific resident needs that could not be met in the facility and the services available at the hospital to meet those needs. The medical record of the resident, who was admitted with acute respiratory failure with hypoxia, lacked documentation of the transfer or discharge information provided to the hospital. There was no evidence of a Nursing Home Transfer and Discharge Notice or a physician's order for the transfer, which is required for emergent transfers to acute care hospitals. Interviews with the Director of Nursing (DON) revealed that there was no documentation of the physician's notification or authorization for the transfer. The DON confirmed that the resident was transferred to the hospital without proper documentation, and there was no record of the time of departure or mode of transportation. The resident had requested to be sent to the emergency room after complaining of chest pain, but the facility did not document the necessary information to support the transfer, nor did they provide the required information to the acute care hospital.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to unmet care needs. Resident #66, who was cognitively intact and required assistance with some activities of daily living, did not receive necessary toenail care. Despite being independent in many areas, the resident experienced pain due to exceptionally long toenails, which had not been clipped since admission. Interviews with staff revealed confusion about responsibilities for toenail care, with CNAs and the shower team unsure of who should address the issue. The resident's sister had also requested podiatry services, but the resident was not seen during the monthly visits. Resident #113, who was non-verbal and had an IV line in place, did not have a care plan addressing IV line maintenance, including flushes and dressing changes. The resident's medical record lacked orders for routine IV care, and the midline dressing had not been changed since insertion, contrary to facility policy. Interviews with nursing staff revealed a lack of clarity regarding the frequency of dressing changes and flushes, with the LPN unaware of specific orders. The MDS coordinator had not updated the care plan to include IV line care, and the Director of Nursing confirmed that care plans were updated based on daily meetings and 24-hour reports. The deficiencies in care planning for both residents highlight a failure to ensure that care plans are comprehensive and person-centered, with measurable objectives and timeframes. The lack of toenail care for Resident #66 and the absence of IV line maintenance for Resident #113 demonstrate a breakdown in communication and responsibility among staff, leading to unmet care needs and potential risks for the residents.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain good grooming and personal hygiene for four residents. Resident #64 was observed with elongated fingernails and brown debris under them, despite having nail clippers at his bedside. He expressed his inability to trim his nails due to his condition and stated that staff had not offered assistance. His care plan indicated he might need cueing for activities of daily living, but there was no record of nail care being provided in the past 30 days. Resident #99 also had elongated fingernails and expressed concern about the potential for injury. His medical record showed moderately impaired cognition, and his care plan required extensive assistance with personal hygiene. However, there was no documentation of nail care being provided. Similarly, Resident #100 had elongated toenails and had not seen a podiatrist since admission, despite having a physician's order for podiatry as needed. His care plan required staff to notify a nurse if toenail trimming was needed, but there was no evidence of such notification. Resident #66 had exceptionally long toenails, causing him pain, and his sister had requested podiatry services. Despite being cognitively intact and requiring assistance with certain activities, there was no record of his toenails being trimmed since admission. Interviews with staff revealed confusion about responsibilities for nail care, with CNAs and nurses unsure of their roles. The facility's policies outlined the importance of regular nail care to prevent infections and injuries, but these were not followed, leading to the deficiencies observed.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that physician-ordered medication, Prozac 60 mg, was available and administered to Resident #18 as prescribed. On two consecutive days, 7/23/24 and 7/24/24, the medication was not administered because it was not available in the medication cart. On 7/24/24, during a medication administration observation, LPN A confirmed that the Prozac was still not available and was on order from the pharmacy. The facility's system for back-up medications, which included a Pyxis machine, did not have Prozac available for Resident #18 or any other resident. Further investigation revealed that there was no notification to the resident's physician regarding the missed doses on 7/23/24 and 7/24/24. LPN A admitted to not calling the physician about the missed doses and was unsure if anyone else had done so. The facility's policy on administering oral medications required reporting in accordance with facility policy and professional standards, but this was not adhered to in this case. The lack of communication and failure to follow protocol contributed to the deficiency in providing necessary pharmaceutical services to meet the resident's needs.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during the survey. Two specific incidents contributed to this deficiency. In the first incident, a Licensed Practical Nurse (LPN) was observed failing to administer Prozac 60 mg to a resident for three consecutive days due to the medication not being available in the medication cart or the facility's Pyxis machine. The LPN did not notify the resident's physician about the missed doses, and the facility's system for back-up medications did not include Prozac, leading to the resident missing their prescribed medication. In the second incident, the same LPN administered only six out of seven prescribed medications to another resident. The LPN failed to administer Lisinopril, as she did not verify the number of medications in the cup against the Medication Administration Record (MAR) before giving them to the resident. The facility's policy on the administration of oral medications was not followed, as the LPN did not ensure all medications were administered as ordered, nor did she report the omission according to facility policy.
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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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Illustrative
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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) |
|---|---|---|---|---|
| Pavilion At Jacksonville, The | 1.1 mi | ★★★★★ | 18 | 0 |
| Shands Jacksonville Medical Center | 2.1 mi | ★★★★★ | 0 | 0 |
| North Bank Center For Rehabilitation And Healing | 3.4 mi | ★★★★★ | 13 | 0 |
| Park Ridge Nursing Center | 3.7 mi | ★★★★★ | 4 | 0 |
| Riverside Post Acute | 4.3 mi | ★★★★★ | 11 | 0 |
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