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 Lanier Rehabilitation Center during CMS and state inspections, most recent first.
The facility's kitchen staff failed to follow proper dish sanitation and hand hygiene procedures, with dishwashing temperatures below required levels and toxic chlorine levels in the dish machine. Staff did not wash hands between glove changes, violating facility policies and posing a risk of foodborne illness.
A resident at the facility was found without necessary fall prevention measures, despite being care planned for fall risk due to muscle weakness and limited mobility. Observations showed the absence of fall mats and signage, and staff interviews confirmed the lack of interventions. The facility's PIP for fall management was not effectively implemented, as audits did not verify interventions in resident rooms, and the DON was unsure if checks were conducted.
The facility's kitchen water heater was not functioning, causing the dish machine's temperatures to fall below the required levels. Staff used a low-temperature dish machine with chlorine bleach and attempted to use hot water from a coffee machine. The water heater had been out of order for weeks, and installation of a new heater was delayed due to contractor availability.
The facility failed to ensure the Dietary Manager attended a Resident Council meeting to discuss food concerns and did not adequately address resident care issues by failing to review resident rights and inform residents of policy updates. Residents were not given the opportunity to verify meeting minutes, and concerns were not properly documented or addressed. The facility's policy for Resident Council meetings was not followed, leading to a deficiency in honoring residents' rights.
A resident with a history of traumatic brain injury and mobility issues experienced multiple falls due to the facility's failure to implement a person-centered care plan. Despite being assessed as high risk for falls, the resident's room lacked fall mats and signage, and the reacher tool was out of reach. Staff interviews revealed a lack of awareness and communication regarding fall prevention interventions, highlighting a deficiency in the facility's care plan implementation.
A facility failed to implement fall prevention measures for a resident at risk, as her room lacked fall mats and signage. Despite being care planned for fall risk, the resident experienced multiple falls. Additionally, another resident's room contained accessible cleaning supplies, posing a safety risk. The facility lacked a protocol for safe storage of such items, and staff interviews revealed communication gaps in implementing care plans.
Improper Dish Sanitation and Hand Hygiene in Kitchen
Penalty
Summary
The facility kitchen staff failed to adhere to proper dish sanitation procedures, hand hygiene, and air drying practices, which are crucial to preventing foodborne illnesses in a healthcare setting. During a kitchen tour, it was observed that the hand sink lacked soap, and the dishwashing process was not conducted at the required temperatures. The dish machine's temperature did not exceed 69 degrees Fahrenheit during both the wash and rinse cycles, contrary to the manufacturer's specifications that require a minimum of 120 degrees Fahrenheit. The Certified Dietary Manager (CDM) acknowledged that the facility's water heater had been out of order for several weeks, and the staff had been using water from a coffee machine to attempt to maintain hot water levels. The dish machine was also found to have a chlorine level exceeding the recommended parts per million (ppm), with test strips indicating a toxic level of 200+ ppm, while the acceptable range is 50 to 100 ppm. The CDM confirmed the toxic level and explained that the facility had been waiting for a contracted maintenance provider to install a new water heater, which had been delayed due to receiving incorrect units and scheduling issues with the technician. Despite these issues, the facility continued to use the dish machine daily, believing that the sanitizer level would compensate for the inadequate water temperature. Additionally, staff members were observed not washing their hands between glove changes during food preparation, which is a violation of the facility's hand hygiene policy. Dietary Aides were seen changing gloves multiple times without washing their hands, even after handling potentially contaminated items. This practice was contrary to the training they had received, which emphasized the importance of handwashing between glove changes. The facility's policies and procedures clearly outlined the need for proper hand hygiene and dish sanitation, yet these were not followed, posing a risk of foodborne illness to the residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement its performance improvement plan's corrective actions to reduce the risk of falling for Resident #64, who was one of four residents reviewed for falls. Observations revealed that Resident #64 was lying on the edge of her bariatric bed without any bed rail or enabler, and there were no fall mats or signs posted in her room. Despite being care planned for fall risk due to muscle weakness and limited mobility, the interventions such as a fall program sign and a low bed with mats were not in place. Resident #64 had experienced multiple falls, and the facility's interdisciplinary team had recommended specific interventions, but these were not implemented. Interviews with staff, including a CNA and an LPN, confirmed the absence of the required interventions in Resident #64's room. The facility's Performance Improvement Plan (PIP) for fall management, led by the Regional Director of Clinical Services, identified the need for education on fall management and ensuring interventions were in place. However, audits did not verify that interventions were implemented in resident rooms, and the Director of Nursing was unsure if checks were being conducted. The Regional Director acknowledged the lack of a system to ensure care plan interventions were verified. The Director of Nursing explained that falls were reviewed in meetings, and the Unit Manager was responsible for ensuring interventions were in place. However, observations in Resident #64's room indicated that the actions outlined in the fall management PIP were not being followed. The facility's policy emphasized the importance of assessing resident care practices and developing plans to correct quality deficiencies, but these were not effectively implemented for Resident #64.
Kitchen Water Heater Malfunction Leads to Inadequate Dish Machine Temperatures
Penalty
Summary
The facility failed to maintain the kitchen's mechanical equipment in safe operating condition, specifically the water heater, which was not functioning. This resulted in the dish machine's wash and rinse temperatures not reaching the manufacturer's specified levels. During a kitchen tour, it was observed that the dish machine's temperature did not exceed 69 degrees Fahrenheit during both the wash and rinse cycles. The Certified Dietary Manager (CDM) explained that the facility had been using a low-temperature dish machine with chlorine bleach for sanitization, and they attempted to use hot water from a coffee machine to compensate for the lack of hot water from the water heater. Interviews with the CDM and the Maintenance Director revealed that the water heater had been out of order for several weeks to a couple of months. The facility had received the correct replacement water heater, but installation was delayed due to the unavailability of the contracted maintenance provider. The Maintenance Director noted that the previous water heater had rusted through, and there were multiple delays in receiving the correct replacement. The manufacturer's specifications for the dish machine required a minimum incoming temperature of 120 degrees Fahrenheit, which was not met due to the water heater's malfunction.
Failure to Honor Resident Council Participation and Address Concerns
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not ensuring the Dietary Manager attended a Resident Council meeting to discuss food concerns, despite being invited. Additionally, the facility did not adequately address issues of resident care and life by failing to review resident rights and inform residents of updates to the facility's policies and procedures. This was evidenced by discrepancies in the Resident Council minutes and the lack of proper documentation and follow-up on residents' concerns. Interviews with residents revealed that they were not given the opportunity to read or verify the accuracy of the Resident Council minutes, and they did not receive copies of these minutes. The Activities Director typically attended the meetings and took notes informally, which were not reviewed or signed off by the residents. Residents expressed concerns about the presence of the Social Services Director, who they felt was intimidating, and they were unsure about how to contact the Ombudsman for assistance. The facility staff did not review residents' rights during the council meetings, and there was no discussion of old business to ensure prior concerns had been addressed. The facility's policy and procedure for Resident Council meetings were not followed, as the minutes were not documented on standard forms, and there was no documentation of which residents' rights or facility policies were discussed. The Administrator and Regional Nurse Consultant confirmed that the facility did not adhere to its own guidelines for documenting and addressing residents' concerns. The Certified Dietary Manager was unaware of the residents' food concerns and had not been notified to attend the meeting. The report indicates that the facility's failure to properly document and address residents' concerns led to a deficiency in honoring residents' rights to participate in council meetings effectively.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a person-centered care plan for fall prevention for a resident, leading to multiple falls. The resident, who was cognitively intact and had a history of traumatic brain injury, muscle weakness, and mobility issues, was assessed as high risk for falls. Despite having a care plan in place that included interventions such as keeping the call light within reach, using fall mats, and posting fall prevention signage, these measures were not consistently implemented. Observations revealed that the resident's room lacked fall mats and signage, and the reacher tool was out of reach, contributing to the resident's inability to prevent falls. Interviews with staff, including CNAs and LPNs, indicated a lack of awareness and communication regarding the resident's fall prevention interventions. The CNAs and LPNs were familiar with the care plan interventions listed in the Kardex, but these were not observed to be in place during multiple visits to the resident's room. The Unit Manager and Director of Nursing acknowledged the oversight, with the DON noting that falls were reviewed daily, and interventions were supposed to be ensured by the Unit Manager. The facility's Fall Management Process required weekly IDT meetings to review falls and ensure interventions were in place, but the observations and interviews suggest a breakdown in this process. The resident's repeated falls and the absence of prescribed interventions highlight a deficiency in the facility's implementation of the care plan, as evidenced by the lack of fall mats, signage, and accessible tools for the resident.
Deficiencies in Fall Prevention and Environmental Safety
Penalty
Summary
The facility failed to ensure that Resident #64's room was free from accident hazards and that appropriate fall prevention measures were in place. Despite being care planned for fall risk due to muscle weakness and limited mobility, Resident #64 experienced multiple falls. Observations revealed that the resident's room lacked fall mats and signage indicating fall risk, as outlined in the care plan. Interviews with staff, including a CNA and LPN, confirmed that the interventions specified in the care plan were not implemented, and the resident was not provided with necessary assistive devices, such as a reacher, which was out of her reach. Additionally, the facility did not ensure the safe use and storage of personal cleaning products for Resident #24. Observations found that aerosol disinfectant spray and bleach wipes were accessible in the resident's room, which was shared with another resident. Despite the resident's cognitive intactness, he had limited motor skills and was unable to use a key to lock his bedside drawer. The facility lacked a written protocol for the safe storage of such items, and the resident's cleaning supplies were not assessed or care planned for safe storage. Interviews with the Director of Nursing and Regional Clinical Director revealed a lack of oversight and communication regarding the implementation of fall prevention measures and the safe storage of cleaning supplies. The facility's failure to adhere to its fall management process and ensure environmental safety for residents resulted in deficiencies in providing a hazard-free environment and adequate supervision to prevent accidents.
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 272 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — 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 Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River City Nursing And Rehab Center | 3 mi | ★★★★★ | 2 | 0 |
| Aviata At Harts Harbor | 4.4 mi | ★★★★★ | 26 | 0 |
| Lakeside Center For Rehabilitation And Healing | 7 mi | ★★★★★ | 6 | 0 |
| Jacksonville Nursing And Rehab Center | 7.8 mi | ★★★★★ | 0 | 0 |
| Pavilion At Jacksonville, The | 8.2 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.