Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Middleburg Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Resident Transfers and Discharges: The facility did not complete the required transfer/discharge notice forms for four residents, and the Ombudsman office did not receive the actual AHCA 3120-002 forms. The SSD said he faxed a monthly discharge list instead of the forms, while the MDS Coordinator/RN confirmed her department issued resident discharge notices but could not confirm when Ombudsman notification occurred and was unaware the actual forms had to be sent.
Failure to honor a resident’s choice for bed mobility accommodations: A resident with intact cognition, weakness, fall history, and oxygen dependence asked for partial bedrails to help with positioning and safety, but the request was not addressed in a timely manner. The resident and her daughter reported repeated attempts to reach the Administrator, while PT documentation showed the request was made during the initial eval and was denied because she had not used rails at home. The Administrator later acknowledged the request had been known since admission and that the rails were not installed until nine days later.
Failure to Provide Required Medicare Beneficiary Notices: Two residents remained in the facility after Medicare Part A ended, but the required SNF ABN, Form CMS-10055, was not issued to explain potential financial liability for noncovered services. Interviews showed the SSD, MDS staff, and an LPN had differing roles in discharge notices, and MDS staff acknowledged the SNF ABN was not being provided as required.
Failure to apply an ordered hand splint: A resident with right-sided hemiplegia, severe cognitive impairment, and limited ROM had an active order for a right resting hand splint for 6 to 8 hours daily with skin checks, but observations showed the brace folded on the nightstand while the resident’s right hand remained stiff and curled. Staff interviews indicated CNAs were responsible for placing splints, yet multiple staff were unaware of the brace, the MAR did not list the order, and the care plan had no splinting focus area.
An RN failed to perform hand hygiene while administering medications to two residents. She wore the same gloves while preparing and giving oral meds, eye drops, a transdermal patch, and a nutritional powder mixture, and did not cleanse her hands when entering or leaving resident rooms or between residents. The DON stated the facility had a PIP and recent training on hand hygiene, but the survey observation showed the RN was not following the facility policy requiring handwashing before handling meds and after removing gloves.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to send a copy of the notice of transfer or discharge, using the Discharge/Transfer Notice AHCA 3120-002 form, to the representative of the Office of the State Long-Term Care Ombudsman for four residents reviewed for discharge requirements. The forms for Residents #126, #150, #151, and #152 were incomplete because no date or time of notification was documented to show when the notices were provided to the Long-Term Care Ombudsman office. During an interview, the Social Services Director stated he was responsible for notifying the local state Ombudsman office of transfers and discharges and that his process was to fax the facility’s monthly discharge and transfer list within the first week of the following month. He confirmed that the actual AHCA 3120-002 forms for the four residents were blank in the section for notice to the Local Long-Term Care Ombudsman Council and stated that he did not send the actual forms to the Ombudsman office, only the monthly admission/discharge list. The MDS Coordinator/RN confirmed that her department issued the discharge notifications to residents and that Social Services was responsible for informing the Ombudsman office, but she could not confirm when those notifications were being provided and was unaware of the requirement to send the actual transfer/discharge forms.
Failure to Honor Resident Choice for Bed Mobility Accommodations
Penalty
Summary
The facility failed to honor a resident’s right to make choices regarding accommodations to support safe bed mobility and positioning by not providing requested partial bedrails in a timely manner for one resident. The resident was admitted for short-term rehabilitation on 01/06/2026 with diagnoses including rhabdomyolysis, generalized muscle weakness, anemia, peripheral vascular disease, and dependence on supplemental oxygen. Her admission MDS showed intact cognition with a BIMS score of 14/15, clear speech, and the ability to understand others. She required substantial to maximal assistance for rolling and partial to moderate assistance for sitting to lying and sitting to standing, and no bedrails were documented on the assessment. The resident and her daughter reported that they asked the Administrator on admission for partial bedrails to assist with positioning in bed, but they did not receive a timely response. The resident stated she was worried about hurting herself because staff were asking her to use the closet door handle and side table to reposition herself. The daughter reported that she repeatedly tried to speak with the Administrator, including leaving a note at the front desk, but said he did not address the request when she approached him in the hallway or when she saw him near the resident’s room. Survey observations and interviews showed that no bedrails were in place during the early part of the survey, and staff described a process in which bedrails were obtained through therapy evaluation and approval. PT documentation noted that the resident requested bedrails for safety and positioning during the initial evaluation, but the request was denied because she had not used them at home. The Administrator later acknowledged he knew about the request the day after admission, had consulted with the DON, and did not follow up with the resident and family until the rails were installed nine days after admission. The facility policy stated that residents have the right to reasonable accommodation of individual needs and preferences unless health or safety would be endangered.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required beneficiary notices to two residents who remained in the facility after their Medicare Part A services ended. Record review showed that Residents #150 and #151 were not issued the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, at the time Medicare A coverage terminated, and the notice explaining potential financial liability for items or services no longer covered by Medicare A was not provided. During interviews, the Social Services Director stated he coordinated resident discharges but was not responsible for issuing the Notice of Medicare Non-Coverage or the SNF ABN, identifying the MDS department as responsible. An LPN working in MDS confirmed she issued discharge notices discussed in the weekly PDPM meeting and was responsible for the SNF ABN, but stated she was unaware that the SNF ABN was required. The MDS Coordinator also confirmed she assisted with NOMNC notifications and acknowledged that the required SNF ABN notification was not being provided as required. The facility policy on discharge planning stated the process would be implemented in accordance with State and Federal regulations and discharge rights at 483.15(b).
Failure to Apply Ordered Hand Splint
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the ordered treatment and services to maintain or improve ROM when it did not ensure daily placement of a physician-ordered right resting hand splint. Resident #66 was admitted with hemiplegia/hemiparesis following a cerebral infarction affecting her right side, along with reduced mobility, muscle weakness, and chronic pain syndrome. Her most recent MDS showed severe cognitive impairment, upper extremity impairment on one side, lower extremity impairment, wheelchair use, dependence for toileting, and substantial to maximal assistance needs for bathing and dressing. On observation, the resident was seen in bed with her right hand stiff and curled toward her palm while the dark blue brace was folded on the nightstand. When asked about the brace, she indicated she did not wear it and appeared to cradle her right hand. A second observation showed the same brace still on the nightstand in the same location, and the resident again pulled her right arm out from under the covers and cradled it rather than wearing the brace. Her family member reported visiting daily and stated they had not seen staff helping her with the brace in months. Record review showed an active physician's order for a right resting hand splint for 6 to 8 hours per day with skin checks before and after use, but the December 2025 MAR did not list the splint order. The active comprehensive care plan also had no focus area for the right-hand contracture, splinting, or skin checks. Staff interviews confirmed that CNAs were responsible for placing splints, but multiple staff members were unaware of the brace or could not confirm who was responsible for applying it. The OT confirmed the resident was not currently receiving therapy and stated restorative nursing or the assigned CNA was expected to place the hand splint when the resident was not active in therapy. The MDS coordinator confirmed the splint order was missed on the quarterly MDS assessment and that no comprehensive care plan was developed or implemented.
Hand Hygiene Not Performed During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and help prevent the development and transmission of communicable diseases and infections. During medication administration observation, RN B did not perform hand hygiene when entering Resident #70's room, while administering oral medications and eye drops, or after removing gloves before leaving the room. RN B wore the same pair of gloves while handling the resident's oral medications and eye drops and did not cleanse her hands before moving on to the next resident. RN B then prepared medications for Resident #47 without performing hand hygiene after caring for Resident #70. While wearing gloves, she prepared oral medications, mixed Juven powder with water, and handled a Nicotine Transdermal patch. She entered Resident #47's room wearing the same gloves and did not perform hand hygiene. RN B applied the patch, handed the resident oral medications, and then gave the resident the cup containing the mixed Juven powder, all while still wearing the same gloves and without hand hygiene before leaving the room. She only cleansed her hands with alcohol-based hand sanitizer after returning to the medication cart and removing the gloves. During interview, RN B stated staff are supposed to wash their hands between residents and upon entrance and exit of resident rooms. The DON stated the facility had a PIP on hand hygiene and had just completed training. Facility policy required handwashing before preparing or handling medications and after removing gloves. Records reviewed showed handwashing education and competency documentation, but RN B was not listed on the education sheets provided after the survey, and handwashing audits reviewed by the facility had documented RN B as performing hand hygiene appropriately on prior dates. On the survey date, however, RN B was observed failing to wash her hands during medication administration for two residents, and the report states the facility's performance improvement plan was ineffective.
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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 Middleburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Fleming Island | 5.5 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Orange Park | 6.2 mi | ★★★★★ | 0 | 0 |
| Isle Healthcare & Rehabilitation Center | 6.3 mi | ★★★★★ | 0 | 0 |
| Orange Park Rehabilitation And Nursing Center | 6.4 mi | ★★★★★ | 0 | 0 |
| Aviata At Orange Park | 7.2 mi | ★★★★★ | 7 | 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.