Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Palm Garden Of Jacksonville during CMS and state inspections, most recent first.
Food was not kept at safe and appetizing temperatures during meal service. A baked chicken item on the holding line measured 104 degrees F, and a test tray on a hallway cart had a hamburger at 128 degrees F, a mechanical soft hamburger at 120 degrees F, green beans at 115.5 degrees F, and mashed potatoes and gravy at 120.5 degrees F. The CDM stated the temperatures should have been hotter, and the facility policy required hot foods to be held at 135 degrees F or greater.
Unsafe food storage and labeling practices were observed in the kitchen and walk-in cooler. Surveyors found an open, undated container of beef base paste, spoiled green peppers with brownish black sections and greenish ooze, an uncovered cake pan during breakfast service, and an open, undated jar of grape jelly. The Dietary Supervisor and CDM acknowledged that opened items should be dated, covered when not being served, and discarded when expired.
Incomplete Discharge Documentation: The facility failed to properly document discharge plans and discharge details for two residents reviewed for transfer/discharge. One resident had a physician order and nursing note indicating discharge with medications, but the record lacked additional discharge documentation and the discharge date was not entered. Another resident had no care plan update for a pending discharge, no documented reason for the transfer, and no physician discharge order in the chart; staff reported family dynamics and a move closer to a daughter.
A resident with multiple chronic conditions, including DM, PVD, prior toe amputations, and a stage IV PI plus a venous/arterial ulcer, did not receive consistent wound treatment and infection management. The wound care note documented Pseudomonas in the left foot wound and a recommendation for topical gentamicin, but the charted MD orders did not include gentamicin. The RN could not produce documentation of contact with the hospice provider, and the resident stated he refused the wound care MD visit but did not refuse wound treatment.
A facility failed to properly label an insulin pen and properly store a resident’s anti-diarrheal medication. An unlabeled insulin pen was found in a bag for a different insulin and resident, while anti-diarrheal medication was observed at a resident’s bedside and later on the nightstand instead of being secured. Staff and the DON described labeling expectations for insulin pens, and the facility policy stated that medications with missing or incomplete labels should be destroyed and reordered.
A resident with multiple chronic conditions, including CVA, hemiplegia, DM, and PVD, had ongoing left-sided tooth pain with tenderness and pain triggered by air or cold. Staff documented the complaint and placed the resident on the in-house dentist list as a priority, but the resident had not yet been seen and no earlier dental care was arranged despite continued pain.
A facility failed to consistently monitor blood glucose levels for a diabetic resident receiving insulin therapy, as per physician orders. Despite the resident's history of diabetes with complications, there were significant gaps in monitoring, with no checks documented for over a month. Interviews with staff revealed inconsistencies in following protocols, and the DON confirmed the absence of a facility policy for documenting blood sugar levels, relying solely on physician orders.
A facility failed to ensure proper review and documentation of a resident's care, including blood glucose monitoring and insulin administration. The resident, with a history of type 2 diabetes, had inconsistent blood glucose checks despite having orders for insulin therapy. Interviews with staff revealed a lack of clear policies for monitoring and documentation, contributing to the deficiency.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not maintained at a safe and appetizing temperature during lunch service and on a test tray after the last resident received a tray. During an observation of lunch service, the baked chicken on the holding line in the main kitchen measured 104 degrees Fahrenheit, and the Certified Dietary Manager stated it should not be that temperature. During a later observation of a test tray on the hallway cart, the hamburger measured 128 degrees Fahrenheit, the mechanical soft hamburger measured 120 degrees Fahrenheit, the green beans measured 115.5 degrees Fahrenheit, and the mashed potatoes and gravy measured 120.5 degrees Fahrenheit. When interviewed, the Certified Dietary Manager stated the food should be hotter than that. The facility policy titled Record of Food Temperatures required hot foods to be held at 135 degrees Fahrenheit or greater and stated no food would be served that did not meet food code standard temperatures.
Unsafe Food Storage and Labeling Practices
Penalty
Summary
Food was not safely stored, labeled, or discarded in the kitchen and walk-in cooler. During a kitchen tour with the Dietary Supervisor, surveyors found an open container of Beef Base Paste in the walk-in cooler that was undated, and two green bell peppers in a cardboard carton dated 8/12/2025 that had shriveled, brownish black sections with a thick greenish substance oozing from them. The Dietary Supervisor stated the paste should have been dated when opened and was unsure why the peppers had not been thrown out. During the same tour, surveyors observed an uncovered cake pan sitting on a stainless-steel counter during breakfast service and an open jar of grape jelly that was undated. The Dietary Supervisor stated the cake should have been covered and was unsure why the jar was not dated. The Certified Dietary Manager stated that items should be dated when opened, covered when not being served, and discarded when expired. The facility policy titled Food Labeling and Dating stated that opened products should be labeled and dated.
Incomplete Discharge Documentation
Penalty
Summary
The facility failed to properly document discharge plans and discharge details for two residents reviewed for transfer/discharge. One resident was care planned to remain in long-term care, but a nursing note and physician order later indicated discharge to Terrace of Jacksonville at family request with transportation arranged for 11:30 and all medications to go with the resident. The record did not contain additional documentation about the discharge, and no documentation was entered for the date of discharge. During interview, the CPS stated the resident had initially been planned to remain in the center and that a note indicated she was going home, but the reason for discharge could not be located. For another resident, the care plan also indicated the resident was to remain in long-term care, but there were no care plan updates showing a pending discharge. The record contained only a note stating the resident was discharged to another facility via transport accompanied by family, with no documentation of the reason for discharge and no physician discharge order present. During interviews, the DCS stated there were family dynamics and that the other facility was closer to the daughter, while the CPS stated a social worker had been contacted by the family and acknowledged that no discharge order was in the record.
Failure to Provide Ordered Wound Care and Infection Management
Penalty
Summary
The facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for a resident with multiple wounds, including a stage IV pressure injury and a venous/arterial ulcer. The resident had significant medical history including cerebrovascular disease, hemiplegia/hemiparesis following cerebral infarction, type II diabetes mellitus with diabetic neuropathy, peripheral vascular disease, prior toe amputations, and idiopathic aseptic necrosis of the left toes. The wound care physician documented that the left lateral foot grew Pseudomonas and noted that the patient refused care and requested the physician sign off the case. The note also stated the patient was advised of the risks of refusing care and of the culture results with a recommendation for antibiotics, and that the physician would sign off at the patient’s request. The dressing treatment plan included daily calcium alginate with silver, topical gentamicin, and a gauze island dressing, but the physician orders in the record included Betadine and dry dressing for the right great toe and calcium alginate with dry dressing for the left partial foot amputation site, with no gentamicin order. During interview, the wound care RN stated that when the wound care physician made a recommendation, he notified the attending physician for agreement, but he could not find documentation of contact with the hospice provider regarding the gentamicin recommendation. The resident stated he refused to be seen by the wound care physician but did not refuse wound treatment or the recommendation, and said the physician was debriding the wound and making it worse even though the wound was almost closing up.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled for one resident to support safe medication administration. During the survey, an unlabeled insulin pen was found in a bag labeled for a different type of insulin and a different resident. The pen was observed without the resident’s name or other identifying information, and the facility’s own staff described that insulin pens should arrive from the pharmacy labeled with the resident’s name, room number, prescription, expiration date, and other pertinent information. Interviews with nursing staff and the DON showed that the unlabeled insulin pen was not handled in a manner consistent with the facility’s stated process. One nurse stated that if an insulin pen was found unlabeled and in the wrong bag, it would be discarded and a new one obtained and labeled. The DON stated that the insulin should be discarded and reordered. The facility’s Pharmacy Services and Procedures Manual stated that medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions should be destroyed and reordered. The facility also failed to ensure medications were properly stored for one resident. Anti-diarrheal medication was observed in a clear plastic bag at the bedside and later on the nightstand of a resident with intact cognition, who stated she had brought the medication with her and denied that a cousin had brought it to the facility. The resident had diagnoses including poly-osteoarthritis, scoliosis, and major depressive disorder, and her orders included multiple PRN bowel medications and loperamide for loose stools. The medication was not secured in a locked compartment or separately locked controlled-drug storage area.
Failure to Obtain Timely Dental Care for Resident With Tooth Pain
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who was experiencing ongoing tooth pain. During a tour, the resident was observed guarding the left side of his face and stated that air hitting the tooth caused severe pain, rating it 6 out of 10 and describing the pain as intermittent when cold contacted the tooth. The resident had a history of cerebrovascular disease, left-sided hemiplegia/hemiparesis following cerebral infarction, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and multiple prior toe amputations. Record review showed that a change-in-condition form documented a left-sided toothache with tenderness on palpation and 8/10 pain, with a recommendation for the resident to see the on-site dentist and the resident representative notified. The care plan addressed oral/dental health problems related to left-sided tooth pain and included arranging dental care as needed, but the resident remained without dental treatment when interviewed later and stated he still had tooth pain and had not been offered an alternative provider when the in-house dentist had no earlier openings. Staff interviews confirmed the issue was known, that the resident had been placed on the in-house dentist’s list as a priority patient, that the next dental visit was scheduled weeks later, and that the resident had not yet been seen by anyone for the complaint.
Failure to Monitor Blood Glucose Levels for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards by not consistently monitoring blood glucose levels for a resident with diabetes. The resident, who had a history of type 2 diabetes mellitus with complications such as chronic kidney disease and polyneuropathy, was prescribed insulin therapy. However, the facility did not consistently perform blood glucose monitoring as per the physician's orders, which included Accu-checks three times a day for a specified period. The medical records revealed significant gaps in blood glucose monitoring, with no documented checks between late June and early August, despite the resident receiving insulin. Interviews with facility staff, including an LPN, the Director of Education, and the Unit Manager, highlighted inconsistencies in following protocols for blood glucose monitoring. The staff acknowledged that residents receiving insulin should have corresponding orders for blood glucose checks, and any refusals should be documented and communicated to the physician. The Director of Nursing confirmed the absence of a facility policy for documenting blood sugar levels and insulin administration, relying solely on physician orders. This lack of a structured policy contributed to the oversight in monitoring the resident's blood glucose levels, which is crucial for managing diabetes effectively. The report references guidelines from reputable sources, emphasizing the importance of regular blood glucose monitoring for patients on insulin therapy to prevent complications such as hypoglycemia.
Deficiency in Blood Glucose Monitoring and Documentation
Penalty
Summary
The facility failed to ensure that the physician or physician representative reviewed the resident's total program of care, including medications and treatments, and signed and dated all orders for a resident who was being monitored for blood glucose levels. The resident, who had a history of type 2 diabetes mellitus with diabetic chronic kidney disease and diabetic polyneuropathy, was receiving insulin therapy. However, there was a lack of consistent documentation and monitoring of blood glucose levels as per the physician's orders. The medical record review revealed that the resident had orders for Humulin N and Insulin Aspart, with specific instructions for administration. Despite these orders, there were inconsistencies in the documentation of blood glucose monitoring, with several instances where blood glucose checks were not recorded, particularly between late June and early August. Interviews with facility staff, including an LPN, the Director of Education, and the Unit Manager, highlighted a lack of clarity and adherence to policies regarding blood glucose monitoring and documentation. The Director of Nursing (DON) confirmed that there was no specific facility policy for documenting blood sugars, insulin administration, or blood glucose checks, relying instead on physician orders. This lack of a structured policy contributed to the deficiency, as regular monitoring and documentation are crucial for managing diabetes effectively, especially when insulin therapy is involved. The absence of consistent blood glucose monitoring and documentation could potentially impact the resident's diabetes management and overall health.
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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) |
|---|---|---|---|---|
| Vivo Healthcare Taylor | 1 mi | ★★★★★ | 2 | 0 |
| Riverwood Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Jacksonville | 1.3 mi | ★★★★★ | 0 | 0 |
| Aviata At Jacksonville | 1.5 mi | ★★★★★ | 10 | 0 |
| Woodland Grove Healthcare & Rehabilitation Center | 1.5 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.