Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Pavilion At Jacksonville, The during CMS and state inspections, most recent first.
Menus and recipes were not followed during meal preparation. Staff were observed preparing meatloaf and mashed potatoes without measuring ingredients, using substitutions such as Manwich sauce, and serving salads that varied widely between residents, with some receiving only lettuce while another resident received a more complete salad. The CDM stated the facility did not always have ingredients and did not always follow recipes, and the RD confirmed that changing recipes compromised the nutritive value of meals and that the salads served were insufficient.
Food service sanitation deficiencies were observed in the kitchen and storage areas, including dark residue in the ice machine seams, food residue on the food processor, debris under the meat slicer blade, a detached milk cooler seal with pooled water, and spoiled onions with gnats present. A Cook/Dietary Aide was also observed preparing meatloaf with dark black crusty areas on the loaves, while the CDM and Maintenance Director gave conflicting statements about responsibility for the cooler seal and ice machine cleaning.
Inaccurate catheter documentation in resident record. A resident with quadriplegia and neurogenic bladder was listed in the Resident Matrix and MDS as having an indwelling catheter, but surveyors observed no catheter, bag, or tubing in the room. Progress notes stated she returned from the hospital without a Foley and was voiding well, while the care plan still reflected Foley use. A CNA said the catheter had been gone for over 2 months, and the MDS Coordinator/ADON said she had missed the status and had not updated the care plans.
Infection control was not followed during insulin administration when an RN injected a clean insulin needle into a multi-dose vial without first cleaning the stopper. In another room, a dried blood stain remained on the floor and was only partially removed later; the housekeeper used an acid bathroom cleaner instead of the facility’s bleach-based blood spill procedure, did not report the spill, and housekeeping leadership confirmed bleach was not available or used.
The facility failed to follow standardized recipes, resulting in unpalatable food and frequent substitutions due to missing items. Staff relied on personal experience rather than standardized procedures, and the Dietary Manager was not a Certified Dietary Manager (CDM). The Registered Dietitian (RD) confirmed the need for better communication and assistance.
The facility failed to obtain a Level II PASARR for two residents diagnosed with mental disorders, including bipolar disorder and schizoaffective disorder. The residents' MDS assessments indicated severe cognitive impairments and mental health issues, but the necessary in-depth evaluations were not conducted, leading to inadequate assessment and care planning.
The facility failed to employ sufficient staff with appropriate competencies in the Dietary Department. Employee D, responsible for the department, did not use recipes and had not completed necessary CDM classes. The RD was only present 16 hours per month and not frequently consulted. The facility did not always receive correct food items, leading to substitutions. The Administrator was unaware of Employee D's CDM application status, and the RD was not involved in QAPI meetings.
The facility failed to provide appropriate discharge summaries for two residents, one with severe cognitive impairment and another with moderate cognitive impairment. Both residents were discharged without a recapitulation of their stay, and the Social Services Director confirmed that no discharge summaries were completed.
Menus and Recipes Not Followed
Penalty
Summary
The facility failed to ensure that menus met residents’ nutritional needs in accordance with established national guidelines, including failure to follow standardized recipes. During kitchen observations, staff were preparing the lunch menu items, including meatloaf homestyle, parsley mashed potatoes, seasoned beans, dinner roll, and brownies. The meatloaf was observed as two unidentifiable loaves covered in dark red sauce on charred paper, with dark black crusty areas on top and in the middle of the loaves. The cook then placed one loaf into a food processor, added water without measuring the amount, blended it, and poured the mixture into a pan, while also adding white flakes and milk without measuring those ingredients. The Certified Dietary Manager stated that the recipes were standard but that the facility made minor changes, including using Manwich sauce instead of tomato paste in the meatloaf. She also stated that the meatloaf was something the facility created and used its own recipe for, and that budget concerns limited food orders. The recipe she provided had not been reviewed or signed by the RD. On follow-up, she stated that the facility did not always follow recipes because it did not always have the ingredients, and she could not explain how the nutritive value established in the RD-developed menus would be maintained when substitutions were made. Additional observations showed other menu preparation issues. Staff were cooking spaghetti noodles in a small metal serving dish because there were no cooking pots or pans in the facility. At lunch, residents on renal diets were served small bowls containing only lettuce, while a resident who was the Resident Council President received a salad with lettuce, tomato, black olives, cheese, purple onions, and croutons. The RD later confirmed that menus and recipes needed to be followed and stated that the salad served to the other residents was insufficient and should have included more than lettuce. Facility policies required standardized menus planned in advance, menus meeting nutritional needs, and RD review and approval of all menus, but the recipes for the meals served were not followed.
Food Service Equipment and Storage Sanitation Deficiencies
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed a dark fuzzy residue and debris along the seams and edges of the ice machine lid, dried yellowish food residue and buildup on the food processor bowl and spindle, and miscellaneous debris in the crevices and seams under the meat slicer blade. The milk cooler had a detached seal with water pooled at the bottom, and a box of sealed juice cups inside the cooler had leaking cups with melting ice in the middle of the box. In dry storage, onions were observed with soft, slimy wet spots and dark fuzzy substance under the papery skin. The nourishment room also had debris and staining on the cabinet floor surface. During meal preparation, a Cook/Dietary Aide was observed preparing meatloaf for the resident lunch meal, and the meatloaf loaves were covered in dark red sauce on charred paper with several spots of dark black crusty substance on top of and in the middles of the loaves. On follow-up kitchen tours, the same sanitation issues remained: the ice machine continued to have dark residue in the seams, the meat slicer still had debris under the blade, the food processor still had residue buildup, and the onions remained in the same condition with gnats circling above and inside the box. The CDM stated that Maintenance was responsible for cleaning the ice machine monthly and keeping a log, while the Maintenance Director stated he had not ordered repairs for the cooler seal and had told the CDM that she needed to do it. The ice machine cleaning log showed it was last cleaned on 2/20/26.
Inaccurate catheter documentation in resident record
Penalty
Summary
The facility failed to maintain Resident #6’s medical record as complete and accurately documented regarding indwelling catheter status. Resident #6 was admitted with quadriplegia, C5-C7, and diagnoses including neuromuscular dysfunction of the bladder and presence of urogenital implants. The facility’s Resident Matrix listed her as having an indwelling catheter, and her quarterly MDS also documented an indwelling catheter present in Section H. However, on observation, Resident #6 was in her room without an indwelling catheter, bag, or tubing. The progress note documented that after returning from the hospital with sepsis, she came back without a Foley catheter and was voiding well, and another note stated there was no Foley catheter. The care plan still stated that she required use of a Foley catheter related to urinary retention secondary to neurogenic bladder. During interview, a CNA stated the resident had a catheter before but it had been gone for over 2 months, and the MDS Coordinator/Assistant DON stated she had missed the catheter status and had not done anything with the care plans.
Infection Control and Blood Spill Cleaning Deficiencies
Penalty
Summary
Proper infection control measures were not followed during insulin administration for Resident #16. On 3/11/2026 at 11:33 AM, Staff A, RN, was observed checking the resident’s blood glucose and determining that 1 unit of insulin coverage was needed per sliding scale order. The nurse then injected a clean insulin needle into the stopper of the resident’s multi-dose vial without first cleaning the stopper. When interviewed shortly afterward, Staff A stated, “What did I forget? I forgot to clean the stopper.” Resident #16’s record showed admission to the facility with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with foot ulcer, type 2 diabetes mellitus with hyperglycemia, and other specified anemias, and the physician’s order directed insulin lispro before meals and at bedtime based on sliding scale. A safe, clean, and home-like environment was not maintained in Resident #25’s room. On 03/09/2026 at 10:07 AM, a dried reddish-brown stain was observed on the floor near the window side of the bed in room [ROOM NUMBER]-B. Resident #25 stated the substance on the floor was blood from his foot and that it happened over the weekend. A second observation on 03/10/2026 at 9:14 AM showed only partial removal of the stain. Photographic evidence was obtained during both observations. Interviews and record review showed the facility’s housekeeping response to the blood stain did not match its written policy. The housekeeper stated she noticed the dried blood stain, sprayed it with an orange cleaning substance in a bottle labeled acid bathroom cleaner, mopped it up, discarded the mop and rag in a red bag, and placed a wet floor sign, but did not report the blood stain to anyone. The housekeeping supervisor stated staff are supposed to clean blood spills by sanitizing with spray, mopping it up, using a clean mop, and washing the blood-stained item separately from other laundry. A tour of housekeeping chemical storage found no bleach available, and the supervisor confirmed housekeepers do not use bleach. The facility policy for cleaning spills or splashes of blood or body fluids required bleach-based disinfectant procedures.
Failure to Follow Standardized Recipes and Ensure Palatable Food
Penalty
Summary
The facility failed to ensure food served was prepared by methods that conserved nutritive value and flavor, as staff did not follow standardized recipes to provide palatable and appetizing food. During a follow-up tour of the kitchen, it was confirmed that no recipes were used for the day's menu, and staff relied on personal experience and estimation rather than standardized procedures. This resulted in unpalatable food, such as cabbage that tasted highly of pepper, which was confirmed through a test tray evaluation. Interviews with multiple kitchen staff revealed a lack of consistency in food preparation methods. Staff members admitted to not using recipes and instead relied on their own cooking knowledge or guidance from the Dietary Manager, who also did not use standardized recipes. Additionally, there were reports of frequent substitutions due to missing food items, and some staff mentioned running out of food one to two days per week. The Dietary Manager, who was not a Certified Dietary Manager (CDM), acknowledged these issues and stated that corrective actions were discussed with the Registered Dietitian (RD). The RD, who worked part-time at the facility, confirmed that the Dietary Manager was not a CDM and required more assistance. The RD was not always informed about substitutions and was working on improving communication with the Dietary Manager. The Administrator, who had been at the facility since February 2024, was unaware of the status of the Dietary Manager's CDM application and stated that corporate oversaw the food budget. The facility's policy required the use of standardized recipes and methods to ensure food was palatable and nutritious, but these guidelines were not being followed, leading to resident complaints about food quality.
Failure to Conduct Level II PASARR for Residents with Mental Disorders
Penalty
Summary
The facility failed to obtain a pre-admission screening and resident review (PASARR), Level II, for two residents diagnosed with mental disorders. Resident #25 was admitted with diagnoses including bipolar disorder, Parkinson's disease, general anxiety disorder, and unspecified dementia. The PASARR completed at admission did not reflect her bipolar disorder or dementia. Her Annual Minimum Data Set (MDS) assessment indicated severe cognitive impairments and various mental health issues, but no Level II PASARR was conducted to address these conditions comprehensively. Similarly, Resident #33 was admitted with diagnoses including unspecified dementia, major depressive disorder, epilepsy, and schizoaffective disorder. The admission PASARR did not include the schizoaffective disorder diagnosis. His Quarterly and Annual MDS assessments documented severe cognitive impairments and mental health issues, but the facility failed to perform an updated screening with the new diagnosis. The Social Services Director confirmed that Level II reviews should have been conducted for both residents but were not completed, leading to inadequate assessment and care planning for their mental health needs.
Failure to Employ Qualified Dietary Manager and Ensure Adequate Nutritional Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. During a kitchen tour, it was revealed that Employee D, who was responsible for the Dietary Department, did not use recipes for meal preparation and relied on traditional cooking methods without measurements. Employee D had been cooking by sight since 2001 and had not completed the necessary Certified Dietary Manager (CDM) classes or applied for the exam, despite being in the role since September 2023. The Registered Dietitian (RD) was only present at the facility for 16 hours per month and was not frequently consulted by Employee D for menu changes or kitchen inspections. The RD expressed concerns about the lack of training and the need to assist Employee D more due to her limited qualifications. Interviews with the RD and the Administrator revealed that the facility did not always receive the correct food items for the menu, leading to substitutions being used approximately twice a month. Employee D was responsible for overseeing the food budget and purchasing food and supplies, but she had not taken the necessary steps to become a certified dietary manager. The RD was not involved in Quality Assurance and Performance Improvement (QAPI) meetings, which were held on Fridays, a day she did not work at the facility. The Administrator was unaware of the status of Employee D's CDM application and relied on corporate oversight for the food budget. The facility's policy and procedure for Dietary Services - Staffing required the employment of sufficient staff with appropriate competencies and skills sets, including a qualified dietitian or a designated director of food and nutrition services who met state requirements. Employee D did not meet these requirements, and the facility failed to ensure frequent consultations with a qualified dietitian. This deficiency was identified through staff interviews, facility record reviews, and observations during kitchen tours, highlighting the facility's failure to comply with state and federal regulations for food and nutrition services.
Failure to Provide Appropriate Discharge Summaries
Penalty
Summary
The facility failed to provide an appropriate discharge summary, including a recapitulation of the stay, for two residents. Resident #54, who had severe cognitive impairment and was dependent on self-care, was discharged home without a planned discharge. Interviews revealed that the resident required a Hoyer lift and received home health and medical equipment, but specifics were not provided. The Social Services Director (SSD) confirmed that no discharge summary was completed for Resident #54. Similarly, Resident #208, who had moderate cognitive impairment and required some assistance with self-care, was discharged home based on insurance coverage. Interviews indicated that the resident received therapy services at home, but no specific information was available. The SSD confirmed that no discharge summary was completed for Resident #208. The facility had not been providing discharged residents with a recapitulation of their stay at the time these residents were discharged.
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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) |
|---|---|---|---|---|
| Jacksonville Rehabilitation And Nursing | 1.1 mi | ★★★★★ | 44 | 0 |
| Shands Jacksonville Medical Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Jacksonville Nursing And Rehab Center | 4 mi | ★★★★★ | 0 | 0 |
| North Bank Center For Rehabilitation And Healing | 4.4 mi | ★★★★★ | 13 | 0 |
| Aviata At Harts Harbor | 4.5 mi | ★★★★★ | 26 | 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.