Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 River City Nursing And Rehab Center during CMS and state inspections, most recent first.
Failure to Date Mark Open Food Items: An open, undated Starbucks Vanilla Latte was found in a nourishment room refrigerator, and on re-check it was still there. In the kitchen, ten open bundles of bread were found in a storage bin with no dates or labels, and one bundle had visible mold. Staff stated opened bread was tied or sealed and stored for the next shift, despite the facility policy requiring opened food items to be labeled and dated.
A facility failed to carry out care plan interventions for two residents. One resident with severe cognitive impairment, right-sided weakness, and fall risk did not have the ordered floor mat at the bedside despite the care plan and physician order. Another resident with dementia, contractures, and a left elbow pressure ulcer did not have the ordered off-loading pillow under the left elbow; staff observed a towel in its place, and an LPN later acknowledged the pillow should have been there. Interviews also showed confusion about fall-risk awareness and documentation of care tasks.
The facility failed to ensure dignity while dining for two residents. One resident was left with an uncovered breakfast tray for 25 minutes before being assisted by a CNA who stood over her while feeding. Another resident struggled to open a nutritional supplement without assistance, and no staff entered to help. Both residents had significant medical histories and required mechanically altered diets.
The facility failed to ensure residents maintained acceptable nutritional status by not providing timely interventions, resulting in significant weight loss for two residents. One resident, with a history of stroke and difficulty swallowing, lost over 14% of her weight and developed a worsening pressure ulcer. Another resident, with severe cognitive impairment, lost over 13% of her weight in six months. Observations revealed inadequate assistance with meals, and interviews highlighted gaps in communication and follow-up between the dietitian and dietary manager.
The facility failed to ensure that all drugs and biologicals were stored in locked compartments with access granted only to authorized personnel. A medication cup containing seven tablets was found unattended in a resident's room, and the resident's private duty aide, who was not authorized to administer medications, stated that the nurse had left them for her to administer. The resident had severe cognitive impairment, and there was no documentation verifying that the resident or the aide was authorized to handle the medications.
Failure to Date Mark Open Food Items
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices by leaving an open 1.18-liter bottle of Starbucks Vanilla Latte in the 400 hallways nourishment room refrigerator without a date mark. During the initial observation on 2/25/26 at 12:53 PM, the undated beverage was found open in the nourishment room, and LPN L was notified. On re-inspection on 2/26/26 at 1:02 PM, the same open, undated bottle was still in the refrigerator and was discarded. During a follow-up kitchen observation on 2/26/26 at 2:42 PM, ten open bundles of bread were found in the cook area storage bin with no dates or labels, and one of the ten bundles had visible mold. The bread was discarded. Staff interviews indicated that kitchen staff were assigned to fill, check labeled items, and clean nourishment rooms, and that opened bread was being tied or sealed and stored for the next shift. The facility policy stated that time/temperature control for safety foods and opened food packages should be labeled, covered, and dated when stored.
Failure to Follow Care Plan Interventions for Fall Prevention and Pressure Relief
Penalty
Summary
The facility failed to implement interventions in the comprehensive care plan for two residents. One resident had diagnoses including spinal stenosis, hemiplegia, polyneuropathy, seizures, dementia, and bipolar disorder, and a quarterly MDS showed severe cognitive impairment with functional impairment of the right upper and lower extremities. Her active physician order and care plan called for floor mats on the right side of the bed, but observations on multiple occasions showed no floor mat at the bedside or in the room. During interview, the assigned CNA stated she was not aware the resident was at risk for falls and had never seen fall mats placed at the bedside. Another resident had diagnoses including contractures of the left hand and both knees, osteoarthritis of the left elbow, dementia, a pressure ulcer at the left elbow, and a TIA. Her quarterly MDS showed impaired memory, severely impaired daily decision-making, and dependence for all care needs with impairment to both upper and lower extremities. Her care plan included an intervention for an off-loading pillow under the left elbow, but observations showed no pillow supporting the elbow on multiple occasions. At one point, a towel was seen under the left elbow instead of the ordered pillow, and the resident’s left elbow bandage was loose and not adhering to the wound. During interview, an LPN stated pressure injury interventions included turning and repositioning, skin sweeps, off-loading, and peri-care, and she later acknowledged that a towel was not supposed to be under the resident’s elbow and that a pillow should have been there. The LPN also stated she did not know whether she had documented the task correctly on the TAR. The DON stated that when staff assist one another with residents, whoever performs the task is responsible for documenting completion and staff should not sign off on tasks they did not do.
Failure to Ensure Dignity While Dining
Penalty
Summary
The facility failed to ensure dignity while dining for two residents. Resident #94 was observed lying in bed with her breakfast tray uncovered for 25 minutes before a CNA assisted her. The CNA was observed standing over the resident while assisting her with her meal. Resident #94 had a history of stroke, right-sided paralysis, difficulty swallowing, and severe cognitive impairment, requiring a mechanically altered diet. On a subsequent observation, another CNA was also seen standing over Resident #94 while assisting her with her meal. Resident #54 was observed lying in bed with her breakfast tray uncovered and struggling to open a Mighty Shake nutritional supplement without assistance. No staff entered her room to assist her during the meal. Resident #54 had a history of stroke, right-sided paralysis, Parkinson's disease, difficulty swallowing, and moderately impaired cognition, also requiring a mechanically altered diet. The facility's policy on Assistance with Meals states that residents should be fed with attention to safety, comfort, and dignity, and staff should not stand over residents while assisting them with meals.
Failure to Provide Timely Nutritional Interventions
Penalty
Summary
The facility failed to ensure residents maintained acceptable parameters of nutritional status by not providing timely nutritional interventions for two residents, resulting in significant weight loss. Resident #54, who had a history of stroke, right-sided paralysis, Parkinson's disease, difficulty swallowing, and weakness, was observed struggling to eat and drink her nutritional supplements. Despite recommendations from a dietitian for additional nutritional support, there were no follow-up Nutrition Progress Notes, and her weight dropped from 188 pounds to 160.6 pounds over three months. Additionally, she developed a stage 2 pressure ulcer that worsened over time, indicating a lack of adequate nutritional and wound care management. Resident #94, who had severe cognitive impairment and a history of stroke, right-sided paralysis, and difficulty swallowing, also experienced significant weight loss, dropping from 172.6 pounds to 149.8 pounds over six months. Despite multiple documented instances of weight loss, there were no follow-up notes from the dietitian addressing this issue. Observations revealed that Resident #94 often received inadequate assistance with meals, consuming only a small portion of her food. The dietary manager was aware of the weight loss but did not communicate effectively with the dietitian or follow up on the discontinuation of a nutritional supplement. Interviews with the dietitian and dietary manager revealed gaps in communication and follow-up regarding the residents' nutritional needs. The dietitian was unaware of the significant weight loss and new wounds in Resident #54 and had not assessed Resident #94 since October 2023. The dietary manager acknowledged the weight loss but did not take appropriate actions to address it, relying on the dietitian to write orders for nutritional interventions. This lack of timely and coordinated care contributed to the residents' deteriorating nutritional status and overall health.
Failure to Secure and Properly Administer Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments with access granted only to authorized personnel. During a tour of the facility, a medication cup containing seven medication tablets was observed unattended on a bedside table in a resident's room. The resident's private duty aide, who was not a certified medication technician but a certified nursing assistant hired by the resident's family, stated that the nurse had left the medications for her to administer. The resident had severe cognitive impairment, and there was no documentation verifying that the resident was safe to self-administer medications or that the private duty aide was authorized to administer them. A review of the resident's medical record showed that the medications were documented as administered by an LPN earlier that day. However, the LPN had no recollection of leaving the medications at the bedside. The facility's policy on medication administration states that medications are to be administered by licensed nurses or other legally authorized staff, in accordance with professional standards of practice. This incident indicates a failure to adhere to the facility's medication administration policy and to ensure the security and proper administration of medications.
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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) |
|---|---|---|---|---|
| Lanier Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Aviata At Harts Harbor | 3.4 mi | ★★★★★ | 26 | 0 |
| Lakeside Center For Rehabilitation And Healing | 5 mi | ★★★★★ | 6 | 0 |
| Jacksonville Nursing And Rehab Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Pavilion At Jacksonville, The | 7.9 mi | ★★★★★ | 18 | 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.