Average — CMS composite of the measures below.
The next survey window likely opens 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 Riverside Post Acute during CMS and state inspections, most recent first.
PASRR screening was not completed for two residents after they developed or were identified with possible MDs. One resident had an earlier PASRR that did not identify anxiety, bipolar disorder, depression, or schizophrenia, but later records showed schizophrenia, depression, GAD, bipolar disorder, severe cognitive impairment, and psychotropic meds. Another resident had an earlier PASRR, later diagnoses of bipolar disorder, depression, dementia with behavioral disturbance, and insomnia, plus orders for memantine, olanzapine, ramelteon, and behavior monitoring. The SSD said the psych provider was expected to identify concerns and that the PASRR should have been updated.
Failure to Provide Fingernail Care: Two residents who required staff help with grooming were observed with elongated, dirty fingernails and brown matter under the nails, and both said they had not received nail care. One resident had stroke-related hemiplegia and speech impairment, while the other had dementia and significant ADL dependence. Staff interviews confirmed that grooming includes nail care and that it should be provided daily and when needed, yet the residents’ care plans and the facility nail-care policy were not reflected in the observed care.
Oxygen flow rates were not set per physician orders for three residents. One resident with COPD and CHF received 4 LPM instead of 3 LPM, another resident with multiple respiratory and cardiac diagnoses was observed with the NC dislodged and the concentrator set above the ordered 2 LPM, and a third resident with COPD was receiving 3 LPM instead of the ordered 4 LPM. Staff interviews and the facility’s oxygen policy confirmed that oxygen settings should be verified and administered per order.
Improper sharps disposal and hand hygiene during fingerstick testing. An RN performing a resident blood glucose check discarded a used lancet in a bathroom trash container, then reached into the trash with an ungloved hand to retrieve it and returned to the medication cart without washing her hands. The RN, DON, and LPN all described the expected process as disposing of the lancet in a sharps container and performing hand hygiene, and facility policies also required sharps to be placed in designated sharps containers and hands to be washed afterward.
Surveyors identified that a call light in a resident's room was nonfunctional for several days, with staff aware of the issue but not ensuring timely repair or reporting. Additionally, water was found dripping from a ceiling vent into a trash bin in another resident's room, with the Maintenance Director unaware of the problem and no work orders submitted for either issue.
The facility failed to follow its grievance policy by not providing required written notifications of the outcomes of grievance investigations for five grievances submitted by four residents. Staff interviews revealed inconsistencies and lack of documentation in the grievance process. The Social Services Director and Assistant did not have access to the Electronic Reporting System, leading to gaps in the process. The Director of Nurses and Administrator acknowledged the deficiencies and the need for process improvements.
PASRR Screening Not Completed for Residents With Newly Evident Mental Disorders
Penalty
Summary
The facility failed to complete the PASRR process for two residents who were identified with newly evident or possible mental disorders. For one resident, the only PASRR on file was dated before admission and stated there were no diagnoses or suspected diagnoses of anxiety disorder, bipolar disorder, depressive disorder, or schizophrenia. The resident’s record later showed diagnoses of schizophrenia, depression, generalized anxiety disorder, and bipolar disorder, along with orders for alprazolam, escitalopram, olanzapine, and trazodone. The resident’s annual MDS also documented severe cognitive impairment with a BIMS score of 4 out of 15. For the second resident, the record showed a PASRR dated before the resident’s admission, while the resident’s chart later included diagnoses of bipolar disorder, depression, unspecified dementia with behavioral disturbance, and insomnia. Physician orders included memantine for dementia, olanzapine for psychosis, ramelteon for insomnia, and behavior monitoring orders for biting, hitting, and sleep-related symptoms. The resident’s MDS documented severe cognitive impairment with a BIMS score of 7 out of 15. The Social Services Director stated that the facility’s process relied on the psychiatric provider to assess residents and identify possible mental disorders, and that she was responsible for referrals to the state-designated authority. She stated that she was not notified by the psychiatric provider for the second resident and confirmed that the PASRR should have been updated. The facility policy required all new admissions and readmissions to be screened for MD, ID, or related disorders, with referral to the state PASRR representative when indicated, but the records reviewed showed that the required PASRR process was not completed for these residents when their conditions became evident.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to provide appropriate fingernail care for two residents who required assistance with grooming. During observations, both residents were found with elongated fingernails and brown matter or soil under the nails, and neither resident had received fingernail care when asked about it. One resident, admitted with diagnoses including hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side and seizures, was observed in a wheelchair with speech impairment and limited ability to use his right hand because of contractures. His left-hand fingernails were observed to be elongated and soiled, and he stated that he had not received fingernail care that day but wanted it. The second resident, admitted with diagnoses including unspecified dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety, was observed in bed with elongated fingernails and brown matter underneath them on repeated observations. She stated that staff had not provided fingernail care and indicated she had considered trying to do them herself. Staff interviews showed that CNAs and an LPN identified grooming as including nail care and stated that grooming should be provided daily and when needed, with nail trimming occurring regularly. One CNA assigned to one of the residents acknowledged that the resident needed fingernail care. Record review showed both residents had care plans that included staff assistance with grooming or personal hygiene. One resident’s MDS reflected moderate cognitive impairment and partial/moderate assistance needs for personal hygiene, while the other resident’s MDS reflected intact cognition but substantial/maximal assistance for personal hygiene and dependence for toileting and transfers. The facility policy on care of fingernails/toenails stated that nail care includes daily cleaning and regular trimming. Despite these documented needs and the policy guidance, the observations and interviews showed that the residents’ fingernails remained unclean and untrimmed during the survey period.
Oxygen flow rates not set per physician orders
Penalty
Summary
The facility failed to provide respiratory therapy consistent with professional standards of practice for three residents receiving oxygen therapy because the oxygen flow rates set for them were not in accordance with their physicians’ orders. Resident #9 was observed receiving oxygen at 4 LPM via nasal cannula, while the active physician’s order was for 3 LPM via nasal cannula for CHF. The resident had diagnoses including COPD and CHF, and the record showed severe cognitive impairment with a BIMS score of 7 out of 15, dependence on staff for several ADLs, and receipt of oxygen and hospice services. Resident #63 was observed with the nasal cannula dislodged and resting against the right cheek, and the resident stated he did not know how long it had been dislodged and did not know how to insert the cannula or manipulate the oxygen flow rate. The concentrator was observed infusing oxygen at 2.5 to 3 LPM, while the physician’s order was for oxygen at 2 LPM via nasal cannula as needed for shortness of breath and for O2 saturation below 92%. The resident’s diagnoses included alcoholic hepatic failure, Parkinson’s disease, CHF, pleural effusion, COPD, asthma, chronic respiratory failure with hypoxia, and pneumonia. A nurse later stated the resident could pull out the cannula but was not mentally or physically capable of independently inserting it or changing the oxygen settings. Resident #181 stated she was supposed to receive oxygen at 4 LPM, but the concentrator was observed set at 3 LPM. The physician’s order was for oxygen at 4 liters per minute via nasal cannula continuously for COPD. Facility staff interviews showed CNA staff understood they should check the concentrator setting and tubing position but not change the flow rate, and an LPN described the proper process as checking orders and setting oxygen per the order. The facility’s oxygen administration policy also required verifying the physician’s order and adjusting the delivery device so the proper flow of oxygen was administered.
Improper Sharps Disposal and Hand Hygiene During Fingerstick Testing
Penalty
Summary
The facility failed to demonstrate safe, sanitary infection control and prevention procedures during resident fingerstick blood glucose monitoring. On 12/04/25 at 12:18 PM, an RN performed a scheduled fingerstick blood glucose check, then discarded the used lancet in a trash container in the resident’s bathroom instead of a sharps container. After the improper disposal was brought to her attention, the RN reached into the trash container with an ungloved hand and retrieved the used lancet. She stated that the lancet did not have a sharp end after use. She then returned to her medication cart without washing her hands, applied hand sanitizer at the cart, and moved on to the next resident. During interview, the RN described the facility’s fingerstick procedure and stated that used lancets were to be disposed of in the sharps container and that hand hygiene was required after the procedure. She acknowledged that she did not wash her hands after the procedure or after retrieving the lancet from the trash container. The DON stated that nursing staff had been trained to dispose of used sharps in sharps containers and that the facility had plenty of them. An LPN later described the fingerstick process and stated that after the procedure the lancet was disposed of in the sharps container and hands were washed. Facility policies reviewed also directed staff to discard contaminated sharps in designated containers and to dispose of the lancet in the sharps disposal container, followed by hand washing.
Failure to Maintain Safe and Functional Resident Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, as evidenced by two specific deficiencies observed during a survey. In one instance, a call light in a resident's room was not functioning properly, with a flashing red light and audible sound persisting for at least two days. Staff members, including a housekeeper and a CNA, were aware of the malfunction but did not ensure it was reported or repaired in a timely manner. The LPN Unit Manager confirmed that the call light in the resident's restroom was broken, and that if an aide required assistance while helping the resident with toileting, they would have to verbally call for help. The Maintenance Director was only made aware of the issue the day before the interview and confirmed that no work order had been submitted for the repair until then. In a separate incident, water was observed dripping from a ceiling vent into a trash bin in another resident's room. The resident, who was identified as a fall risk and required assistance with toileting, was present in the room but was unsure how long the issue had persisted. The Maintenance Director confirmed that there were no active or completed work orders for this room and stated he was not previously aware of the water leak. These deficiencies were identified through direct observation, staff and resident interviews, and review of the facility's maintenance reporting system.
Failure to Provide Written Notifications of Grievance Resolutions
Penalty
Summary
The facility failed to follow its grievance policy by not providing required written notifications of the outcomes of grievance investigations for five grievances submitted by four residents. Interviews with staff, including a Registered Nurse, Licensed Practical Nurse, Social Services Director (SSD), and Social Services Assistant (SSA), revealed that the facility's process for handling grievances was inconsistent and lacked proper documentation. The SSD and SSA did not have access to the Electronic Reporting System (ERS), which was supposed to be used for logging and tracking grievances, leading to gaps in the process and failure to issue written resolutions within the required timeframe. A review of the facility's grievance log from December 2023 to April 2024 showed that grievances related to property loss, food temperature, room temperature, and access to medical records were not followed up with written notifications of resolution. The facility's policy required that grievances be acknowledged within seven working days and a final written decision be provided within 30 days, but this was not done for any of the grievances reviewed. The Social Services Director was unaware of the requirement to send written notifications, indicating a lack of training or communication regarding the grievance policy. The Director of Nurses (DON) and the Administrator acknowledged the deficiencies in the grievance process during their interviews. The DON was unaware that the SSD did not have access to the ERS and did not question the lack of complaints and grievances in the reports presented to the Quality Assurance and Performance Improvement (QAPI) committee. The Administrator admitted that the process was ineffective and had multiple gaps that needed to be addressed. The facility's policy clearly outlined the steps and timelines for handling grievances, but these were not followed, resulting in a failure to provide residents with the required written notifications of grievance resolutions.
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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) |
|---|---|---|---|---|
| Park Ridge Nursing Center | 0.7 mi | ★★★★★ | 4 | 0 |
| North Bank Center For Rehabilitation And Healing | 2.5 mi | ★★★★★ | 13 | 0 |
| Shands Jacksonville Medical Center | 3 mi | ★★★★★ | 0 | 0 |
| Westside Oaks Rehabilitation & Nursing Center | 4 mi | ★★★★★ | 19 | 4 |
| Jacksonville Rehabilitation And Nursing | 4.3 mi | ★★★★★ | 44 | 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.