Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace Of Jacksonville, The during CMS and state inspections, most recent first.
Food items in the kitchen and unit nourishment rooms were found unlabeled and undated, including bread, buns, cereal, frozen foods, syrups, creamer, drinks, and resident food items. Surveyors also found an expired yogurt and other items with no date markings in the refrigerator and freezer. Staff stated that opened foods must be labeled and dated and that expired items should be checked in the nourishment rooms.
A resident with a suprapubic catheter and diagnoses including UTI and catheter-related infection was observed twice with the catheter collection bag uncovered and exposed on the side of the bed, visible from the doorway. The care plan and physician orders called for the drainage bag to be covered for dignity and kept below the bladder, and the DON stated catheter bags should be covered at all times.
An LPN left a prepared dose of Ativan on top of an unlocked med cart while away from the cart and diluted the medication with water even though the order allowed crushing but not dilution. In a separate observation, an LPN administered two different eye drops to another resident without washing hands or changing gloves between medications and left the med cart unlocked while out of sight. These actions resulted in a 14% med error rate.
The facility failed to conduct Level II PASRR screenings for two residents with serious mental illness (SMI) diagnoses. One resident, admitted with bipolar disorder and other conditions, had a Level I PASRR indicating the need for a Level II evaluation, which was not completed. Another resident with dementia and schizophrenia also lacked a Level II PASRR, despite active prescriptions for psychotropic medications. The facility's policy requires such screenings, but they were not performed, as confirmed by staff interviews.
The facility failed to issue refunds within the required 30-day timeframe for three residents. Refunds were delayed or issued in increments due to issues such as fraudulent checks and lack of communication between the facility and corporate office.
Food Items Left Unlabeled and Undated in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices by not ensuring food items were properly labeled and dated in the main kitchen and nourishment rooms. During observations on 05/04/2026, surveyors found one basket of onions, two loaves of bread, one bag of hamburger buns, one bag of pasta noodles, and one bag of sugar frosted flakes cereal in the dry storage room with no labels or dates. The same day, a box of bananas in the kitchen service area and one pie and one container of bags of chicken in the freezer were also observed with no labels or dates. On 05/06/2026, surveyors again observed the same box of bananas beside a serving tray containing bananas with no date or label, along with two loaves of bread, one bag of [NAME] buns, one bag of hamburger buns, and one bag of sugar frosted flakes cereal in dry storage with no dates or labels. The kitchen freezer also contained one box of frozen pancakes and one container of plastic bags of chicken with no dates or labels. On 05/07/2026, the front nourishment room refrigerator contained multiple items with no date markings, including syrups, creamer, drink mixes, non-alcoholic beer, to-go food, limes, and chicken wings, as well as one expired Chobani yogurt and one gallon of chocolate milk with no date marking. The Memory Care unit nourishment room refrigerator also contained several items with no labels or dates, including diet coke, Jell-o, whipped cream, coffee creamer, and jelly. Staff interviews confirmed that food items were supposed to be labeled and dated when opened and that expired items were to be checked in nourishment rooms.
Uncovered urinary catheter bag exposed to view
Penalty
Summary
The facility failed to ensure a resident’s right to a dignified existence when the resident’s urinary catheter collection bag was left uncovered and exposed on the side of the bed, visible from the open doorway. Surveyors observed this condition on two separate occasions, and the report notes photographic evidence was obtained during both observations. The resident had a suprapubic catheter order in place for neurogenic bladder and was documented as dependent for toilet transfers with an indwelling catheter. The resident’s record also showed diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, urinary tract infection, and disorder of the kidney and ureter. The care plan included covering the drainage bag for dignity and keeping it below the level of the bladder, and the active physician’s orders included a dignity bag in place for privacy every shift. During interview, an LPN stated catheter bags should always be below the bladder and covered in a blue bag, and the DON stated urinary catheter bags should be covered at all times.
Medication Administration Errors and Unsecured Cart
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with three errors identified out of 27 opportunities for error, resulting in a 14% error rate. The errors affected two residents during medication administration observations and involved failure to administer medications as ordered and failure to follow recognized standards of practice. For one resident, an LPN prepared Ativan 0.5 mg, diluted it with water in a medication cup, and then walked away from the medication cart to administer another medication, leaving the Ativan sitting on top of the cart while the cart was out of his line of sight in the Memory Care unit. Multiple residents were nearby and could have accessed the medication. The resident's physician orders allowed the medication to be crushed but did not allow it to be diluted with water. For another resident, an LPN administered Tobradex eye drops and then olopatadine eye drops without washing hands or changing gloves between the two different eye medications, and she also left the medication cart unlocked while walking away from it. The facility policy required the cart to be kept closed and locked when out of sight and required handwashing and drying before treating each eye.
Failure to Complete Required Level II PASRR Screenings
Penalty
Summary
The facility failed to provide the required Level II PASRR screenings for two residents with serious mental illness (SMI) diagnoses. Resident #82 was admitted with diagnoses including unspecified dementia, bipolar disorder, and Pseudobulbar affect, and was receiving multiple psychotropic medications. Despite a Level I PASRR completed by the acute care hospital indicating the need for a Level II PASRR, no such evaluation was found in the resident's electronic medical record. The Regional Nurse Consultant was unable to provide the missing Level II PASRR, as it was not completed prior to her employment. Resident #62, who had diagnoses of dementia, major depressive disorder, and paranoid schizophrenia, also lacked a Level II PASRR. Her medical record showed active prescriptions for medications addressing anxiety and depression. The MDS assessment indicated moderate cognitive impairment, but the PASRR section was left blank. Interviews with the Social Services Director and the Director of Nursing confirmed that a Level II PASRR was required but not completed for this resident. The facility's policy mandates that all new admissions and readmissions undergo a Level I PASRR screening, with referrals for Level II evaluations if necessary. The policy outlines the responsibilities of the social services department in making these referrals. However, the facility failed to adhere to these procedures, resulting in the absence of required Level II PASRR screenings for the two residents in question.
Failure to Issue Timely Refunds to Discharged Residents
Penalty
Summary
The facility failed to issue refunds to residents or their representatives within the required 30-day timeframe from the date of discharge for three out of six sampled residents. Resident #1 was discharged on 3/25/24, and although a refund request was made on 4/9/2024, the total amount had not been refunded, with the facility issuing the refund in increments due to issues with a fraudulent check. Resident #5 was discharged on 9/13/23, but the refund was not issued until 3/26/24, well beyond the 30-day requirement. Resident #6 was discharged on 3/2/24, and although a refund request was made on 3/4/24, the refund check was not issued until 5/12/2024 and had not been mailed as of 5/20/2024. Interviews with the Business Office Manager (BOM) and the Corporate Controller revealed that the delays and failures in issuing refunds were due to a lack of clear communication and oversight between the facility and the corporate office responsible for issuing the checks. The BOM was unable to provide explanations for the delays and confirmed that some refunds had not been issued or were issued past the required timeframe. The Corporate Controller acknowledged the oversight and confirmed the issues with the refund process, including the fraudulent check incident for Resident #1 and the delayed issuance for Residents #5 and #6. The facility's policy mandates refunds within 30 days of discharge, which was not adhered to in these cases.
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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) |
|---|---|---|---|---|
| River Garden Hebrew Home For The Aged | 1.1 mi | ★★★★★ | 0 | 0 |
| Aviata At San Jose | 1.9 mi | ★★★★★ | 1 | 0 |
| Westminster Woods On Julington Creek | 4.5 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Jacksonville | 4.7 mi | ★★★★★ | 0 | 0 |
| Woodland Grove Healthcare & Rehabilitation Center | 5.1 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 August 2026) and official state health department websites.