Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 The Pavilion At Crescent Lake during CMS and state inspections, most recent first.
A facility failed to ensure physician documentation included reasons for disagreeing with consultant pharmacist recommendations for multiple residents. Records showed repeated MRRs involving medication interactions, dose reductions, and administration instructions were marked disagree and signed by the physician or provider without any written explanation, and the DON stated the facility did not expect a rationale when the physician disagreed.
Failure to maintain resident rooms and bathrooms in a clean, homelike condition. Observations found rusted and exposed metal on a bathroom door frame, peeling paint with exposed drywall and holes near a sink area, and multiple areas of discoloration and damage in another resident’s room and shared bathroom, including missing drywall, dark staining, blackish substance on shower surfaces and an emergency call light cord, and taped AC unit edges with gaps. The ADM and Maintenance staff acknowledged the known repair issues, and prior rounding logs documented maintenance concerns such as paint under the sink and a door frame.
A facility failed to ensure MDS assessments accurately reflected resident status for three residents. One resident’s MDS omitted psychotic and delusional disorders despite documented diagnoses and mental health history; another resident’s MDS failed to indicate suctioning even though the resident had a trach, used suctioning, and had orders for trach care and suction; and a third resident’s MDS did not document a life expectancy of less than 6 months despite hospice admission records and certification of terminal illness.
PASARR screening was not accurately completed for 3 residents reviewed for behavioral management. A resident with MDD, another with anxiety and depression, and a third with anxiety and autistic disorder all had PASSR forms that did not reflect the documented diagnoses shown in the MDS and mental health provider notes. The SS Director stated she reviewed PASSR forms only to confirm the facility name and did not compare the listed diagnoses against the form.
A care planning deficiency was identified for two residents. One resident had physician orders for O2 via nasal cannula with titration to keep SPO2 above 90%, but oxygen was not included as a care plan focus. Another resident had PTSD documented in the admission record and mental health history, but PTSD was not addressed in the care plan. The MDS Coordinator acknowledged both omissions.
An LPN crushed and administered all of a resident’s medications, including potassium chloride ER, even though the physician order was for an extended-release tablet. The DON and APRN both stated that extended-release medication should not be crushed, and the LPN acknowledged the error.
A resident with an order for Losartan 25 mg BID for HTN, with instructions to hold if BP was below 90/50 or pulse was below 60, had the medication documented as given multiple times when the pulse was under the ordered limit. Interviews with the DON, an LPN, and an APRN confirmed that nurses were expected to follow physician orders, and the facility policy stated medications must be administered in accordance with prescriber orders.
A CNA entered a resident’s room on EBP and made the bed while wearing only gloves, and later served multiple residents’ meals without sanitizing hands between residents. An RN placed a nasal cannula back on a resident after it had fallen on the floor, and an LPN used a visibly soiled enteral flush syringe without rinsing it after medication and feeding administration.
Failure to post current nurse staffing information daily. The staffing posting area across from the elevator was empty, and a later posting on the 100 hall showed an outdated staffing sheet. The Receptionist did not know where the posting belonged, while the Administrator, DON, and HR/Staffing Coordinator gave different descriptions of where and when the staffing sheet was supposed to be posted.
The facility failed to properly store and cover food, as evidenced by an open package of bologna in the nutrition room refrigerator and uncovered half-cut bananas on resident trays. The Dietary Manager confirmed the lack of a food tray delivery policy, contributing to these deficiencies.
A resident with a PICC line did not receive appropriate dressing changes as per facility policy, leading to a deficiency. Observations showed the dressing was lifting and improperly maintained with gauze underneath. Interviews with staff revealed a lack of understanding of the policy, which requires weekly dressing changes or more frequently if compromised. The facility's policy mandates specific dressing intervals to prevent infections, which were not followed.
The facility staff failed to adhere to physician orders for oxygen administration for three residents, resulting in incorrect oxygen levels being administered. Despite physician orders specifying lower oxygen rates, residents were observed receiving higher levels without documented clinical justification or physician notification. The facility's policy on oxygen administration was not followed, leading to deficiencies in respiratory care.
Physician Disagreements on Pharmacy Reviews Lacked Documented Rationale
Penalty
Summary
The facility failed to ensure that physician documentation included a reason for disagreeing with consultant pharmacist recommendations for 5 of 5 residents reviewed, including Residents #2, #6, #8, #10, and #26. The record review showed multiple pharmacist recommendations were marked “disagree” by the physician or provider, but the medical record did not contain a documented rationale or explanation for the decision in the physician summary, progress notes, or on the recommendation forms. For Resident #6, pharmacist recommendations addressed spacing hydrocodone and Valium dosing and re-evaluating diazepam 10 mg at bedtime because the literature cited a lower maximum recommended geriatric dose. In each instance, the physician checked “disagree” and continued the medications without documenting a reason. For Resident #2, several interim medication regimen reviews identified concerns involving Eliquis and aspirin, amiodarone and Lexapro, and the need for diagnosis/indication documentation for aripiprazole; the physician repeatedly selected “disagree,” signed the forms, and did not document any explanation. Another recommendation for Resident #2 regarding Advair administration instructions was routed to nursing, but the DON stated she could not locate it on the resident’s orders or MAR. Additional records showed the same pattern for other residents. For Resident #10, the pharmacist recommended considering a dose reduction for haloperidol due to possible contribution to falls, syncope, orthostatic hypotension, dizziness, and drowsiness; the provider disagreed without rationale. For Resident #26, recommendations included reassessment of Phenergan and later changes to tamsulosin timing and trazodone dose reduction; the provider disagreed and signed without explanation. For Resident #8, recommendations to reduce trazodone and gabapentin doses were also marked disagree without rationale. The DON stated that the pharmacy recommendations did not include a rationale and that the facility did not expect one when the physician disagreed, while the physician stated he reviewed and signed the forms but did not write comments or explanations when he disagreed.
Failure to Maintain Resident Rooms and Bathrooms in Clean, Homelike Condition
Penalty
Summary
The facility failed to ensure residents had a clean, homelike environment. During observations, Resident #76’s bathroom door on the left-hand side toward the bottom corner was rusted, with metal portions of the door frame exposed and extending outward. Resident #58’s room wall where the sink is located had peeling paint, exposed drywall, and holes. The Administrator’s monthly walk-through documentation dated 9/22/2025 and 10/15/2025 both noted holes by the soap dispenser in Resident #58’s room. Resident #81’s room also had multiple environmental concerns. The wall under the sink was discolored light brown with missing drywall or plaster, and the shared bathroom had a dark brown triangular discolored area behind the toilet. The shower area wall and tile were discolored with a blackish substance, especially around the bottom edges of the floor and on the emergency call light cord, and the air conditioning unit next to the bed had silver tape around the edges with gaps observed. The Maintenance Director stated there had been a leak from the sink behind the wall in Resident #81’s room and that the bathroom wall needed to be redone where there had been a leak behind the toilet. The rounding log from 1/17/2025 documented maintenance issues for Resident #81’s room, including paint under the sink and the door frame. The facility’s Maintenance Service policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment, and that maintenance personnel are responsible for keeping the building in good repair and free from hazards.
Inaccurate MDS Assessments for Diagnosis, Suctioning, and Hospice Prognosis
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status for 3 residents. The facility policy stated that interdisciplinary observation and assessment were to be used to ensure the most accurate assessment of resident functional capacity. Review of the records showed that Resident #9’s quarterly MDS dated 10/21/2025 did not include psychotic disorder or delusion disorder in Section I, even though the admission record listed delusional disorders and psychotic disorder with delusions, and a mental health provider note documented a history of dementia, depression, delusional disorders, psychotic disorder, cognitive communication deficit, muscle weakness, and hypertension. The MDS Coordinator stated the MDS would have to be modified because the resident did have diagnoses of psychotic disorder and delusional disorders. Resident #2’s quarterly MDS dated 11/05/2025 documented a BIMS score of 15 out of 15 and indicated oxygen therapy and tracheostomy care, but suctioning was marked as no. The resident’s census data listed diagnoses including COPD, heart failure, type 2 diabetes, anxiety disorder, tracheostomy status, dependence on supplemental oxygen, and paroxysmal atrial fibrillation. The care plan stated the resident had a tracheostomy and did her own trach care including suctioning, administered her own nebulizer treatments, and used continuous oxygen. Physician orders dated 1/02/2026 also directed self trach care and nebulizer treatment and referenced trach, oxygen, and suction. The MDS RN stated she did not know why suctioning was not marked and acknowledged the resident had a tracheostomy and used suctioning. Resident #35’s significant change MDS dated 12/24/2025 documented BIMS 15 out of 15, dependence for mobility and most care, incontinence, and hospice care under special treatments or programs, but did not mark a prognosis of less than 6 months of life expectancy as yes. The resident’s admission data listed diagnoses including nondisplaced fracture of the left tibia, generalized anxiety disorder, type 2 diabetes, acute kidney failure with tubular necrosis, and end stage renal disease. The care plan identified hospice care and renal insufficiency related to ESRD, and physician orders and hospice records documented admission to hospice for acute kidney injury with certification of terminal illness and an imminence of death of less than 6 months. The MDS RN stated she did not mark the prognosis question yes because she did not see documentation stating that prognosis, and the DON stated the expectation was that the MDS nurse would review the documentation and correctly enter the information.
PASARR screens omitted documented mental health diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for 3 of 8 residents reviewed for behavioral management. Resident #26 was admitted with major depressive disorder, but the PASSR dated 8/18/2025 did not identify depressive disorder or suspected mental illness in Section I: PASSR Screen Decision-Making. The resident’s quarterly MDS documented depression under active diagnoses, and a mental health provider note later listed a past psychiatric history of major depressive disorder. Resident #8 was admitted with anxiety disorder and depression, but the PASSR dated 11/29/2025 did not identify depressive disorder or anxiety disorder in Section I. The quarterly MDS documented depression and anxiety, and a mental health provider note later listed a past psychiatric history including generalized anxiety disorder and major depressive disorder. Resident #11 was admitted with anxiety disorder and autistic disorder, but the PASSR dated 8/29/2025 did not identify autistic disorder or anxiety disorder in Section I. The quarterly MDS documented autistic and anxiety diagnoses, and a mental health provider note later listed a past psychiatric history including anxiety and autistic disorder. During interview, the Social Service Director stated she oversaw PASARR in the facility, requested one if a resident did not have one, and reviewed forms only to confirm the facility name, not to compare listed diagnoses against the form.
Incomplete Care Plans for Oxygen Therapy and PTSD
Penalty
Summary
Failure to develop a complete care plan was identified for Resident #11 and Resident #10. Resident #11 had physician orders dated 9/24/2025 and 1/2/2026 for oxygen 2L via nasal cannula, with titration to maintain SPO2 greater than 90% every shift for low oxygen saturation less than 90%, but the resident’s care plan did not include oxygen as a focus. During interview, the MDS Coordinator stated that Resident #11’s care plan did not include oxygen as a focus or intervention and would need to be updated. Resident #10 was admitted with a diagnosis including post-traumatic stress disorder, and a mental health provider note dated 12/18/2025 documented psychiatric history including anxiety disorder, major depressive disorder, and PTSD. Review of Resident #10’s care plan did not show PTSD as a focus. During interview, the MDS Coordinator stated that PTSD was not mentioned in the care plan and that a focus would need to be added. The facility policy stated that CAA triggers are used as a basis for care planning, with additional areas care planned as determined by the IDT, additional assessment, diagnoses, facility policy, or other resident-specific concerns.
Improper Crushing of Extended-Release Medication
Penalty
Summary
The facility failed to administer medication appropriately when Staff E, the Unit Manager/LPN, prepared Resident #1’s medications and crushed all of the medications before giving them to the resident. One of the medications was Potassium Chloride Extended Release, and the physician order dated 1/2/2026 directed Klor-Con 10 Oral Tablet Extended Release 10 MEQ to be given by mouth once daily for hypokalemia. The medication was observed being crushed and administered during the medication pass. During interviews, the DON stated that extended-release medication should not be crushed and that the nurse should contact the provider to change the medication to a liquid or another form that can be crushed. Staff E stated that extended-release medication cannot be crushed and acknowledged contacting the provider and the family after the event. The APRN stated that extended-release medication should not be crushed and described the event as a one-time occurrence, noting there were no messages from nursing staff about any health concerns for the resident.
Medication Given Despite Hold Parameters
Penalty
Summary
The facility failed to ensure physician orders were followed for medication parameters for Resident #9, who had an order for Losartan Potassium 25 mg twice daily for hypertension with instructions to hold the medication if blood pressure was less than 90/50 or pulse was less than 60 and to notify the MD. Review of the resident’s MAR showed multiple instances in which Losartan was documented as administered even though the resident’s pulse was below the ordered parameter, including pulse readings of 53, 58, 59, 55, 56, 54, and 58 on various medication passes. During interviews, the DON stated nurses were expected to follow physician orders and call the provider if clarification was needed, and an LPN stated that a check mark meant the medication was given. The APRN stated nurses were to follow physician orders as given and contact the provider with questions. The facility policy titled Administering Medications stated medications are to be administered in accordance with prescriber orders, including any required time frame.
Infection Prevention and Control Failures During Resident Care and Dining
Penalty
Summary
The facility failed to prevent the possible spread of infection during care for a resident on enhanced barrier precautions. During an observation, the resident’s room door had an enhanced barrier sign posted and PPE hanging outside the door, but a CNA entered the room and made the resident’s bed while wearing only gloves and no gown. The CNA also collected soiled linen from the floor near the bathroom and placed it in a transparent plastic bag. The resident’s physician orders did not include enhanced barrier precautions, although the wound care record documented a stage 4 pressure wound to the sacrum and the DON stated the resident was on enhanced barrier precautions because of the pressure ulcer. The facility policy stated that changing linens is a high-contact activity requiring gown and gloves. The facility also failed to follow hand hygiene and equipment handling practices during resident care and dining. A CNA delivered meal trays to multiple residents in the common area and dining room, assisting with meal setup and cutting meat, but did not sanitize hands between residents until after serving several trays. In another observation, an RN found a resident’s nasal cannula on the floor and placed it back on the resident’s nose without cleaning or replacing it. During enteral medication administration and bolus feeding, an LPN used a flush syringe that had visible residue, did not rinse it after use, and placed it back in the plastic bag. The DON stated staff should sanitize hands between residents, that anything found on the floor should be discarded and replaced, and that the gastric tube flush syringe should have been rinsed after use.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post the current nurse staffing information daily, including the facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, and the resident census. During an observation on 1/05/2026 at 9:35 AM, the plastic document holder for the daily staffing posting in the main hallway across from the elevator was empty and contained no documents. During interviews, the Receptionist stated she did not know where the staffing information was supposed to be posted, while the Administrator stated it was to be posted in the main hallway near the nurses' station on the 100 hall. An observation later that morning found a staffing sheet posted across from the nurses' station on the first floor dated Tuesday, August 12, 2025. The Administrator stated the current staffing sheet was expected to be posted daily, the DON stated it was supposed to be posted by 9:00 AM near the lobby across from the elevator, and the HR/Staffing Coordinator stated she posted the staffing sheet in the morning after the morning meeting, usually after 9:30 AM.
Deficiencies in Food Storage and Delivery Practices
Penalty
Summary
The facility failed to ensure the safe storage, covering, and labeling of food in the nutrition room and during food tray delivery to residents. During an observation, an open package of bologna was found in the first-floor nutrition room refrigerator, neither dated nor sealed. The Dietary Manager confirmed the oversight, acknowledging that it is the dietary staff's responsibility to check and clean nourishment rooms as needed. Additionally, during a breakfast meal delivery, half-cut bananas on individual resident trays were not covered, and the Dietary Manager was unable to provide a reason for this lapse. Further investigation revealed that there was no existing policy and procedure for food tray delivery, as confirmed by the Dietary Manager. The facility's policy on foods brought by family or visitors was reviewed, which outlines the requirements for labeling and storing such foods. However, this policy does not address the issues observed with facility-prepared food storage and delivery. The lack of a specific policy for food tray delivery contributed to the deficiencies noted during the survey.
Failure to Maintain PICC Line Dressing According to Standards
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a central venous catheter, specifically a peripherally inserted central catheter (PICC) line. Observations revealed that the PICC line dressing was not maintained according to professional standards, as it was lifting on three sides and had a 2 x 2 gauze pad underneath, which is not in accordance with the facility's policy. The dressing was dated several days prior, indicating it had not been changed as required by the physician's orders and facility policy. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Practical Nurses (LPNs), and the Director of Nursing (DON), revealed inconsistencies in understanding and implementing the facility's policy on PICC line care. Staff members were unaware that gauze should not be placed under the transparent dressing and that dressings should be changed more frequently if compromised. The ADON and DON confirmed that the dressing should be changed weekly or as needed if it becomes loose or soiled, and that gauze should not be used under the transparent dressing unless for a short period when the line is first inserted. The facility's policy on central venous catheter care, last revised in 2022, specifies that dressings should be changed at least every seven days for transparent dressings and every two days for gauze dressings. The policy also mandates immediate dressing changes if the dressing is damp, loosened, or visibly soiled. Despite these guidelines, the staff failed to adhere to the policy, resulting in the deficiency noted during the survey.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility staff failed to follow physician orders and ensure proper oxygen administration for three residents, leading to deficiencies in respiratory care. Resident #27, diagnosed with conditions including congestive heart failure and atherosclerotic heart disease, was observed receiving oxygen at 4 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted over multiple observations, and there was no documentation of any clinical need for the increased oxygen rate or notification to the physician about the change. Similarly, Resident #30, with diagnoses such as heart failure and diabetes, was observed receiving oxygen at 3 liters per minute instead of the ordered 2 liters per minute. The nursing progress notes did not reflect any changes in the resident's condition or respiratory status that would justify the increased oxygen rate, nor was there any record of physician notification regarding this change. Resident #46, who had acute and chronic respiratory failure among other conditions, was found to be receiving oxygen at 6 liters per minute, despite the physician's order for 3 liters per minute. The resident confirmed they could not adjust the oxygen concentrator themselves, and staff verified the incorrect setting. The facility's policy on oxygen administration was not adhered to, as staff failed to verify and maintain the prescribed oxygen levels, leading to these deficiencies.
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Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crescent City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Flagler Health And Rehabilitation Center | 15.5 mi | ★★★★★ | 12 | 0 |
| Radiant Nursing And Rehab At Palatka | 17.5 mi | ★★★★★ | 1 | 0 |
| Palatka Center For Rehabilitation And Healing | 18.7 mi | ★★★★★ | 3 | 0 |
| Aviata At Grand Oaks | 20.6 mi | ★★★★★ | 1 | 1 |
| Avante At Ormond Beach, Inc | 25.1 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 July 2026) and official state health department websites.