Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Arcadia Care Jacksonville during CMS and state inspections, most recent first.
The facility did not ensure that an RN was on duty for at least eight hours each day, as shown by staffing schedules over a two‑month period that documented multiple days without the required RN coverage. During an interview, the Administrator acknowledged there was no staffing policy, stated they followed state guidelines, and confirmed there were days without RN presence in the building. At the time, 63 residents were documented as residing in the facility on the CMS 671 form.
A resident with severe cognitive impairment and a history of psychosis and dyskinesia experienced worsening involuntary movements due to the facility's failure to coordinate a neurology consult and ensure medication delivery. The resident's care plan was not adequately followed, leading to a gagging incident with improperly prepared food. Communication lapses among staff further delayed appropriate medical response.
A resident with multiple health conditions developed a new pressure ulcer due to the facility's failure to adhere to the care plan and promptly report skin changes. Despite interventions like repositioning and using a low air loss mattress, the resident's skin condition worsened, and the issue was not communicated to nursing staff in a timely manner, resulting in a facility-acquired wound.
The facility failed to provide a Registered Nurse (RN) on duty for 8 hours a day, seven days a week, from November 1 to November 18, 2024. The Director of Nurses confirmed the absence of full-time RNs, relying instead on three per diem RNs, resulting in insufficient RN coverage. This deficiency potentially affects all 75 residents, as the facility lacks a specific staffing policy and follows CMS guidelines.
The facility failed to provide 12 hours of annual competency training for three CNAs, as required. The Human Resources Director acknowledged the oversight, stating that while staff were given access to training resources, there was no oversight to ensure completion. This deficiency could potentially affect all 75 residents at the facility.
The facility failed to provide written notification to residents and their representatives before hospital transfers, affecting six residents. Instances included residents with intact cognition and those with dementia or moderately impaired cognition being transferred without written explanations. Staff interviews revealed a lack of awareness of the policy requiring written notices, highlighting a systemic issue in the facility's discharge and transfer procedures.
The facility exhibited multiple infection control deficiencies, including improper hand hygiene, glove use, and PPE adherence. CNAs and LPNs failed to wash hands between glove changes, did not sanitize a blood glucose monitor properly, and neglected to wear gowns during procedures requiring them. These actions were inconsistent with the facility's policies, affecting several residents.
A resident with multiple medical conditions, including MS and quadriplegia, expressed a preference to eat in his room due to the noise in the dining room. Despite being cognitively intact and dependent on staff for eating, the facility required him to eat in the dining room, citing short staffing. This action violated the resident's rights to choose his daily routines, as acknowledged by the facility's administrator.
A resident with severe cognitive impairment and involuntary movements experienced a fall and a gagging incident due to inappropriate meal size. Despite staff awareness, the physician was not notified immediately, contrary to facility policy, resulting in delayed medical intervention.
A resident with Schizoaffective Disorder was involved in a physical altercation, hitting another resident during a Bingo game. Despite staff presence, the incident occurred, indicating a failure to prevent abuse. An investigation was initiated, and the facility's policy prohibits such mistreatment.
The facility failed to provide discharge summaries for two residents, one with sepsis, pneumonia, and cerebral infarction, and another with pneumonia and malignant neoplasms. Despite providing medications and discharge papers, the electronic medical records lacked discharge summaries. Interviews revealed the absence of a policy on discharge summaries.
A resident with multiple health conditions, including MS and quadriplegia, was observed smoking without a protective apron, resulting in cigarette ashes falling on his clothing. Despite the facility's policy requiring safe smoking conditions, staff did not enforce the use of the apron or remove the ashes, leading to a deficiency.
The facility failed to provide complete incontinent care for three residents, leading to deficiencies in their care. A resident with multiple sclerosis was left with soap suds on the skin after care, while another with COPD and schizo-affective disorder did not have all areas cleansed and dried. A third resident with dementia also received inadequate care, with CNAs failing to rinse and dry the peri-area and other parts. These actions were contrary to the facility's incontinence care policy.
A resident with Multiple Sclerosis and severe cognitive impairment had a nonfunctioning G-tube that was not properly addressed by the facility. An LPN was unable to verify the G-tube placement due to difficulty in aspirating residual liquid, a recurring issue that had been reported but not resolved. Despite this, the LPN prepared to flush the tube without consulting the DON or physician, contrary to facility policy. The resident was eventually sent to the hospital for a tube placement check.
A facility failed to administer medications as ordered, resulting in a 16.22% error rate. An LPN gave a resident 10 mg of Lexapro instead of 20 mg of Escitalopram Oxalate. Another resident missed doses of Breo Ellipta, Aspirin, and Cholecalciferol due to unavailability and oversight. The facility's policy requires adherence to physician orders.
A resident with severe cognitive impairment and multiple diagnoses was not provided with the physician-ordered mechanical soft diet, leading to a gagging incident. The resident, who required supervision during meals, was served large pieces of turkey, contrary to the dietary order. Despite staff presence, the incident was not immediately reported to the physician, and the resident required further medical attention. Interviews revealed communication lapses and non-adherence to dietary orders and facility policies.
A facility failed to address residents' needs timely due to a non-functional call system, leading to residents feeling neglected and humiliated. One resident had to urinate in a water pitcher after staff failed to respond for over an hour, resulting in a UTI. Despite alternative alert systems like cow bells, residents reported these were ineffective, especially with closed doors due to COVID isolation. The facility acknowledged the issue, citing a delay in receiving a replacement part for the call system.
The facility failed to ensure proper use of PPE during a COVID-19 outbreak, with staff observed not wearing required equipment and residents expressing concerns about care. Observations showed staff wearing masks improperly and lacking gowns when entering isolation rooms. Interviews revealed inconsistencies in staff understanding of PPE protocols, despite facility policies mandating full PPE for COVID-19 positive rooms.
The facility failed to maintain an effective call system, leaving residents unable to communicate with staff for assistance. Residents were given inadequate alternatives like cow bells and air horns, which did not effectively alert staff. Despite being cognitively intact and requiring assistance, residents experienced delays in care, with some resorting to extreme measures like using an air horn. The call light system had been down for weeks, and the facility had no estimated repair date, leading to significant communication lapses.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) on duty for at least eight hours each day, as required. Review of the facility’s daily staffing schedules for the period from 1/1/2026 through 2/28/2026 showed that no RN worked at least eight hours on multiple specific dates: 1/4, 1/10, 1/11, 1/17, 1/18, 1/24, 1/25, 1/31, 2/1, 2/7, 2/8, 2/14, 2/15, 2/21, 2/22, and 2/28 of 2026. During an interview on 3/3/2026 at 9:40 AM, the Administrator stated that the facility did not have a staffing policy, that they followed state guidelines, and acknowledged there were days without RN coverage in the building. The facility’s CMS 671 form dated 3/1/2026 documented that 63 residents were residing in the facility at the time of the survey. No additional resident-specific clinical details or medical histories were provided in the report beyond the total census of 63 residents who could be affected by the lack of RN coverage.
Failure to Coordinate Neurology Consult and Medication for Resident
Penalty
Summary
The facility failed to coordinate necessary services for a neurology consult for a resident, identified as R30, who was experiencing abnormal movements, falls, and a gagging incident. R30, who has a history of psychosis, schizoaffective disorder, drug-induced subacute dyskinesia, and schizophrenia, was admitted with severe cognitive impairment and required assistance with daily activities. Despite these needs, the facility did not ensure timely follow-up on a neurology consult, which was crucial given the resident's worsening involuntary movements. R30's care plan and medical records indicated a need for close monitoring due to the risk of falls and potential adverse side effects from antipsychotic medications. However, the facility's records showed a gap in documenting the Abnormal Involuntary Movement Scale (AIMS) assessments between November 2023 and October 2024, which could have provided critical insights into the progression of R30's condition. Additionally, there was a failure to ensure the resident received the prescribed Austedo medication, which was intended to manage the involuntary movements, due to insurance issues that were not communicated effectively to the prescribing nurse practitioner. The deficiency was further compounded by an incident where R30 gagged on improperly prepared food that did not meet the mechanical soft diet requirements. Despite staff witnessing the incident, there was a lack of immediate communication to the licensed practical nurse on duty, which delayed appropriate medical response. These failures in coordination and communication contributed to the resident's increased risk and deterioration in condition, highlighting significant lapses in the facility's care protocols.
Failure to Prevent Pressure Ulcer in Resident
Penalty
Summary
The facility failed to prevent a pressure injury for a resident who was admitted with multiple health conditions, including cerebrovascular disease, femur fracture, mild protein-calorie malnutrition, and joint replacement surgery aftercare. The resident was cognitively intact but dependent on staff for mobility and had a care plan in place to manage skin integrity, which included turning and repositioning every two hours, using a low air loss mattress, and floating heels while in bed. Despite these interventions, the resident developed a new pressure ulcer on the left buttock, which was not promptly identified or treated by the staff. Observations revealed significant redness and skin tears on the resident's buttocks, which had been present for about a week before being reported. The lead CNA and another CNA observed the condition during peri-care, but it was not communicated to the nursing staff until later. When the LPN was informed, she acknowledged the skin breakdown and initiated treatment. The facility's policy required daily skin assessments and prompt reporting of changes, which were not adhered to in this case, leading to the development of a new facility-acquired wound.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for 8 hours a day, seven days a week, for the period from November 1, 2024, to November 18, 2024. This deficiency was observed during a survey, where it was noted that on November 18, 2024, at 9:00 AM, no RN was on duty. Additionally, on November 19, 2024, at 10:14 AM, the Director of Nurses (DON) confirmed that the facility does not employ any full-time RNs and relies on three per diem RNs, which results in the inability to provide consistent RN coverage as required. The facility's daily staffing schedule from November 1, 2024, to November 18, 2024, documented the absence of an RN for the required hours. The DON also stated that the facility does not have a specific staffing policy and follows Central Management Services (CMS) guidelines. This lack of RN coverage has the potential to affect all 75 residents at the facility, as documented in the CMS 671 Long Term Care Application for Medicare and Medicaid.
Deficiency in CNA Annual Training
Penalty
Summary
The facility failed to provide the required 12 hours of annual competency training for Certified Nursing Assistants (CNAs) to three out of five CNAs reviewed (V13, V31, and V36). This deficiency was identified through interviews and record reviews, which revealed that the training records did not document the completion of the necessary training hours. The Human Resources Director, V35, acknowledged that these CNAs did not receive the required in-service training. V35 explained that while she provides staff with access to the training site and login information, she does not oversee the completion of the training, expecting staff to fulfill the requirement independently. The facility's policy on employee training, dated September 2023, states that all workforce members will be trained on policies and procedures related to protected health information as necessary for their job functions. However, the policy does not appear to have been effectively implemented in this case, as evidenced by the lack of documented training for the CNAs. The facility has a census of 75 residents, all of whom could potentially be affected by this training deficiency.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives before transferring them to the hospital, as required by regulations. This deficiency was identified for six residents (R7, R12, R17, R36, R54, R72) out of a sample of 35. The report highlights multiple instances where residents were transferred to the hospital without receiving a written explanation of the reasons for their transfer, nor were their representatives or the ombudsman notified in writing. For instance, R17 was transferred to the hospital on three separate occasions without receiving a written notice explaining the reasons for the transfers, despite having intact cognition as per his Minimum Data Set. Similarly, R54, who had moderately impaired cognition, was transferred multiple times without written notification being provided to the resident or their family. In another case, R12, who has a diagnosis of dementia, was sent to the emergency room following a fall, but there was no documentation of a bed hold or written notice of the transfer. The facility's policy, revised in October 2022, mandates that residents and their representatives be notified in writing of any transfer or discharge, including the reasons for such actions. However, interviews with staff, including LPNs and the Regional Nurse, revealed a lack of awareness and adherence to this policy, as they admitted to not providing written explanations to residents being transferred to the hospital. This systemic failure to comply with notification requirements constitutes a significant deficiency in the facility's discharge and transfer procedures.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple instances of inadequate hand hygiene, improper glove use, and failure to wear appropriate personal protective equipment (PPE). During the toileting of a resident, two CNAs donned gloves without performing hand hygiene. Similarly, an LPN was observed administering medication and using a blood glucose monitor without sanitizing hands between glove changes. The LPN also failed to properly sanitize the blood glucose monitor after use, which was used for multiple residents, contrary to the facility's policy requiring thorough disinfection. Another incident involved an LPN providing tube feeding to a resident with a gastrostomy tube without wearing a gown, which is required for such procedures. Additionally, a CNA was observed performing incontinent care on a resident without changing gloves or performing hand hygiene between tasks, despite handling soiled materials. This practice was inconsistent with the facility's policy, which mandates handwashing and glove changes when moving from contaminated to clean tasks. Further deficiencies were noted during catheter and peri care for a resident, where CNAs failed to perform hand hygiene between glove changes and touched clean items with contaminated gloves. The facility's policies on glove use and hand hygiene were not followed, as staff did not wash hands before donning gloves or after removing them, nor did they change gloves after touching contaminated surfaces. These lapses in infection control practices were observed across multiple staff members and residents, indicating a systemic issue within the facility.
Failure to Accommodate Resident's Dining Preference
Penalty
Summary
The facility failed to accommodate a resident's preference to eat in his room, which is a violation of Resident's Rights. The resident, who is cognitively intact, has multiple medical conditions including multiple sclerosis, quadriplegia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. He is dependent on staff for all activities of daily living, including eating, and prefers to eat in his room due to the noise and commotion in the dining room. Despite his preference, the resident was observed eating in the dining room on multiple occasions. The resident expressed dissatisfaction with being required to eat in the dining room, stating that the facility cited short staffing as the reason for not accommodating his preference. The facility's Statement of Resident Rights affirms that residents have the right to choose their daily routines, including where they eat. The administrator acknowledged that residents have the right to eat in their rooms if they choose, yet the facility did not honor this right for the resident in question.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to report changes in condition to the physician for a resident, identified as R30, who was observed with severe spastic jerky movements and involuntary motions. R30, who has diagnoses including Psychosis, Schizoaffective Disorder, and Schizophrenia, was seen in the hallway with unsteady movements, resulting in a fall into a surveyor. Despite assistance from an LPN, R30 remained unsteady and nearly fell again while attempting to sit. This incident was not immediately reported to the physician as required by the facility's policy. Additionally, R30 experienced a gagging incident during a meal, where she was served large pieces of turkey instead of a mechanical diet. Despite the CNAs informing the LPN about the gagging incident, the physician was not notified until later in the evening. The facility's policy mandates immediate notification of the physician in such cases, but this was not adhered to, leading to a delay in medical intervention for R30.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for one resident, identified as R52, who was involved in a physical altercation with another resident. R52, who has a diagnosis of Schizoaffective Disorder and is cognitively intact, was reported to have intentionally hit another resident on the hand during a Bingo game. The incident was documented in R52's General Note, and an investigation was initiated, with staff and resident interviews conducted. The facility's Abuse Prevention and Reporting Policy prohibits abuse, neglect, and mistreatment of residents, yet the incident occurred despite staff presence at the time.
Failure to Provide Discharge Summaries for Residents
Penalty
Summary
The facility failed to provide discharge summaries for two residents, which was identified during a review of discharge procedures. One resident was admitted with diagnoses including sepsis, pneumonia, and cerebral infarction. Upon discharge, the resident's progress notes indicated that medications and discharge papers were given to the resident and their daughter, but the electronic medical records lacked a discharge summary. Another resident, admitted with diagnoses such as pneumonia and malignant neoplasms, also had no discharge summary documented in their electronic medical records. Interviews with the Social Services Director and the Regional Nurse Consultant revealed that discharge summaries were not documented for these residents, and the facility did not have a policy in place regarding discharge summaries.
Failure to Ensure Smoking Safety for Resident
Penalty
Summary
The facility failed to protect a resident, identified as R8, while smoking, which was observed during a survey. R8, who is cognitively intact but has multiple sclerosis, quadriplegia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, is dependent on staff for all self-care activities. Despite having a care plan that includes wearing a smoking apron for safety, R8 refuses to wear it due to discomfort, particularly in hot weather. The facility's policy requires safe smoking conditions, but R8 was observed smoking without the apron, resulting in cigarette ashes falling on his clothing. On multiple occasions, staff members, including an Activity Aid and the Activity Director, supervised R8 while smoking but did not enforce the use of the smoking apron or remove the ashes from his clothing. The Social Services Director acknowledged R8's refusal to wear the apron and his right to smoke, but no alternative measures were implemented to prevent ashes from falling on him. The facility's Smoking Safety Policy allows for the restriction of smoking privileges in cases of hazardous behavior, but this was not enforced in R8's case, leading to the deficiency.
Incomplete Incontinent Care for Residents
Penalty
Summary
The facility failed to provide complete incontinent care for three residents, leading to deficiencies in their care. Resident R16, who has multiple sclerosis and is severely cognitively impaired, was observed receiving incomplete care when a CNA failed to rinse and dry the peri-area and buttocks after cleansing, leaving soap suds on the skin. This was contrary to the facility's policy, which requires rinsing and drying after washing. Similarly, Resident R31, with diagnoses including COPD and schizo-affective disorder, did not receive complete care as the CNA did not cleanse or dry the right hip, buttock, and thigh after changing the saturated incontinent brief. The care plan for R31 indicated a need for assistance with toileting and regular checks, which were not fully adhered to during the observed care. Resident R43, diagnosed with COPD and dementia, also received inadequate care. The CNAs involved did not rinse or dry the soapy suds from the peri-area, abdominal fold, and groins, and failed to cleanse the left hip, buttock, and back of the thigh. The facility's incontinence care policy outlines specific steps for washing, rinsing, and drying, which were not followed in these instances. Interviews with other CNAs and the Director of Nurses confirmed the expectation that all areas should be cleansed and dried during incontinent care, highlighting a discrepancy between expected and actual care practices.
Failure to Address Nonfunctioning Gastrostomy Tube
Penalty
Summary
The facility failed to recognize and address a nonfunctioning Gastrostomy tube (G-tube) for a resident diagnosed with Multiple Sclerosis, who was severely cognitively impaired and reliant on a feeding tube. During an observation, a Licensed Practical Nurse (LPN) attempted to aspirate residual liquid from the resident's stomach to verify the G-tube placement but was unable to pull back the plunger more than 0.25 to 0.5 centimeters. The G-tube visibly closed in on itself during the attempt, indicating a malfunction. The LPN acknowledged that the G-tube was often difficult to aspirate but stated it always flushed well, and mentioned having requested a replacement for the G-tube multiple times without success. Despite being unable to verify the G-tube placement, the LPN prepared to instill a water flush, but was stopped by the surveyor, who advised consulting the Director of Nurses or the Physician. The LPN agreed that she was unable to check the placement at that time. The resident's nurse notes documented the inability to collect residual prior to tube feeding and indicated that the Primary Care Provider ordered the resident to be sent to the hospital for a tube placement check or new tube installation. The facility's policy required notifying a physician to request an X-ray if there was suspicion of feeding tube misplacement, which was not initially followed by the LPN.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 16.22%, which is significantly higher than the acceptable threshold of 5%. This deficiency affected two residents. One resident was administered 10 mg of Lexapro instead of the prescribed 20 mg of Escitalopram Oxalate for major depressive disorder. This error occurred during the morning medication pass by an LPN. Another resident did not receive their prescribed Breo Ellipta inhalation for chronic obstructive pulmonary disease because the medication was not available. Additionally, this resident did not receive their prescribed doses of Aspirin and Cholecalciferol during the medication pass. The LPN acknowledged the unavailability of Breo Ellipta and confirmed that the resident missed their dose. The facility's policy mandates that medications be administered according to the physician's orders, which was not adhered to in these instances.
Failure to Provide Physician-Ordered Diet
Penalty
Summary
The facility failed to provide diets as ordered by the physician for a resident, identified as R30, who was reviewed for quality of care. R30 was admitted with multiple diagnoses including Psychosis, Schizoaffective Disorder, and Schizophrenia, and was noted to be severely cognitively impaired. The resident's care plan indicated an increased nutritional risk due to various conditions and required a mechanical soft diet with ground meat texture and thin liquids, along with staff supervision during meals. However, during an observation, R30 was served a meal that did not meet these dietary requirements, leading to a gagging incident. On the day of the incident, R30 was observed eating a meal that included large pieces of turkey, which was not cut into bite-sized pieces as required by the mechanical soft diet order. The resident, who exhibited spastic and jerky movements, attempted to eat the turkey using a plastic fork and subsequently began to gag. Despite the presence of staff, the resident was not provided with the necessary supervision and assistance, resulting in the resident spitting out the food and drink. The incident was not immediately reported to the physician, and the resident's condition worsened, necessitating a chest x-ray and transport to a local hospital. Interviews with facility staff revealed a lack of communication and adherence to dietary orders. A CNA reported the incident to an LPN, but the LPN was initially unaware of the gagging incident. The facility's policies on diet orders and fall prevention were not effectively implemented, as evidenced by the failure to provide the correct diet and necessary supervision for R30. The facility's quality assurance programs were expected to monitor such issues, but the deficiency in care for R30 highlighted a lapse in following established protocols.
Failure to Address Residents' Needs Timely Due to Non-Functional Call System
Penalty
Summary
The facility failed to promote residents' dignity by not addressing their needs in a timely manner, as evidenced by the experiences of four residents. One resident, R2, reported that due to non-functional call lights, she was forced to urinate in her water pitcher after staff failed to respond to her needs for over an hour and a half. This incident left her feeling humiliated and subsequently led to a urinary tract infection. Despite being provided with alternative alert systems like a cow bell and an air horn, these measures were ineffective in gaining staff attention, especially with her room door closed due to COVID isolation. Another resident, R3, also experienced issues with the non-functional call system and had to resort to contacting hospice to get assistance from the facility staff. R3, who is cognitively intact and requires substantial assistance with toileting, reported that the bell provided as an alternative was not effective in summoning help. Similarly, R4 and R5 faced challenges with the call system, relying on cow bells that were not audible enough to alert staff, leading to delays in receiving care. R4 expressed dissatisfaction with the care, comparing the facility to a psych ward, and noted that staff only entered the room for essential tasks like meals and medications. The facility's administrator acknowledged the ongoing issue with the call light system, which had been down since early August, and stated that they were waiting for a replacement part. In the interim, residents were provided with cow bells, and staff were instructed to perform extra rounds and 15-minute checks on residents unable to use the bells. However, these measures were insufficient, as residents continued to report unmet needs and feelings of neglect.
Inadequate PPE Usage During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) to prevent the spread of COVID-19. Observations revealed that staff did not consistently wear the required PPE when entering rooms of residents on droplet/contact precautions. For instance, a surveyor noted the absence of gowns outside a resident's room, despite signage indicating their necessity. Additionally, staff members were observed wearing masks improperly, such as below the nose, which compromises their effectiveness. Several residents, including those with confirmed COVID-19 diagnoses, expressed concerns about the care they received. One resident, who was on droplet/contact precautions, reported feeling neglected and believed that the virus was brought into the facility by staff. Another resident, also on precautions, mentioned experiencing delays in assistance from staff since testing positive. These accounts highlight the residents' perception of inadequate care and potential exposure due to lapses in infection control practices. Staff interviews further revealed inconsistencies in understanding and implementing PPE protocols. Some staff members incorrectly stated that no residents on their hallway had COVID-19, while others admitted to not wearing full PPE when required. The facility's policy, dated March 2020, mandates the use of N95 respirators, gowns, gloves, and eye protection for healthcare personnel entering rooms of residents with confirmed or suspected COVID-19. Despite this, observations and staff statements indicate a lack of compliance with these guidelines, contributing to the facility's ongoing COVID-19 outbreak.
Deficient Call System in LTC Facility
Penalty
Summary
The facility failed to maintain an effective call system, impacting the ability of residents to communicate with staff when assistance was needed. This deficiency was observed through multiple instances where residents were provided with inadequate alternatives, such as cow bells and air horns, which were not effective in alerting staff. Residents reported that the call lights had not been functioning for some time, and despite being given various tools to signal for help, staff did not respond promptly or at all. One resident, who was cognitively intact and required substantial assistance with toileting, resorted to using an air horn after a cow bell and pressure pad alarm failed to summon help. This resident expressed feelings of humiliation after being left in urine and having to urinate in a water pitcher due to the lack of response from staff. Another resident, also cognitively intact and requiring maximal assistance, had to call hospice to get help because the staff did not respond to the bell provided. Similar issues were reported by other residents, who stated that staff only entered their rooms for essential tasks like meals and medications. The facility's administrator and maintenance director acknowledged the ongoing issue with the call light system, which had been down since early August. Despite ordering a replacement part, there was no estimated delivery date, leaving residents to rely on ineffective cow bells. The facility's policy required hourly room checks until the system was repaired, but residents continued to experience delays in receiving care, highlighting a significant lapse in ensuring timely and effective communication between residents and staff.
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What surveyors actually found near you
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Prairie Village Healthcare Ctr | 0.6 mi | ★★★★★ | 7 | 1 |
| Grove Health & Rehab Ctr, The | 1.1 mi | ★★★★★ | 18 | 1 |
| Jacksonville Skld Nur & Rehab | 1.3 mi | ★★★★★ | 2 | 0 |
| Cass County Senior Living & Rehabilitation Llc | 14 mi | ★★★★★ | 16 | 0 |
| Scott County Nursing Center | 18.8 mi | ★★★★★ | 7 | 0 |
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