Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 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.
A resident fell and reported right arm/wrist pain, prompting a STAT x-ray order to rule out fracture. Nursing documented that the x-ray vendor could not complete the study until later, but there was no documented physician notification about the delay. The resident continued to have pain, bruising, and swelling before being sent to the hospital, where an upper extremity fracture was diagnosed and the resident returned with a cast and sling.
A resident with a history of verbal and physical aggression was involved in multiple resident-to-resident altercations, including one with another resident in the foyer and another in the dining room. Staff observed yelling and physical contact, and one incident was substantiated as abuse after interviews with the residents and CNA. The other residents involved had cognitive impairment, including dementia and moderate impairment, increasing their vulnerability during these interactions.
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.
An LPN found opened multidose insulin vials on a med cart without open dates and an opened multidose Tuberculin vial in an unlocked refrigerator without a date. The refrigerator also contained liquid multidose Lorazepam for two residents, and the LPN stated the meds should be under a double-lock system and that the Tuberculin vial should have been discarded.
Improper Food Storage and Labeling: Surveyors observed expired food items in the refrigerator, including salad dressing, lettuce, sweet pickle relish, and soy sauce, and found a pitcher of chicken broth on a delivery cart without a label or prep/discard date. A Dietary Aide confirmed the items were expired, and the Administrator stated Dietary staff were expected to discard expired items and ensure foods and beverages were labeled and dated when opened.
The facility failed to answer call lights timely for several cognitively intact residents who required ADL assistance, with residents reporting long waits and call lights staying on for hours; Resident Council minutes also noted overnight staff were often missing in action. The facility also failed to provide dignified dining assistance when a CNA stood beside a resident while feeding her lunch instead of sitting beside her, despite the resident requiring supervision or touch assistance during eating.
Call lights were left out of reach for multiple residents despite care plans directing staff to keep them accessible. A resident with severe cognitive impairment and multiple chronic conditions had the call light on the floor, a legally blind resident with severe cognitive impairment had it hanging above the bed while seated in a wheelchair, another resident had it on the floor while in bed, and a cognitively intact resident had it hanging on the opposite side of the bed and stated staff needed to attach it to the bed. The DON stated call lights were expected to be within residents’ reach at all times, and the facility policy required call lights to be available and easily accessible.
Lack of Evening and Weekend Activities: The facility failed to provide an ongoing activity program to meet residents’ interests and needs, with no observed activities during the survey day and no activity staff scheduled on the prior weekend. Several cognitively intact residents stated there were no evening activities or every-other-weekend activities, and the Resident Council President reported the issue had continued because of budget limits and limited activity staffing. A resident with Asperger’s syndrome and autistic disorder was observed pacing in the hallway while no activities were taking place.
Unlabeled Oxygen Tubing and Humidifiers: A facility failed to label oxygen tubing and humidification bottles for multiple residents receiving O2 therapy. Residents with COPD were observed with undated tubing, empty or partially filled humidifiers, and oxygen tubing on the floor or not in place; one LPN confirmed the equipment was not in place, not labeled, and empty.
A facility failed to provide mail every Saturday for two cognitively intact residents reviewed for resident rights. During a resident council meeting, both residents stated they did not receive mail each Saturday, and one reported that activity staff only worked every other weekend and delivered the mail. The Administrator stated mail was only delivered every other Saturday and that the facility did not have a mail policy, but followed resident rights for mail.
Failure to provide needed ADL care and meal assistance: one resident with severe cognitive impairment and weight loss was observed wandering, eating on the go, and receiving inconsistent help during meals, while another resident with multiple chronic conditions was repeatedly observed unshaven, with dirty fingernails, and eating in bed with the HOB at about 30 degrees while coughing. The care plans called for grooming, nail care, and meal assistance, but staff observations showed these needs were not consistently met.
Failure to Maintain Ordered Wound Dressings and Treat New Wounds: The facility failed to provide ordered wound care for three residents. One resident with multiple chronic ulcers and severe cognitive impairment was repeatedly observed with foot and ankle wounds left uncovered, and staff were unaware of a new blackened toe wound. Another resident with diabetes, PVD, and cognitive impairment was observed without a wheelchair cushion and with a gluteal fold wound that had no dressing, despite an order for treatment. A third resident’s foot wound dressing was not changed as ordered, and an LPN applied treatment without cleansing the wound first, contrary to the PO.
Improper transfer and ambulation assistance led to an accident involving two residents. One resident who required a full mechanical lift and 2-person assist was transferred while staff did not keep hands on the sling throughout the lift, and another resident with severe cognitive impairment, unsteady gait, weakness, and dyskinesia ambulated without a gait belt, fell backward against a wall, and then to the floor while being redirected by a CNA.
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 Complete STAT X-Ray and Notify Physician After Resident Fall
Penalty
Summary
The facility failed to follow a physician’s STAT x-ray order and failed to notify the physician when the ordered x-ray could not be completed for a resident who fell and reported right wrist pain. The resident had diagnoses including schizophrenia, other lack of coordination, vitamin D deficiency, and cognitive communication deficit. After the fall, nursing documentation noted pain rated 5 out of 10 and a new order from the physician for an immediate x-ray of the right arm and wrist due to pain and crepitus. The x-ray company reported that no x-ray was available until two days later, but the nursing notes did not document any contact with the physician about the delay. During the delay, the resident continued to receive pain medication, and nursing notes later documented bruising, swelling, and ongoing elbow and wrist pain. The resident was then sent to the hospital for evaluation and treatment, where x-rays showed an acute mildly widened fracture of the lateral distal right humeral epicondyle with questionable intra-articular extension. The resident returned to the facility with a diagnosis of upper extremity fracture and a fiberglass cast on the right arm. The administrator stated that nursing staff are expected to notify the physician when a STAT order cannot be completed as ordered, and the physician stated staff are expected to obtain an alternative diagnostic service or additional instructions if a STAT order is unable to be obtained.
Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident in multiple resident-to-resident altercations. In one incident, R1 and R2 were involved in an altercation in the front foyer while waiting for a smoke break. R1 stated that R2 made contact first, and then R1 pulled R2 to the ground and held R2's arms for safety. Staff separated the residents and assessed both with no injuries noted, and R2 refused vital signs. The investigation documents that an LPN heard yelling and observed R1 holding R2's hands, and a CNA also heard yelling and observed R1 holding R2's hands. R1 had a history of verbal and physical altercations, difficulty adjusting to the facility, frequent refusal of services, and frequent need for redirection. R1's care plan identified mood and behavior issues and potential for verbal aggression. R2 had severe cognitive impairment and a diagnosis of dementia, with a BIMS score of 14/15. In another substantiated incident, R1 and R4 were involved in an altercation in the dining room when R1 approached R4, spoke to R4, and swung an arm, making contact with R4. The investigation also documented that a CNA witnessed R1 hitting R4. The Administrator stated the allegation of abuse was substantiated after interviews with R1, R4, and the CNA. R4 had moderate cognitive impairment with a BIMS score of 6/15. Additional staff statements described R1 as verbally abusive to other residents and staff daily, and another CNA reported seeing R1 exchange words with R4 and land one punch to R4's cheek before separating the residents and notifying the nurse and Administrator.
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.
Improper Medication Storage and Missing Open Dates
Penalty
Summary
The facility failed to properly store medications and discard expired medication. On 3/1/2026 at 8:32 AM, the 100-hall medication cart was inspected and contained two opened and partially used multidose Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) vials for R56 and R7, and neither vial had an open date documented. During interview, an LPN stated that opened insulin vials and pens are dated when first accessed and used, and that the open date is used to track the shortened 28-day expiration period so the medication can be removed from use and destroyed when due. On the same day at 8:34 AM, the medication room was inspected and the unlocked refrigerator inside the room, with the lock hanging open, contained an opened and partially used multidose Tuberculin vial with no open date, along with liquid multidose bottles of Lorazepam for R58 and R35. An LPN verified that the Tuberculin vial was open, in use, and had no handwritten date, and stated it should be disposed of and not in use. The LPN also stated the Tuberculin vial was stock medication for residents with an order and no allergy, and stated that R58's and R35's Lorazepam should be under a double lock system, which was not in place because the refrigerator was not locked.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to ensure foods were properly stored, labeled, dated, and discarded when expired in accordance with sanitary food service practices. During an initial kitchen tour on 3/1/26 at 8:15 AM, the surveyor observed expired food items in the large double-door refrigerator, including a 1-gallon container of salad dressing approximately 1/4 full with an expiration date of 2/2025, 3 large bags of wilted lettuce with an expiration date of 2/26/26, a 1-gallon container of sweet pickle relish approximately 1/4 full with an expiration date of 12/18/25, and a 1-gallon open container of soy sauce almost full with an expiration date of 12/21/25. A Dietary Aide was present and confirmed the items were expired and should have been discarded. During the same tour, the surveyor observed a pitcher approximately 3/4 full of a yellow liquid on a food delivery cart that did not have a label identifying the contents and did not have a preparation or discard date. A staff member confirmed the liquid was chicken broth. On 3/3/26 at 10:12 AM, the Administrator stated she expected Dietary staff to promptly discard expired food items and ensure all food and beverages are labeled and dated when opened. The facility’s CMS 671 form dated 3/1/26 documented 63 residents residing at the facility.
Delayed Call Light Response and Undignified Feeding Assistance
Penalty
Summary
The facility failed to answer call lights timely for 4 of 6 residents reviewed for dignity, including residents who were cognitively intact and required assistance with activities of daily living. During interviews on 3/2/2026, R19 stated there was not enough staff to provide care, that only 2 CNAs were on the hall, and that call lights took a long time to be answered. R41 stated the facility did not have enough staff and that when she needed something, the call light could stay on for hours. R20 stated there was not enough staff and that it took a long time to answer call lights. R50 stated that it takes a long time to answer call lights. The Resident Council Minutes dated 10/28/2025 documented that overnight staff were missing in action most of the time and that some call lights stayed on for 2 hours. The facility also failed to provide dining assistance in a dignified manner for R24. On 3/3/2026 at 11:45 AM, a CNA was observed standing beside R24 while feeding her lunch, and did not sit beside her during the meal. R24's MDS documented severe cognitive impairment and that she required supervision or touch assistance during eating, with verbal cues and/or touching, steadying, or contact guard assistance as she completed the activity. A CNA later stated that when feeding residents, staff should sit beside the resident and would never stand when feeding a resident. The facility policy on Dignity stated that residents should be cared for in a manner that maintains or enhances dignity and respect, including avoiding staff standing over residents while assisting them to eat.
Call lights left out of reach for multiple residents
Penalty
Summary
The facility failed to ensure resident call lights were within reach for 4 of 6 residents reviewed for call lights in a sample of 38. R9, who had diagnoses including transient cerebral ischemic attack, COPD, asthma, type 2 diabetes mellitus with diabetic neuropathy, idiopathic peripheral autonomic neuropathy, non-pressure chronic ulcers of the right lower leg and heel/midfoot, and atrial fibrillation, was severely cognitively impaired and dependent on staff for mobility. Although the care plan directed staff to ensure the call light was in reach, the call light was observed on the floor under the bed during the initial tour, and R9 stated it could not be reached. R26, who was legally blind and severely cognitively impaired, required assist of 2 and a mechanical lift for transfers; despite care plan interventions stating the call light should be within reach, it was observed hanging on the wall above the bed while the resident was sitting in a wheelchair. The DON stated she expected call lights to be within residents’ reach at all times. R29 was observed in bed with the head of bed elevated, and the call light was on the floor out of reach. R29’s care plan documented ADL self-care performance deficits related to weakness, impaired mobility, neuropathy, chronic respiratory failure, peripheral venous insufficiency, and dementia, along with interventions to encourage use of the call light and keep it within reach. R50, who was cognitively intact and had an ADL self-care performance deficit related to activity intolerance and muscle weakness, was observed in bed with the call light hanging over the outlet on the opposite side of the bed and out of reach; the resident later stated the call light was out of reach and that staff needed to attach it to the bed. The facility policy stated residents who can use a call light should have it available at all times and within easy accessibility at the bedside or another reasonable accessible location.
Lack of Evening and Weekend Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet residents’ interests and needs during evenings and every other weekend for 5 of 5 residents reviewed for activities. On 3/1/26, R62 was observed pacing and walking in circles in the hallway, and no activities were observed taking place throughout the day. R62’s admission record documented diagnoses of Asperger’s syndrome and autistic disorder. During the survey, the activity calendar listed morning news, social hour club, afternoon movie, word puzzles, and evening news for 3/1/26, but the survey team did not observe any of those activities occurring, including during the times they were scheduled. Observations of common areas and the activity room showed residents sitting around without stimulation or entertainment. Resident interviews confirmed the lack of evening and weekend programming. R19, who was cognitively intact and identified himself as President of the Resident Council, stated the facility had not had activities every other weekend for a long time because of budget cuts, that there were only 2 employees in the activity department, and that there were no evening activities. R20, R10, and R52 each stated there were no activities in the evenings or every other weekend, and R10 and R20 said they would like more activities. V10, the Activity Assistant, stated there was no activity staff scheduled the prior weekend and no staff provided activities. V1, the Administrator, stated no activity department staff were scheduled every other weekend and that the facility was not budgeted for activity staff every weekend. The facility’s February and March 2026 activity calendars showed limited weekend scheduling and no set times for some weekend activities, and the facility’s policy required an ongoing program of activities, including a minimum of 4-7 organized activities daily and programs for residents who cannot effectively plan their own activity pursuits.
Unlabeled Oxygen Tubing and Humidifiers
Penalty
Summary
The facility failed to label oxygen tubing for 4 of 6 residents reviewed for oxygen therapy. On 3/1/2026, R29 was observed in bed with oxygen via nasal cannula, with undated tubing and an unlabeled humidification bottle that was less than 1/4 full. R29’s record documented COPD and chronic respiratory failure with hypoxia, and physician orders directed oxygen at 2 liters per nasal cannula with tubing changed weekly and as needed. R29’s care plan identified altered respiratory status and difficulty breathing related to COPD. R58 was observed in bed with the oxygen concentrator at the head of the bed, oxygen tubing on the floor, and an undated humidification bottle that was half full. R58’s record documented COPD, and the care plan and physician orders directed oxygen therapy via nasal cannula at 2 liters as needed with tubing changed every Wednesday night shift. R57 was observed sitting in bed with oxygen next to her, tubing on the floor, and an empty humidifier with no date on the tubing or humidifier; she stated she was supposed to always wear her oxygen and that the tubing fell and she could not reach it. R56 was observed sitting in bed with oxygen on her face, an empty humidifier, and no date on the tubing or humidifier; she stated she was not sure if or when her oxygen was changed. A LPN verified that R56’s and R57’s oxygen was not in place, not labeled, and empty, and stated that the oxygen should be in place and labeled.
Failure to Deliver Resident Mail Every Saturday
Penalty
Summary
The facility failed to provide residents with mail every Saturday for 2 of 5 residents reviewed for resident rights. During a resident council meeting, two cognitively intact residents stated they did not receive mail every Saturday, and one resident reported that activity staff only worked every other weekend and delivered the mail. Record review showed both residents were cognitively intact on their MDS assessments. The Administrator stated that mail was only delivered every other Saturday and also stated that the facility did not have a mail policy, but followed resident rights for mail.
Failure to Provide Needed ADL Care and Meal Assistance
Penalty
Summary
The facility failed to ensure residents who required assistance received needed ADL care, including grooming, nail care, and proper assistance and positioning during meals. The deficiency involved 2 of 6 residents reviewed for ADL care, including one resident who was observed with visibly dirty hair and fingernails and another resident who was not consistently assisted or positioned appropriately while eating. One resident had diagnoses including unspecified protein calorie malnutrition, generalized anxiety disorder, restlessness, and agitation. The resident’s MDS documented a need for supervision or touching assistance with eating, and the care plan called for set-up assistance and encouragement with meals. During lunch observation, the resident was seen wandering, pacing, and eating while walking in the hallway and dining room. Staff were observed prompting the resident to come to the dining room, handing food items to the resident, and later feeding with a fork while the resident ate with hands and then used a spoon only after verbal prompting. The resident’s record also documented significant weight loss and use of supplements for weight status. Another resident had diagnoses including TIA, COPD, asthma, diabetes with neuropathy, atrial fibrillation, and chronic leg and heel ulcers. The resident’s MDS documented severe cognitive impairment and dependence on staff for bathing and toileting hygiene, and the care plan directed extensive assistance with personal hygiene, including checking nail length and trimming and cleaning nails as needed. The resident was observed in bed appearing unkempt, unshaven, and with dark debris under the fingernails on both hands on multiple occasions. The resident was also observed eating lunch in bed with the head of the bed at approximately 30 degrees, coughing while attempting to feed self, and with dirty fingernails visible during the meal. The DON agreed the resident was not positioned high enough for safe eating, and the administrator stated staff were expected to clean residents’ hands and fingernails before meals and properly position residents prior to eating.
Failure to Maintain Ordered Wound Dressings and Treat New Wounds
Penalty
Summary
The facility failed to provide ordered wound treatment and care for three residents with skin impairments. R9 had multiple diagnoses including diabetes with neuropathy, peripheral autonomic neuropathy, chronic ulcers of the right lower leg and heel, and atrial fibrillation, and was documented as severely cognitively impaired and dependent on staff for mobility. R9’s physician orders required wound cleansing, collagen, ABD pads, and gauze dressings to the left dorsal foot, left medial ankle, and right dorsal foot every night shift and as needed. During observation on multiple occasions, R9’s wounds were left uncovered and exposed to the environment, with blood-tinged wound bases noted, and staff acknowledged the wounds were uncovered. The TAR and progress notes did not document that dressings were applied on the day shift when the wounds were observed uncovered. Surveyors also observed a new blackened area on the bottom of R9’s second right toe that staff stated they were not aware of. R1 had diagnoses including type 2 diabetes, COPD, dysphagia, CHF, hypertension, PVD, encephalopathy, and cardiomegaly, and was moderately cognitively impaired and dependent on staff for mobility. R1’s care plan identified risk for skin impairment related to obesity, diabetes, PVD, incontinence, and non-compliance with turning and repositioning. A physician order required treatment to the right upper thigh wound with calcium alginate and bordered foam. Surveyors observed R1 sitting in a wheelchair without a wheelchair cushion, and staff stated they had never seen a cushion in the wheelchair or in the room. When R1 was transferred to bed, an approximate 2 cm round wound was observed on the right gluteal fold, and no dressing was present. The administrator stated the wound should have had a dressing, and the wound physician stated he would expect a pressure relieving cushion in the wheelchair and a dressing on the wound at all times. R50 was cognitively intact and had diagnoses including type 2 diabetes mellitus with diabetic neuropathy and a non-pressure chronic ulcer of the foot. R50 stated the dressing to the wound was supposed to be changed daily but was not. On observation, the wound dressing on the right foot was removed and had tan drainage. The LPN then applied treatment but did not cleanse the wound with wound cleanser before applying med honey and a border dressing, despite the physician order requiring cleansing with wound cleanser, honey, and border foam daily and as needed. The wound physician stated treatments were expected to be done as ordered.
Improper Transfer and Ambulation Assistance
Penalty
Summary
The facility failed to provide proper assistance with ambulation and transfers for 2 of 4 residents reviewed for accidents. One resident with dementia and an ADL self-care performance deficit was transferred using a mechanical lift, but the sling was not continuously controlled by staff during the transfer. On 3/3/2026, two CNAs secured the sling to the lift, one CNA operated the lift while the other initially held the resident in the sling, then removed hands once the resident was in the air and turned away to position the reclining wheelchair before placing hands back on the sling to guide the resident into the chair. The resident’s care plan documented the need for a full mechanical lift and 2-person assist for transfers between surfaces, and the resident’s face sheet listed weakness. A second resident with severe cognitive impairment, a BIMS score of 2, unsteadiness on feet, weakness, lack of coordination, dyskinesia, and multiple psychiatric diagnoses was observed ambulating without a gait belt. The resident exited the room with a CNA beside them, walked to the dining room with the CNA placing hands on the resident to steady them, then stood up from the chair and exited the dining room. While the CNA attempted to redirect the resident in the hallway, the resident had an unsteady gait, fell backward against the wall striking the handrail, and fell to the floor. The resident’s care plan called for one-person physical assist with a gait belt for transfers and locomotion on the unit, and the facility policy stated that use of a gait belt for all physical assist transfers is mandatory.
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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Illustrative
What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 15 | 1 |
| Grove Health & Rehab Ctr, The | 1.1 mi | ★★★★★ | 6 | 1 |
| Jacksonville Skld Nur & Rehab | 1.3 mi | ★★★★★ | 1 | 0 |
| Cass County Senior Living & Rehabilitation Llc | 14 mi | ★★★★★ | 13 | 0 |
| Scott County Nursing Center | 18.8 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.