Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jacksonville Skld Nur & Rehab during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including ESRD, prior lumbar issues, essential tremor, and a left BKA, who used a manual wheelchair and was assessed as high fall risk, was transported to an appointment in the facility’s small van. During the return trip, the wheelchair tipped backwards in the van while the resident was strapped in and the wheelchair brakes were locked, causing the resident to strike the back of the head and upper back on the van floor and complain of headache and back pain. Staff and the resident reported that the wheelchair had been secured, and the van’s strap system included a red lever that, if contacted, could loosen the straps. Subsequent imaging documented an acute L1 compression fracture, demonstrating that the facility failed to ensure the wheelchair was safely and securely positioned during transport as required by its transportation policy.
A resident with severe cognitive impairment and a history of behavioral symptoms became agitated due to a delusional belief and physically struck another cognitively impaired resident on the cheek. Staff intervened immediately, and no injuries were found, but the incident showed a failure to prevent resident-to-resident abuse as required by facility policy.
Staff failed to perform hand hygiene and use gloves appropriately during meal service and direct care, including handling food without sanitizing hands and not following enhanced barrier precautions. A nurse also did not change gloves or perform hand hygiene while administering IV antibiotics to a resident with a midline IV, and reused an alcohol wipe during the procedure, contrary to facility policy.
A resident with multiple risk factors for skin breakdown developed a facility-acquired, unstageable pressure ulcer that was not identified until it had progressed significantly. Despite care plan interventions and facility policy requiring regular skin assessments and prompt reporting, the pressure ulcer was only discovered during a wound dressing change, with the wound nurse acknowledging it should have been found earlier.
A resident with severe cognitive impairment and a history of falls was found on the floor with an injury after required bed bolsters, intended to prevent falls, were not properly secured as outlined in the care plan. The bolsters were found loose and not clipped to the bed at the time of the incident.
A resident with severe cognitive impairment and high fall risk experienced a fall resulting in injuries due to the facility's failure to implement necessary interventions. The resident was not wearing nonskid footwear, and alarms were not in place at the time of the fall. Staff interviews revealed confusion about the resident's fall prevention measures, and the facility lacked a specific fall prevention policy. The root cause analysis identified bladder spasms and medication changes as contributing factors.
The facility failed to maintain properly inflated air mattresses for three residents, resulting in safety hazards and an unwitnessed fall. A resident with severe cognitive impairment fell from bed due to mattress deflation, sustaining a laceration and skin tears. Other residents reported frequent deflation issues, and staff acknowledged recurring problems with air mattresses. The facility lacked a policy or maintenance program for air mattresses, contributing to the deficiency.
A resident with cognitive deficits and a history of falls fell and sustained a head laceration while being assisted by a CNA. The CNA momentarily removed support to adjust a stuck bed remote, leading to the fall. Staff noted the resident's need for constant supervision and physical support due to safety awareness issues. The facility lacked a documented Fall Prevention policy.
The facility failed to prevent potential food contamination, affecting all 83 residents. Staff were observed handling food with bare hands, not restraining hair properly, and neglecting hand hygiene. A CNA fed a resident with bare hands, while the Director of Nurses and another CNA handled sandwiches without gloves. The Dietary Aide scratched her head and face without washing hands during meal prep. These actions violated the facility's policies on hand washing, staff attire, and meal assistance.
The facility failed to provide necessary oxygen to two residents, resulting in one resident becoming cyanotic with a dangerously low oxygen saturation level. Staff interviews revealed a lack of communication and protocol for switching residents from portable oxygen tanks to concentrators, and the facility's oxygen administration procedure was not followed.
The facility failed to properly store and label Tuberculin and Insulin vials, affecting all 83 residents. Open and partially used vials were found without open dates, contrary to the facility's Medication Storage policy.
The facility failed to properly dispose of soiled linens and perform hand hygiene between glove changes for four residents during incontinent care. Staff did not follow the facility's infection prevention and control program, leading to multiple instances of improper hand hygiene and handling of soiled items.
The facility failed to provide timely and complete incontinent care for five residents, including proper hand hygiene and glove changes. Observations confirmed that staff did not perform hand hygiene or change gloves appropriately while providing care, and residents were left in soiled conditions multiple times. The care provided was incomplete, with areas not being properly cleaned or dried, leading to potential skin integrity issues.
A resident with multiple diagnoses and a risk for falls experienced inadequate lighting in her room for over a month, despite informing the maintenance staff. The room remained dark, affecting the resident's comfort and safety, and the facility's policy on providing adequate lighting was not followed.
Wheelchair Not Properly Secured During Van Transport Leading to Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s wheelchair was properly secured during transport in the facility’s van, resulting in the wheelchair tipping over. The resident involved had multiple medical diagnoses, including Type 2 diabetes mellitus, end stage renal disease, peripheral vascular disease, lumbar intervertebral disc degeneration, prior L1 vertebral fracture, low back pain, essential tremor, and a left below-knee amputation. The resident was cognitively intact, used a manual wheelchair for locomotion, did not ambulate, and was assessed as a high fall risk with care plans identifying risk for falls related to her diagnoses and medications. On the day of the incident, the resident was transported to an appointment in the facility’s small van. Upon returning, her wheelchair tipped backwards in the van while she was strapped in with the wheelchair brakes engaged. The resident reported that she was strapped in properly and that the driver did not accelerate or brake abruptly when the wheelchair tipped. Staff interviews confirmed that the resident’s wheelchair brakes were locked and that she was secured in the van at the time of the incident. The Maintenance Director and the transport CNA indicated that the van’s wheelchair securement system uses straps with a red lever that, if pressed or contacted (for example, by a resident’s foot), could loosen the straps securing the wheelchair. After the wheelchair tipped, the resident hit the back of her head and upper back on the floor of the van. Nursing documentation and staff interviews describe a small hematoma to the back of the resident’s head, complaints of headache and lower back pain, and the resident’s refusal of immediate hospital evaluation and x‑rays. The facility initiated in‑house assessment and monitoring, and subsequent imaging, including a CT scan of the lumbar spine, later documented an acute L1 compression fracture along with degenerative disc disease and facet arthrosis. The facility’s transportation policy states that it is the facility’s responsibility to ensure any resident transported by facility vehicle has a safe and secure transport, which was not achieved in this incident when the wheelchair tipped while the resident was secured in the van.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with severe cognitive impairment and dementia. One resident, who had a history of accusatory statements, verbal aggression, and misperceptions related to Alzheimer's disease, became agitated after observing another resident speaking with a female peer. Due to her cognitive impairment and delusional belief that the other resident was her deceased husband cheating on her, she attempted to strike him on the cheek, making contact with her fingertips. Staff immediately intervened and separated the residents, and both were assessed with no injuries noted. Interviews with staff and documentation confirmed that both residents involved were confused and cognitively impaired. The incident occurred in a common area near the nurse's stations, where the aggressor approached and made contact with the other resident's cheek. The facility's abuse policy prohibits all forms of abuse, neglect, and mistreatment, but the event demonstrated a failure to prevent physical abuse between residents, as required by regulation.
Failure to Follow Hand Hygiene and Infection Control Protocols
Penalty
Summary
Multiple staff members failed to follow proper hand hygiene and infection control protocols during meal service and while providing direct care. During meal distribution, staff including a CNA, Activity Director, and Activity Assistant did not sanitize their hands or don gloves before handling food or serving meal trays to residents. In one instance, a CNA removed a sandwich from its bag with bare hands and handed it to a resident without performing hand hygiene. Additionally, staff did not perform hand hygiene before donning gloves when entering a resident's room under enhanced barrier precautions, despite posted signage instructing them to do so. A Registered Nurse, while administering IV antibiotics to a resident with a midline IV access for a urinary tract infection, failed to change gloves or perform hand hygiene between tasks, and reused an alcohol wipe during the procedure. The facility's own hand hygiene policy requires hand hygiene before and after handling invasive devices and after contact with objects in the resident's immediate vicinity. These lapses were observed across multiple staff and residents, and were confirmed by staff interviews and review of facility policies.
Failure to Timely Identify Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to identify a pressure ulcer in one resident who was at high risk for skin breakdown due to cognitive deficits, decreased sensation, diabetes mellitus, neuropathy, incontinence, and edema. During a wound dressing change, the wound nurse observed an unstageable pressure ulcer on the resident's sacrum, characterized by slough and eschar, absence of granulation tissue, and a red peri-wound area with foul-smelling drainage. The wound was determined to be facility-acquired, and the wound nurse acknowledged that the pressure sore should have been detected before reaching an unstageable stage. Review of the resident's care plan indicated interventions for monitoring skin integrity and prompt physician notification of skin breakdown, but the new pressure ulcer was not identified until it had progressed significantly. Facility policy requires regular observation, measurement, and documentation of pressure areas, as well as immediate reporting of skin conditions by certified nursing assistants. Despite these protocols, the pressure ulcer was not identified in a timely manner, resulting in a facility-acquired, unstageable wound.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a required intervention to prevent falls for a resident with severe cognitive impairment and a history of falls and fracture. The resident's care plan identified the use of bolsters clipped to the bed as an intervention for positioning and fall prevention. However, on the date of the incident, the resident was found on the floor beside the bed with a 3 cm scratch to the left cheek, and it was documented that the bolsters were not clipped to the bed but were instead loose and laying on the bed. The facility's policy required the interdisciplinary team to investigate and implement appropriate interventions, but the intervention of securing the bolsters was not followed, contributing to the resident's fall.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a fall for a resident identified as R2, who was at high risk for falls. On the morning of 3/6/2025, R2 was observed sitting in a recliner with a pad alarm in place and a call light within reach. However, on 2/19/2025, R2 experienced a fall that resulted in injuries, including a laceration to the chin and a fracture of the right mandibular condyle. Interviews with staff revealed that R2 did not have his alarms on, nor was he wearing nonskid footwear at the time of the fall. Additionally, there was confusion among staff regarding whether R2's pad alarm was in place during the night of the incident. R2's medical history included severe cognitive impairment, a high risk for falls, and diagnoses such as Neurocognitive Disorder with Lewy Bodies and a wedge compression fracture. The care plan for R2, dated prior to the fall, included interventions such as fall mats, a low bed, and personal alarms. However, these interventions were not effectively implemented or communicated to the staff, as evidenced by the lack of alarms and appropriate footwear at the time of the fall. The root cause analysis conducted after the fall identified bladder spasms and the urge to void as contributing factors, exacerbated by the discontinuation of medications during a recent hospitalization. The facility's policy required a thorough investigation of accidents and incidents, including identifying the root cause and implementing appropriate interventions. Despite this policy, the facility did not have a specific fall prevention policy in place, and the lack of consistent implementation and communication of fall prevention measures contributed to the incident. The assistant administrator confirmed the absence of a fall prevention policy, highlighting a gap in the facility's approach to managing fall risks for residents like R2.
Air Mattress Deflation Leads to Resident Fall and Safety Concerns
Penalty
Summary
The facility failed to ensure the proper inflation of air mattresses for three residents, leading to safety hazards and an unwitnessed fall. Resident R2, who has severe cognitive impairment and is at risk for falls, was found on the floor with a laceration and multiple skin tears after her air mattress deflated. The incident report identified the root cause as air mattress deflation, and it was noted that the mattress had been reset and bolsters added. Interviews with staff revealed that the deflation of air mattresses was a recurring issue, often due to unplugged CPR plugs or pinched tubing when the bed was raised too high. Resident R4, who has moderate cognitive impairment, reported frequent issues with her mattress deflating, stating that nothing was done about it. Similarly, Resident R5, who is cognitively intact, also reported that his mattress deflates often, making it uncomfortable. The facility's administrator acknowledged the problem with deflating mattresses and mentioned that they had started purchasing a different brand, but issues persisted. The facility did not have a policy regarding air mattresses or perform assessments for residents using air loss mattresses. The air mattress manual provided by the facility indicated that proper patient assessment, monitoring, equipment use, and maintenance are required to reduce entrapment risk. It also included guidelines for cleaning the air filter cotton every three months. However, the Maintenance Director stated that there was no maintenance or preventative program for the air mattresses, and issues were often addressed through a work order system. The lack of a structured maintenance program and the recurring deflation issues contributed to the deficiency in ensuring a safe environment for the residents.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate safety and supervision for a resident, identified as R3, who was at risk for falls due to cognitive deficits and a history of falls. R3's care plan indicated a need for assistance with activities of daily living and specified that R3 required one-person physical assistance for bed mobility and dressing. On the day of the incident, a CNA was assisting R3 with getting dressed while R3 was sitting on the side of the bed with the bed elevated. The CNA momentarily removed her support from R3 to adjust a stuck bed remote, during which time R3 fell forward, resulting in a laceration to the forehead that required sutures. Interviews with staff revealed that R3 was dependent on staff for care and could not sit on the side of the bed independently. Staff members emphasized the need to be directly in front of R3 and maintain physical contact due to R3's tendency to reach out and pick at things randomly. The incident report and staff statements confirmed that the CNA had raised the bed too high, causing R3's feet to be off the floor, which contributed to the fall. The facility did not have a documented Fall Prevention policy, which may have contributed to the lack of adequate supervision and safety measures for R3.
Food Handling and Hygiene Deficiencies
Penalty
Summary
The facility failed to handle food in a manner that prevents potential contamination, affecting all 83 residents. During breakfast, a Certified Nurse Aide (CNA) was observed feeding a resident with her bare hands, repeatedly handling toast without gloves. In the kitchen, a Dietary Aide and a Corporate Dietary Supervisor were seen with improperly restrained hair, and the Dietary Aide was observed scratching her head and face without washing her hands before continuing meal preparation. Additionally, the Director of Nurses was seen handling residents' sandwiches with bare hands, tearing and altering the food before serving it to the residents. Further observations included a CNA assisting a resident with lunch by handling a grilled cheese sandwich with bare hands, dipping it into soup, and feeding it to the resident. The facility's policies on hand washing, staff attire, and meal assistance were not adhered to, as evidenced by the lack of proper hand hygiene and hair restraint among staff members. The facility's administrator acknowledged that all kitchen staff should wear hair nets, wash hands when necessary, and avoid touching residents' food with bare hands.
Failure to Provide Necessary Oxygen to Residents
Penalty
Summary
The facility failed to provide necessary oxygen to two residents who required it, resulting in one resident becoming cyanotic with a dangerously low oxygen saturation level. Resident 26, who had multiple diagnoses including COPD and dependence on supplemental oxygen, was found with an empty portable oxygen tank on two separate occasions. On the first occasion, the resident's oxygen saturation was 88% and improved after being connected to an oxygen concentrator. On the second occasion, the resident was found with an oxygen saturation of 51%, and her condition improved only after the oxygen concentrator was used. Staff interviews revealed that there was a lack of communication and protocol regarding the switching of residents from portable oxygen tanks to concentrators upon returning to their rooms. The Director of Nursing and other staff members acknowledged the issue and indicated that there was no existing policy for transporting residents on oxygen. Additionally, the facility's oxygen administration procedure policy was not followed, as evidenced by the empty tanks and lack of humidifiers. Resident 56 also experienced issues with oxygen administration. The resident's daughter reported that the oxygen tank was frequently empty, and she had to replace it herself during visits. The facility's failure to ensure that oxygen tanks were filled and functioning properly, as well as the lack of adherence to the oxygen administration procedure, contributed to the deficiencies observed by the surveyors.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label medications, specifically Tuberculin and Insulin vials, which has the potential to affect all 83 residents. During an inspection of the 100-Hall Medication Storage Room, an open and partially used multi-dose vial of Tuberculin was found without an open date. Additionally, the Medicare medication cart contained several open and partially used multi-dose vials of Lantus, Gargling, and Humalog, all without open dates. Licensed Practical Nurse (LPN) V6 confirmed that the Tuberculin is a stock medication used for all residents and should have an open date to track its expiration. V6 also stated that insulin pens should have the resident's name and open date once in use, as the expiration date decreases once opened. Registered Nurse (RN) V25 corroborated that a new Tuberculin multi-dose vial should have an open date or expiration date placed on it, and once opened, its use-by date shortens to 30 days. V25 also confirmed that insulin pens should be labeled with the open date or expiration date once removed from the box. The facility's Medication Storage policy mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, and that drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling. The policy also requires that medications be administered before the manufacturer's expiration date.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to properly dispose of soiled linens and perform hand hygiene between glove changes for four residents during incontinent care. For instance, a CNA did not sanitize hands before donning new gloves while providing care to a resident who is frequently incontinent of urine. Another CNA, while assisting a resident with multiple diagnoses including Brown-Sequard Syndrome and morbid obesity, failed to perform hand hygiene before and after changing gloves during the resident's cleaning process. This resident was dependent on staff for all ADLs and was always incontinent of both bowel and bladder. In another instance, two CNAs did not perform hand hygiene before donning gloves while providing care to a resident with severe cognitive impairment and multiple diagnoses including dysphagia and chronic kidney disease. The CNAs also failed to perform hand hygiene after removing gloves and before leaving the room. Additionally, a CNA was observed throwing soiled washcloths and pads on the floor while providing care to a resident who was incontinent of urine and bowel, and did not perform hand hygiene after handling the soiled items. The facility's policies on perineal care and hand hygiene were not followed, as staff did not perform hand hygiene before and after direct contact with residents, after removing gloves, or after handling soiled linens. These actions are contrary to the facility's infection prevention and control program, which emphasizes hand hygiene as the primary means to prevent the spread of infections. The failure to adhere to these policies was observed in multiple instances involving different residents and staff members, indicating a systemic issue in the facility's infection control practices.
Inadequate Incontinent Care and Hand Hygiene
Penalty
Summary
The facility failed to provide timely and complete incontinent care for five residents, including proper hand hygiene and glove changes. Resident R48, who has multiple diagnoses including Brown-Sequard Syndrome and Hemiplegia, reported being left in a saturated brief for extended periods, particularly during mealtimes. Observations confirmed that staff did not perform hand hygiene or change gloves appropriately while providing care, and R48 was left in soiled conditions multiple times, including during meals and therapy sessions. The care provided was incomplete, with areas not being properly cleaned or dried, leading to potential skin integrity issues. Resident R55, who has severe cognitive impairment and multiple diagnoses including CHF and chronic kidney disease, was also subjected to inadequate care. Staff failed to perform hand hygiene before and after donning gloves, did not dry cleaned areas, and did not cleanse all necessary areas during incontinence care. Similar issues were observed with Resident R37, who is cognitively intact but dependent on staff for toileting. The care provided was incomplete, with staff failing to cleanse all areas of incontinence and not performing hand hygiene. Resident R180, who requires assistance with ADLs due to weakness and decreased mobility, also received inadequate care. Staff did not clean all areas of incontinence and failed to dry the cleansed areas. Additionally, Resident R23, who is frequently incontinent of urine, was not properly rinsed or dried after being cleaned with soapy water. The facility's policies and procedures for perineal care and incontinence care were not followed, leading to multiple instances of inadequate care and potential risks for the residents involved.
Failure to Provide Adequate Lighting for Resident
Penalty
Summary
The facility failed to provide adequate lighting for a resident, leading to a deficiency in accommodating the resident's needs and preferences. The resident, who has multiple diagnoses including Polyneuropathy, Morbid obesity, and Major Depressive disorder, prefers to spend most of her time in her room. Despite being cognitively intact, the resident is dependent on staff for various activities of daily living and is at risk for falls. The resident's care plan specifically mentions the need for adequate lighting to mitigate fall risks. However, observations revealed that the resident's room was very dark, and the over-bed lights were burnt out. The resident reported that she had informed the maintenance staff about the issue a month prior, but the lights had not been fixed due to delays in obtaining parts and the maintenance staff's busy schedule. Further observations and interviews confirmed the inadequate lighting in the resident's room. A wound nurse attending to the resident also noted the poor lighting conditions, indicating the need for additional light sources to perform wound care. The Maintenance Director acknowledged the issue and mentioned that he was in the process of switching to LED bulbs but had not yet completed the task. Despite having received the necessary parts a week prior, the maintenance staff had not prioritized the replacement of the burnt-out bulbs. The facility's policy on providing a homelike environment with adequate lighting was not adhered to, resulting in the deficiency.
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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 | 0.7 mi | ★★★★★ | 7 | 1 |
| Arcadia Care Jacksonville | 1.3 mi | ★★★★★ | 1 | 0 |
| Grove Health & Rehab Ctr, The | 1.4 mi | ★★★★★ | 18 | 1 |
| Cass County Senior Living & Rehabilitation Llc | 14.2 mi | ★★★★★ | 16 | 0 |
| Scott County Nursing Center | 17.9 mi | ★★★★★ | 7 | 0 |
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