Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Legacy At Jacksonville during CMS and state inspections, most recent first.
Failure to Timely Report Alleged Verbal Abuse: An LPN heard a CNA make a threatening statement toward a dependent resident with dementia-related diagnoses after the resident spit out juice, but the allegation was not reported to the DON/Administrator until days later. The resident had impaired cognition, required total assistance with ADLs, and had a care plan noting a history of trauma related to alleged verbal abuse. Facility policy required immediate reporting of suspected abuse, including within 2 hours when abuse was alleged.
Improper eye drop administration and controlled substance count documentation were observed. An LVN administered artificial tears to a resident without using the full eye drop technique described in the facility policy, including gloves, pulling down the lower eyelid, and instructing the resident to look up. In addition, an RN and LVNs on multiple med carts either signed narcotic count sheets at the start of the shift or failed to sign them at shift change, despite stating they knew the count should be verified and documented after completion.
Failure to complete a baseline care plan within 48 hours of admission for a resident with pneumonia, CHF, CKD, COPD, prostate cancer, osteoarthritis, and weakness. The resident had a BIMS score of 00, required extensive ADL assistance, and had multiple allergies listed in physician orders, but no baseline care plan was found in the record. The DON stated the 48-hour care plan should have been completed on admission and that it was not done because the Nursing admission assessment was incomplete.
An LVN received a delivery of hydrocodone-acetaminophen tablets for a resident with dementia and diabetes, then placed the controlled medication card on the nurse’s station desk instead of securing it under double lock as required. The LVN charted for about two hours with the narcotics at her workstation, left to assist another resident without locking them up, and returned to find the medication card missing. Other LVNs confirmed seeing the delivery but did not see the drugs locked away or left in the open, and no residents were noted near the nurse’s station during the period. The resident had an active PRN order for hydrocodone-acetaminophen, had received a dose earlier that day with remaining tablets documented on the narcotic log, and later appeared calm and pain-free, reporting that pain medication was available and effective.
A resident with a feeding tube did not have enhanced barrier precautions (EBP) included in her care plan, despite requiring them. The care plan acknowledged the feeding tube but omitted EBP, and there was no physician order for EBP. Staff interviews confirmed the care plan was incomplete and did not reflect all necessary interventions, contrary to facility policy.
A resident with a feeding tube did not receive care in accordance with enhanced barrier precautions, as both a CNA and an LVN provided incontinent care without donning required PPE. There was no EBP signage or PPE available outside the room, and the resident's care plan and orders did not address EBP. Staff interviews confirmed awareness of EBP requirements, but the lapse occurred after the resident changed rooms and necessary precautions were not maintained.
The facility failed to inform residents about how to file grievances, as revealed by interviews and record reviews. Residents were unaware of the grievance process, and grievance forms were not readily available at designated locations. The Social Worker and Administrator had not adequately communicated or facilitated the grievance process, leading to a deficiency in resident rights awareness.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in their care plans. One resident's assessment was incorrectly coded for restraint use, despite no evidence of restraints. Another resident's assessment inaccurately reflected their PASRR status, due to a misunderstanding of the requirements. These errors were acknowledged by the facility's staff, highlighting a need for accurate documentation.
A facility failed to maintain an effective infection control program when an LVN did not don a gown before administering medication through a PICC line for a resident with multiple diagnoses. The LVN did not recognize the need for Enhanced Barrier Precautions, and there was no signage or PPE container outside the resident's room. The DON confirmed the expectation for staff to follow EBP guidelines to reduce infection risks.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse involving a resident was reported immediately to the Administrator, and no later than 2 hours after the allegation was made. The resident involved had diagnoses including neurocognitive disorder with Lewy bodies, major depressive disorder, and Parkinsonism. Records also showed he was dependent on staff for all ADLs, unable to complete the MDS interview, and had care plan interventions related to impaired cognition and a history of trauma that could be negatively affected by alleged verbal abuse from staff. According to the PIR and staff interviews, on 5/1/2026 CNA A was providing juice to the resident when the resident spit it out. LVN B stated she heard CNA A say, “you better be glad that did not hit me or I would have slit your throat.” LVN B did not report the statement to the Administrator at that time. She later said she asked another staff member whether it needed to be reported and that it was reported to the DON a few days later. RN C stated she did not hear the full interaction and was later contacted to provide a statement after the incident. The DON stated she learned of the allegation on 5/3/2026, and the Administrator stated she was notified by text message on 5/3/2026, even though the incident occurred on 5/1/2026. The facility policy required an immediate verbal report to the Abuse Preventionist or designee, and if the allegation involved abuse or bodily injury, the report was to be made within 2 hours. The Administrator and DON both stated staff were aware the incident should have been reported immediately and that the delay meant the allegation was not brought forward in the required timeframe.
Improper Eye Drop Administration and Controlled Substance Count Documentation
Penalty
Summary
Pharmaceutical services were not provided in a manner that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident and for five medication carts reviewed. During a medication pass observation, an LVN administered artificial tears to a 74-year-old female resident with diagnoses including COPD, dysphagia, hypothyroidism, hypertension, chronic viral hepatitis C, contracture of the left hand, cognitive communication deficit, failure to thrive, and myalgia. The resident’s physician order directed artificial tears ophthalmic solution to be instilled in both eyes three times daily for dry eyes. During the observation, the LVN assembled the equipment and used general aseptic technique, but did not use the proper technique for eye drop administration. The LVN did not don gloves, did not gently pull down the lower eyelid to create a conjunctival pocket, and did not instruct the resident to look upward during instillation. The LVN stated she had been trained in the proper administration and care of eye drops and described the correct technique during interview. The DON stated nursing staff were trained in the proper administration of eye drops and acknowledged that the observed steps of the procedure were not followed. The facility also failed to ensure proper controlled substance count documentation on multiple medication carts. On one cart, an RN signed both the oncoming and off-going shift count sheets at the beginning of the shift; on another cart, an LVN did the same. On two other carts, one LVN and another LVN did not sign the controlled substance count sheets at the beginning of their shifts. Interviews with the nurses reflected awareness that the narcotic count sheet should be signed only after the count is completed and verified at shift change. The DON stated nurses should only sign after verifying the medications on hand matched the controlled drug count record and said she was not aware staff were not signing at the correct times.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #92. The resident was an [AGE] year-old male admitted with diagnoses including pneumonia, chronic congestive heart failure, chronic kidney disease, COPD, malignant neoplasm of the prostate, osteoarthritis, and weakness. His physician orders listed allergies to aluminum hydroxide, calcium carbonate, cefdinir, magnesium carbonate, magnesium hydroxide, and Protonix. An admission MDS showed a BIMS score of 00, indicating difficulty with short-term memory, orientation, and attention, and that he required extensive assistance with most activities of daily living. The medical record showed that Resident #92 did not have a baseline care plan. The resident was discharged from the facility on 02/14/2026. During interview, the DON stated that a 48-hour care plan should have been completed when the charge nurse admitted the resident, and that the Nursing admission Assessment was intended to identify concerns and trigger the baseline care plan. The DON said the baseline care plan was not completed because the Nursing admission Assessment was incomplete, and she was new to the facility and unsure who was responsible for ensuring baseline care plans were completed. The facility policy stated that the baseline care plan was to be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and PASARR recommendations if applicable.
Unsecured Hydrocodone Tablets Left at Nurse’s Station and Subsequently Missing
Penalty
Summary
The deficiency involves the facility’s failure to securely store controlled medications in accordance with professional standards and facility policy. On the 400 hall, an LVN received a delivery of hydrocodone-acetaminophen 5-325 mg tablets for a male resident with Type 2 diabetes, senile degeneration of the brain, and unspecified dementia. The resident had an order for one tablet by mouth every 8 hours as needed for pain, with a 30‑day supply (90 tablets) last filled on 1/15/2026 and a next fill date of 2/10/2026. On 2/10/2026 at approximately 3:00 p.m., after another nurse co-signed for receipt of the controlled medication, the LVN placed the hydrocodone medication card containing 45 tablets on the desk at the nurse’s station instead of immediately locking it in the medication cart as required. The LVN then began charting and kept the hydrocodone tablets at the nurse’s station for approximately two hours. During this time, she became distracted, left the nurse’s station to respond to a resident’s needs, and forgot to secure the narcotics. When she returned, the medication card was missing. The LVN later documented that she had set the card down beside her while charting and that she was unable to locate the medication after searching medication carts, medication rooms, supply closets, and the treatment cart. Other LVNs working that day reported seeing the LVN take delivery of the medication but did not see whether it was locked up, and they did not observe the medication lying out in the open or residents near the nurse’s station counter during the relevant timeframe. Record review showed that the resident had received a dose of hydrocodone-acetaminophen earlier that morning at 7:30 a.m., with 30 tablets remaining on the narcotic administration log, and that the resident had an as‑needed order for moderate to severe pain. Subsequent observation of the resident found him seated in a wheelchair in a common area watching television, appearing calm and in no acute distress, with no facial grimacing or observable signs of physical distress. The resident reported that he took pain medication as needed, that it was always available when requested, and that it effectively controlled his pain. The facility’s written policy for controlled medications stated that Schedule II medications are to be stored under double lock in a locked cabinet or safe, separate from all other medications, which was not followed in this incident.
Failure to Develop Comprehensive Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's medical, nursing, mental, and psychosocial needs. Specifically, a resident who was admitted with a feeding tube did not have enhanced barrier precautions (EBP) included in her care plan, despite requiring them. Record review showed that the care plan acknowledged the feeding tube but omitted EBP, and there was no physician order for EBP in the resident's consolidated orders. The resident was cognitively intact, dependent on staff for all activities of daily living, incontinent of bowel and bladder, and required a feeding tube. Interviews with facility staff, including the MDS nurse, DON, and regional reimbursement nurse, confirmed that the care plan was incomplete and did not reflect all necessary interventions for the resident. Staff acknowledged that the comprehensive care plan should have included EBP and that its omission could result in a lapse of care. The facility's policy requires that care plans be person-centered and address all identified needs, but this was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who required enhanced barrier precautions (EBP) due to the presence of a feeding tube. Observations revealed that a CNA and an LVN provided incontinent care and repositioning to the resident without donning the required personal protective equipment (PPE), such as gowns and gloves. There was no signage on the resident's door indicating the need for EBP, nor was PPE available outside the room. The resident's care plan did not address EBP, and there was no physician order for EBP in the resident's records. Interviews with staff confirmed that both the CNA and LVN were aware that residents with feeding tubes should be on EBP and that proper PPE should be used during care. The LVN stated she was unsure why the necessary signage and PPE were not present and admitted to forgetting to use PPE. The DON, who also served as the infection prevention nurse, acknowledged responsibility for ensuring EBP measures were in place and attributed the lapse to the resident's recent room change, during which EBP signage and supplies were not transferred. The facility's policy required EBP for residents with indwelling medical devices, such as feeding tubes, but this protocol was not followed in this instance.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to ensure that residents were informed of how to file a grievance, affecting all eight residents interviewed confidentially. During a review of resident council meeting minutes from October 2024 to January 2025, it was found that the grievance form and its usage had not been explained to the residents. Interviews with the residents revealed that they were unaware of how to file a grievance, as neither the Activity Director nor the Social Worker had reviewed or explained the grievance process to them. The Social Worker stated that she explains the grievance form to residents when they have an issue but admitted she had never explained it to the resident council. She also mentioned that grievance forms were supposed to be available at the nurse's stations and the Administrator's office, but none were found during the surveyor's visit. The Administrator claimed to have reviewed the grievance form with residents in October 2024, but her signature was not on the meeting's signature log. Additionally, it took the Administrator over five minutes to produce a blank grievance form when requested.
Inaccurate MDS Assessments for Restraint Use and PASRR
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #17's quarterly MDS assessment was inaccurately coded for restraint use, despite no evidence of restraints being used. Observations and interviews with the resident and staff confirmed that no restraints were in place, and the MDS Nurse admitted the error was a typo. The Director of Nursing (DON) also confirmed the facility was restraint-free and acknowledged the incorrect coding. Resident #54's admission MDS assessment was inaccurately coded regarding the Preadmission Screening and Resident Review (PASRR). The resident had a history of mental illness, as indicated by previous PASRR evaluations, but the MDS assessment incorrectly marked the resident as not having a serious mental illness. The MDS Coordinator misunderstood the PASRR requirements, believing that since the resident did not qualify for specialized services, they should be marked as not having a mental illness. The DON also expressed confusion about the PASRR process, indicating a misunderstanding of the requirements. These inaccuracies in the MDS assessments could potentially place residents at risk for not receiving appropriate care and services. The errors were attributed to misunderstandings and misinterpretations of the RAI Version 3.0 Manual guidelines, which the facility used for completing MDS assessments. The facility's staff, including the MDS Nurse and DON, acknowledged the errors and the need for accurate documentation.
Infection Control Deficiency Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN B, who did not don a gown before administering medication through a PICC line for a resident. This oversight occurred during a medication pass observation, where LVN B verified the medication order, prepared the intravenous piggyback setup, and administered the antibiotic without wearing the required PPE gown. LVN B later acknowledged the importance of donning the appropriate PPE to reduce infection risk but did not consider the PICC line as a central line requiring such precautions. Additionally, there was no signage or PPE container outside the resident's room to indicate the need for Enhanced Barrier Precautions (EBP). The resident involved was an elderly female with multiple diagnoses, including encephalopathy, sepsis, pneumonia, acute cystitis, hemiplegia, and Type II Diabetes Mellitus. The facility's policy on Enhanced Barrier Precautions, which mandates the use of gowns and gloves during high-contact activities with residents having indwelling medical devices, was not followed. The Director of Nursing, who also serves as the Infection Preventionist, stated that the facility's policy requires staff to adhere to EBP guidelines to minimize infection transmission risks. Despite in-service training on infection control and EBP, the staff failed to implement these precautions effectively.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Oaks Health And Rehabilitation Center | 3.1 mi | ★★★★★ | 12 | 0 |
| Avir At Jacksonville | 3.2 mi | ★★★★★ | 1 | 0 |
| Cherokee Trails Nursing Home | 11.9 mi | ★★★★★ | 20 | 0 |
| The Arbors Healthcare And Rehabilitation Center | 13.1 mi | ★★★★★ | 18 | 0 |
| Bluebonnet Point Wellness | 15.4 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.