Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jacksonville Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a sanitary and safe environment, with 16 rooms exhibiting issues such as biological growth, pest presence, dirty and damaged fixtures, and unaddressed maintenance needs. These deficiencies were confirmed by staff interviews and a lack of maintenance work orders, affecting a significant number of residents.
The facility failed to employ a Certified Dietary Manager (CDM) or certified food service manager, despite not having a full-time registered dietitian (RD). The kitchen manager lacked necessary credentials, and the facility relied on a regional RD present only part-time. The administrator misunderstood regulatory requirements, leading to noncompliance with Florida Administrative Code 59A-4.110, potentially affecting all residents.
The facility failed to meet food service safety standards, using expired buns and improperly testing a malfunctioning dish machine. Refrigerators in nourishment rooms exceeded safe temperatures, and logs were incomplete. Staff lacked training and knowledge of kitchen processes, leading to potential risks for residents.
The facility's dish machine failed to reach the required sanitizing temperature of 180°F, posing a risk of foodborne illness. Kitchen staff were unaware of the machine's operational requirements, and the Maintenance Director confirmed it was not functioning correctly. Despite service attempts, the machine remained out of service, failing to meet necessary sanitizing standards.
The facility failed to maintain a safe and sanitary environment, with deteriorating door frames and a tripping hazard near the 3rd floor elevator. Additionally, a resident's enteral nutrition pump was found with dried product and was sticky, with staff unclear on cleaning responsibilities. The Administrator was unaware of these issues, despite daily rounds intended to identify such problems.
A resident with acute respiratory failure was transferred to an acute care hospital without proper documentation of the transfer's basis, unmet needs, or services available at the hospital. The facility did not provide a Nursing Home Transfer and Discharge Notice or a physician's order for the transfer. Interviews with the DON confirmed the lack of documentation, including the time of departure and mode of transportation, despite the resident's request to be sent to the ER after experiencing chest pain.
Two residents in a facility did not receive necessary care due to inadequate care planning. One resident experienced pain from long toenails that had not been clipped since admission, while another resident had an IV line without a care plan for maintenance, leading to a lack of routine flushes and dressing changes. Staff interviews revealed confusion about responsibilities and a failure to update care plans based on new needs.
The facility failed to provide necessary nail care for four residents, resulting in elongated and untrimmed fingernails and toenails. Despite care plans indicating the need for assistance, there was no documentation of nail care being provided. Interviews with staff revealed confusion about responsibilities, and the facility's policies on nail care were not followed.
A resident did not receive their prescribed Prozac 60 mg for three consecutive days due to unavailability in the medication cart and Pyxis machine. The LPN did not notify the physician about the missed doses, contrary to facility policy. This resulted in a deficiency in providing necessary pharmaceutical services.
The facility experienced an 8% medication error rate due to two incidents involving an LPN. In one case, a resident missed three doses of Prozac because it was unavailable, and the physician was not notified. In another case, the LPN failed to administer Lisinopril to a resident, as she did not verify the medications against the MAR. The facility's medication administration policy was not followed in both instances.
Failure to Maintain Sanitary and Safe Physical Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, functional, sanitary, and comfortable physical environment for residents, staff, and the public. During a facility tour, 16 resident rooms were found with various deficiencies, including black biological growth under toilet rims, dark stains inside toilet bowls, black biological film on window rails, dead and live cockroaches, dirty and torn floor mats, dust buildup on vents, water-damaged ceilings with biological growth, missing door thresholds with exposed screws, stained and damaged walls, holes around plumbing, broken floor tiles, and full garbage cans. Additional issues included dirty wash bins, used urinals left on floors, brown-colored scratches on toilet seats, and missing floorboards. An industrial-sized fan in a hallway was covered in dirt and dust, and a wheelchair stored in a hallway was found with food particles and damaged wheels. Interviews with staff and review of facility documentation revealed that these environmental concerns were not reported through maintenance work orders, and daily housekeeping procedures outlined in facility policy were not consistently followed. The Director of Housekeeping and the Administrator confirmed that the observed issues should have been addressed by staff as part of their daily responsibilities. The lack of adherence to cleaning and maintenance protocols resulted in unsanitary and unsafe conditions affecting 40 out of 117 residents.
Noncompliance in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skills to manage the food and nutrition services effectively. During a survey, it was discovered that the facility did not have a Certified Dietary Manager (CDM) or a certified food service manager, despite not having a registered dietitian (RD) employed on a full-time basis. The kitchen manager, identified as Kitchen Manager O, was not certified and only held a high school diploma. The facility relied on a regional RD, who was not an employee of the facility and was only present three days a week, to oversee clinical duties. However, the RD was not responsible for the budget, and the kitchen manager was tasked with ordering and purchasing food without the necessary credentials. Interviews with the facility's administrator revealed a misunderstanding of the regulatory requirements, as she believed that having a dietary director and a consulting dietitian negated the need for a CDM. The administrator confirmed that there was no specific training provided for the kitchen processes and acknowledged the facility's noncompliance with the Florida Administrative Code 59A-4.110, which outlines the requirements for food and nutrition services. The lack of a qualified CDM or certified food service manager had the potential to affect all residents in the facility.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Expired buns were used during meal service, and dietary staff were unable to properly test the dish machine, which was not functioning correctly. The dish machine's final rinse temperature was below the required level, and chemicals were not being dispensed as needed. Additionally, the dish machine test log was pre-dated with test results, indicating a lack of proper documentation and oversight. Refrigerators in the nourishment rooms on the 2nd and 3rd floors were found to have temperatures exceeding the safe limit of 41 degrees Fahrenheit. The temperature logs for these refrigerators were incomplete, and an open, unlabeled, and undated candy bar was discovered in the 3rd floor nourishment room refrigerator. These issues suggest a failure in maintaining proper food storage conditions, which could potentially affect all residents in the facility. Interviews with staff revealed a lack of knowledge and training regarding the kitchen processes and equipment. The Kitchen Manager and dietary aides were unable to identify whether the dish machine was high or low temperature, and there was confusion about the correct test strips to use for sanitation testing. The Administrator was unaware of the pre-dated sanitation log and the identity of the staff member who signed it, further highlighting the facility's inadequate oversight and management of food safety protocols.
Dish Machine Fails to Meet Sanitizing Requirements
Penalty
Summary
The facility failed to maintain its dishwashing equipment in safe operating condition, as observed during a survey. The dish machine, which was supposed to function as a high-temperature sanitizing unit, did not reach the required final rinse temperature of 180 degrees Fahrenheit. Instead, it only reached 130 degrees Fahrenheit, and there was no evidence of chemical sanitizing agents being dispensed from the buckets into the machine. The kitchen staff, including the Kitchen Manager and Dietary Aide, were unaware of the machine's operational requirements and did not know how to address the issue, indicating a lack of training or communication regarding the equipment's maintenance and operation. The Maintenance Director confirmed the machine was not functioning correctly and was unable to determine why the chemicals were not being dispensed. Despite attempts to rectify the situation, including a service visit from a dishwasher company, the machine continued to fail in reaching the necessary sanitizing temperature. The Administrator was informed that the machine was operable without chemicals if it reached the required temperature, but subsequent tests showed it consistently failed to do so. At the time of the survey exit, the dish machine remained out of service, and no technicians had returned to resolve the issue.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment in several areas, including eight resident rooms and the 3rd floor elevator area. Observations revealed that door frames in these rooms were rusted and deteriorating, with some having missing floor tiles and holes in the walls. Additionally, a floorboard near the 3rd floor elevator was raised, creating a tripping hazard. The Maintenance Director acknowledged awareness of the disrepair but had not reported it to the Administrator, citing challenges in conducting repairs due to the facility's near-capacity status and the need to relocate residents during renovations. The facility also failed to maintain a sanitary environment for a resident receiving enteral feeding. The resident's enteral nutrition pump was repeatedly observed with dried and splattered nutrition product on it, and it was sticky to the touch. Interviews with staff, including an LPN and a CNA, revealed a lack of clarity regarding responsibility for cleaning the enteral nutrition pumps. The facility's policy on cleaning and disinfection of resident-care items was reviewed, but it was undated and did not specify who was responsible for cleaning the equipment. The Administrator was unaware of the deteriorating conditions and the issues with the enteral nutrition pump. Despite the facility's practice of conducting daily Angel Rounds to identify problems, the deterioration of door frames and other issues were not documented in the checklists for the months reviewed. The Administrator acknowledged the difficulty in addressing these issues due to the facility's capacity constraints and the need for resident relocation during repairs.
Failure to Document Resident Transfer to Acute Care Hospital
Penalty
Summary
The facility failed to document the basis for a resident's transfer to an acute care hospital, including the specific resident needs that could not be met in the facility and the services available at the hospital to meet those needs. The medical record of the resident, who was admitted with acute respiratory failure with hypoxia, lacked documentation of the transfer or discharge information provided to the hospital. There was no evidence of a Nursing Home Transfer and Discharge Notice or a physician's order for the transfer, which is required for emergent transfers to acute care hospitals. Interviews with the Director of Nursing (DON) revealed that there was no documentation of the physician's notification or authorization for the transfer. The DON confirmed that the resident was transferred to the hospital without proper documentation, and there was no record of the time of departure or mode of transportation. The resident had requested to be sent to the emergency room after complaining of chest pain, but the facility did not document the necessary information to support the transfer, nor did they provide the required information to the acute care hospital.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to unmet care needs. Resident #66, who was cognitively intact and required assistance with some activities of daily living, did not receive necessary toenail care. Despite being independent in many areas, the resident experienced pain due to exceptionally long toenails, which had not been clipped since admission. Interviews with staff revealed confusion about responsibilities for toenail care, with CNAs and the shower team unsure of who should address the issue. The resident's sister had also requested podiatry services, but the resident was not seen during the monthly visits. Resident #113, who was non-verbal and had an IV line in place, did not have a care plan addressing IV line maintenance, including flushes and dressing changes. The resident's medical record lacked orders for routine IV care, and the midline dressing had not been changed since insertion, contrary to facility policy. Interviews with nursing staff revealed a lack of clarity regarding the frequency of dressing changes and flushes, with the LPN unaware of specific orders. The MDS coordinator had not updated the care plan to include IV line care, and the Director of Nursing confirmed that care plans were updated based on daily meetings and 24-hour reports. The deficiencies in care planning for both residents highlight a failure to ensure that care plans are comprehensive and person-centered, with measurable objectives and timeframes. The lack of toenail care for Resident #66 and the absence of IV line maintenance for Resident #113 demonstrate a breakdown in communication and responsibility among staff, leading to unmet care needs and potential risks for the residents.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain good grooming and personal hygiene for four residents. Resident #64 was observed with elongated fingernails and brown debris under them, despite having nail clippers at his bedside. He expressed his inability to trim his nails due to his condition and stated that staff had not offered assistance. His care plan indicated he might need cueing for activities of daily living, but there was no record of nail care being provided in the past 30 days. Resident #99 also had elongated fingernails and expressed concern about the potential for injury. His medical record showed moderately impaired cognition, and his care plan required extensive assistance with personal hygiene. However, there was no documentation of nail care being provided. Similarly, Resident #100 had elongated toenails and had not seen a podiatrist since admission, despite having a physician's order for podiatry as needed. His care plan required staff to notify a nurse if toenail trimming was needed, but there was no evidence of such notification. Resident #66 had exceptionally long toenails, causing him pain, and his sister had requested podiatry services. Despite being cognitively intact and requiring assistance with certain activities, there was no record of his toenails being trimmed since admission. Interviews with staff revealed confusion about responsibilities for nail care, with CNAs and nurses unsure of their roles. The facility's policies outlined the importance of regular nail care to prevent infections and injuries, but these were not followed, leading to the deficiencies observed.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that physician-ordered medication, Prozac 60 mg, was available and administered to Resident #18 as prescribed. On two consecutive days, 7/23/24 and 7/24/24, the medication was not administered because it was not available in the medication cart. On 7/24/24, during a medication administration observation, LPN A confirmed that the Prozac was still not available and was on order from the pharmacy. The facility's system for back-up medications, which included a Pyxis machine, did not have Prozac available for Resident #18 or any other resident. Further investigation revealed that there was no notification to the resident's physician regarding the missed doses on 7/23/24 and 7/24/24. LPN A admitted to not calling the physician about the missed doses and was unsure if anyone else had done so. The facility's policy on administering oral medications required reporting in accordance with facility policy and professional standards, but this was not adhered to in this case. The lack of communication and failure to follow protocol contributed to the deficiency in providing necessary pharmaceutical services to meet the resident's needs.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during the survey. Two specific incidents contributed to this deficiency. In the first incident, a Licensed Practical Nurse (LPN) was observed failing to administer Prozac 60 mg to a resident for three consecutive days due to the medication not being available in the medication cart or the facility's Pyxis machine. The LPN did not notify the resident's physician about the missed doses, and the facility's system for back-up medications did not include Prozac, leading to the resident missing their prescribed medication. In the second incident, the same LPN administered only six out of seven prescribed medications to another resident. The LPN failed to administer Lisinopril, as she did not verify the number of medications in the cup against the Medication Administration Record (MAR) before giving them to the resident. The facility's policy on the administration of oral medications was not followed, as the LPN did not ensure all medications were administered as ordered, nor did she report the omission according to facility policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 191 citations issued within 25 miles in the last 12 months — including the 7 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Pavilion At Jacksonville, The | 1.1 mi | — | 18 | 0 |
| Shands Jacksonville Medical Center | 2.1 mi | — | 0 | 0 |
| North Bank Center For Rehabilitation And Healing | 3.4 mi | — | 13 | 0 |
| Park Ridge Nursing Center | 3.7 mi | — | 4 | 0 |
| Riverside Post Acute | 4.3 mi | — | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Jacksonville Rehabilitation And Nursing.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.