Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Carolina Rivers Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hemiplegia and moderate cognitive impairment fell off the bed during incontinence care due to inadequate assistance, resulting in injuries. The resident was care planned for two-person assistance, but a nursing assistant attempted the task alone, leading to the fall. The resident was assessed and sent to the emergency department for further evaluation.
A resident with serious mental illness diagnoses was not referred for a PASRR Level II screen due to an oversight by the facility's social worker. The resident's diagnoses included psychoactive substance abuse with psychotic disorder, depression, and anxiety, but these were not reflected in the PASRR Level I screen. The oversight was identified during an audit, and the facility's DON and Administrator confirmed the expectation for accurate PASRR screening.
A facility failed to ensure a PRN order for Ativan, a psychotropic medication, was time-limited for a resident with anxiety disorder. The medication was administered over a period exceeding the required 14-day limit, despite notifications from the Pharmacy Consultant. Interviews with staff revealed awareness of the oversight, with the Director of Nursing acknowledging the error and the Nurse Practitioner admitting the order slipped through the cracks.
The facility inaccurately coded the MDS assessments for two residents regarding their Level 2 PASRR status. One resident with unspecified psychosis and depression and another with schizoaffective disorder, depression, and anxiety had their serious mental illness status omitted from their MDS. The Administrator and MDS Coordinator acknowledged the errors, highlighting a need for accurate review before MDS transmission.
Resident Falls Due to Inadequate Assistance During Care
Penalty
Summary
The facility failed to prevent a resident from rolling off the bed during care, resulting in an abrasion of the posterior scalp and left ankle soft tissue swelling. The resident, who was admitted with a diagnosis of hemiplegia following a stroke affecting the left side, was care planned to be totally dependent on two-person assistance for bed mobility. However, during incontinence care, a nursing assistant attempted to perform the task alone, which led to the resident rolling off the bed and sustaining injuries. The incident occurred when the nursing assistant was performing incontinence care and the resident, who was moderately cognitively impaired and dependent on assistance for bed mobility, tensed up and moved forward, causing her to roll off the bed. The nursing assistant was unable to prevent the fall, and the resident was found on the floor between her bed and her roommate's bed. The resident was assessed by a nurse, who observed a dime-sized opening on the resident's right posterior head with minimal bleeding, and the resident was subsequently sent to the emergency department for further evaluation. Interviews with the nursing staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that the nursing assistant should have had assistance in the room to provide incontinence care, as per the resident's care plan. The failure to adhere to the care plan for two-person assistance during bed mobility was identified as the primary factor leading to the resident's fall and subsequent injuries.
Failure to Refer Resident for PASRR Level II Screening
Penalty
Summary
The facility failed to refer a resident with newly evident diagnoses of serious mental illnesses for a Pre-Admission Screening and Annual Resident Review (PASRR) Level II screen. This deficiency was identified for one of the four sampled residents reviewed for PASRR. The resident in question was admitted with diagnoses including unspecified other psychoactive substance abuse with psychoactive substance-induced psychotic disorder and depression. Despite these diagnoses, the comprehensive admission Minimum Data Set (MDS) assessment did not consider the resident to have a serious mental illness or intellectual disability according to the state Level II PASRR process. The resident's diagnosis list was updated to include an anxiety disorder, yet the North Carolina PASRR Level I screen did not reflect any mental health diagnoses. The facility's social worker, responsible for completing PASRR screens, acknowledged the oversight in marking the screen tool incorrectly by not selecting the mental health diagnoses. This oversight was discovered during an audit of residents who may need PASRRs. Interviews with the Director of Nursing and the Administrator confirmed the expectation that all diagnoses should be included in the PASRR screen to ensure accurate determination for resident placement.
Failure to Implement Time-Limited PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure a physician's order for a PRN psychotropic medication, Ativan, was time-limited for a resident reviewed for unnecessary medications. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease and anxiety disorder, was prescribed Ativan 0.5 mg for anxiety without a stop date within the required two-week period. The medication was administered multiple times over a period exceeding the 14-day limit, from June 20, 2024, to August 6, 2024. The Pharmacy Consultant identified the lack of a stop date in their medication regimen reviews in both June and July, notifying the Director of Nursing of the discrepancies. Despite this, the issue was not addressed until the medication was discontinued on August 6, 2024. Interviews with the Pharmacy Consultant, Director of Nursing, Nurse Practitioner, and Administrator revealed awareness of the oversight, with the Director of Nursing acknowledging the error and the Nurse Practitioner admitting the order slipped through the cracks. The Administrator confirmed the expectation for staff to follow regulations regarding PRN medication stop dates.
Inaccurate MDS Coding for PASRR
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in relation to the Level 2 Pre-Admission Screening and Resident Review (PASRR). Resident #9, who was admitted with diagnoses of unspecified psychosis and depression, had a PASRR Level 2 Determination Notification letter indicating a serious mental illness. However, the annual MDS did not reflect this status. The Administrator acknowledged the incorrect coding during an interview, emphasizing the need for accuracy before transmitting the MDS. Similarly, Resident #13, diagnosed with schizoaffective disorder, depression, and anxiety, also had a PASRR Level 2 Determination Notification letter. Yet, her annual MDS failed to indicate her serious mental illness status as per the state PASRR process. The MDS Coordinator admitted to the incorrect coding and described her process for checking PASRR information, which involved consulting the electronic medical record and, if necessary, social services. Both residents' MDS assessments were inaccurately coded, leading to the deficiency.
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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) |
|---|---|---|---|---|
| Premier Nursing And Rehabilitation Center | 2.6 mi | — | 0 | 0 |
| Brook Stone Living Center | 20.2 mi | — | 0 | 0 |
| Woodbury Wellness Center Inc | 28 mi | — | 1 | 0 |
| The Laurels Of Pender | 31.3 mi | — | 11 | 0 |
| Riverpoint Crest Nursing And Rehabilitation Center | 31.5 mi | — | 9 | 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 August 2026) and official state health department websites.