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 Premier Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A nurse aide assisted a severely cognitively impaired resident with dysphagia by standing rather than sitting at eye level during a meal, despite a chair being available and facility expectations to sit for dignity reasons. The DON confirmed that staff are expected to sit when assisting residents with meals.
Two residents had inaccuracies in their MDS assessments: one was not coded for having a PEG feeding tube and receiving tube feedings, and another was incorrectly coded as being discharged to a hospital instead of home. The errors were due to staff being unaware of the resident's current status or making unintentional coding mistakes, as confirmed by interviews with the DM, DON, and MDS nurse.
Several residents did not have their care plans properly developed or implemented, including a resident who was not assisted into a Geri chair as required, a resident with a PEG tube whose care plan omitted tube management, and two residents using BiPAP/CPAP machines for respiratory support without corresponding care plan interventions or physician orders. Staff interviews confirmed lack of awareness or oversight in following or updating care plans.
The facility did not obtain physician orders for BiPAP and CPAP use for two residents who were using these devices nightly, and failed to administer oxygen therapy as ordered for a resident with a tracheostomy, instead providing oxygen via nasal cannula at a lower rate based on the resident's preference without updating the care plan or notifying the physician.
A resident with significant mobility impairments was provided with bilateral quarter length side rails without documented attempts at alternatives, assessment of entrapment risk, review of risks and benefits, or obtaining informed consent. Multiple staff interviews revealed confusion about responsibility for completing the side rail assessment, and no documentation of the required process was found in the medical record.
A resident with a tracheostomy was observed receiving oxygen at 3L/min via nasal cannula, despite a physician's order for 4L/min via tracheostomy. Nursing staff documented in the MAR that the resident was receiving oxygen as ordered, rather than reflecting the actual administration method and rate. The DON and Administrator confirmed that the nurse should have contacted the provider to update the order instead of inaccurately documenting the care provided.
Staff failed to follow Enhanced Barrier Precautions by not wearing gowns during high-contact care activities, such as tracheostomy care and skin care, for residents with indwelling medical devices. Despite EBP signage and available PPE, nurses performed these procedures with gloves only, contrary to facility policy and prior education.
A resident with a diagnosis of dependence on supplemental oxygen was observed receiving O2 at 4 liters per minute instead of the prescribed 3 liters per minute. Despite documentation indicating compliance, staff interviews revealed a failure to ensure the correct administration of O2.
The facility failed to secure a medication cart on the 700-hall, leaving it unlocked and unattended on two separate occasions. Nurse #7 admitted to not locking the cart, and both the DON and Administrator confirmed that the cart should be locked unless the nurse is present.
The facility's QAA failed to maintain procedures and monitor interventions, leading to repeated deficiencies in areas such as MDS accuracy, care plan development, ADL care, fall prevention, medication security, and infection control. Specific issues included inaccurate MDS coding, inadequate care plans, insufficient assistance with eating and incontinence care, and lapses in hand hygiene and medication security.
A nurse aide failed to perform hand hygiene after handling items in a resident's room before delivering a meal to another resident. Despite the availability of hand sanitizer and prior training, the NA admitted to forgetting the protocol, which was confirmed by the Director of Nursing and the Administrator.
The facility failed to offer the flu vaccine during the flu season for two residents who were assessed as cognitively intact. Both residents had no documentation of being offered the flu vaccine, and the responsible nurses could not recall if they had offered the vaccine and did not document it.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
A nurse aide failed to treat a resident with dignity during a meal by standing while assisting the resident with eating, rather than sitting at eye level. The resident involved was severely cognitively impaired, totally dependent on staff for eating, and had a diagnosis of dysphagia. Observation showed the nurse aide standing next to the resident, who was seated in a specialized wheelchair, despite a chair being available in the room. The nurse aide stated she chose to stand, although facility expectations, as confirmed by the Director of Nursing, were for staff to sit while assisting residents with meals to maintain dignity, particularly for those with dementia.
Inaccurate MDS Coding for Nutrition and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of swallowing/nutritional status and hospitalization. For one resident, who had a percutaneous endoscopic gastrostomy (PEG) feeding tube in place and was receiving regular water flushes via the tube, the quarterly MDS assessment did not reflect the presence or use of the feeding tube or the administration of fluids through it. The Dietary Manager, responsible for coding the Swallowing/Nutrition section, was unaware that the resident still had a PEG tube at the time of assessment. Both the Director of Nursing and the Administrator confirmed that the MDS should have accurately documented the resident's feeding tube status. In another case, a resident's Discharge MDS assessment was incorrectly coded as a discharge to a short-term general hospital, when in fact the resident was discharged home. The error was acknowledged by the MDS nurse, who stated it was unintentional. The Director of Nursing and the Administrator both confirmed that the discharge location was home, not a hospital, and that the MDS assessment should have reflected this.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to implement and develop comprehensive, individualized care plans for several residents in key areas, as observed and documented by surveyors. One resident with severe cognitive impairment and functional limitations was dependent on staff for all transfers and mobility, with a care plan specifying daily use of a Geri chair. Despite this, repeated observations over several days showed the resident remained in bed, and staff interviews revealed that nurse aides either did not follow the care plan, were unaware of its requirements, or did not prioritize the intervention due to other tasks or lack of equipment in the room. The resident's responsible party confirmed that the resident was not regularly assisted into the Geri chair as intended. Another resident with a PEG feeding tube had a physician's order for regular tube flushes and received a significant portion of daily fluid intake via the tube. However, the care plan did not address the use of the feeding tube, despite the Minimum Data Set (MDS) assessment triggering a Care Area Assessment (CAA) for feeding tube use. Both the dietary manager and the DON acknowledged that the feeding tube should have been included in the care plan, but it was omitted without explanation. Additionally, two residents using noninvasive mechanical ventilators (BiPAP and CPAP machines) for respiratory conditions did not have their device usage reflected in their care plans. In both cases, the residents were observed using the devices, and staff confirmed their ongoing use. However, there were no corresponding physician orders or care plan interventions for these devices. MDS nurses responsible for care planning admitted to missing these interventions, either due to reliance on memory or because the care planning system did not automatically prompt for respiratory care based on MDS coding. The DON and administrator confirmed that these omissions were contrary to expected practice.
Failure to Obtain Physician Orders and Administer Respiratory Care as Ordered
Penalty
Summary
The facility failed to obtain necessary physician orders for the use of respiratory equipment for two residents and did not administer oxygen therapy as ordered for a third resident. One resident with a history of acute and chronic respiratory failure and obesity hypoventilation syndrome was admitted with instructions from the hospital to use a BiPAP machine at night and during naps. Despite the resident using the BiPAP machine nightly since admission, there was no physician order for its use, and the Medical Director was unaware the resident was using the device. The facility administration acknowledged that an order should have been requested at admission but was not. Another resident with a diagnosis of sleep apnea was observed using a CPAP machine, which she brought from home and used nightly. Nursing documentation confirmed the use of the CPAP, but there was no physician order for its use. The Medical Director was also unaware of this resident's use of the CPAP machine, and facility leadership confirmed that an order should have been obtained at admission but was not. A third resident with a tracheostomy had a physician order for oxygen at 4L per minute via tracheostomy to maintain oxygen saturation above 90%. However, the resident was consistently observed receiving oxygen at 3L per minute via nasal cannula, not as ordered. Nursing staff documented that the resident was receiving oxygen as ordered, but in interviews, admitted to providing oxygen via nasal cannula at a lower rate due to the resident's preference. The Medical Director and facility staff were not informed of the change in administration, and the care plan was not updated to reflect the actual practice or the resident's preference.
Failure to Complete Required Side Rail Assessment and Consent
Penalty
Summary
The facility failed to follow required procedures before installing and utilizing bilateral quarter length side rails for a resident. Specifically, there was no evidence that alternatives to side rails were attempted, that an assessment for entrapment risk was conducted, or that the risks and benefits of side rail use were reviewed with the resident. Additionally, informed consent was not obtained prior to the installation and use of the side rails. These omissions were identified through observations, record review, and interviews with the resident and staff. The resident involved was admitted with acute and chronic respiratory failure, was cognitively intact, and had impairments in both upper and lower extremities, requiring substantial to maximum assistance with bed mobility. The resident was observed multiple times with the side rails in the raised position and stated she needed them for bed mobility and positioning. Interviews with staff revealed confusion regarding responsibility for completing the side rail assessment, with the admitting nurse indicating it was the Unit Manager's responsibility, while the DON and Administrator stated the admitting nurse should have completed the assessment. No documentation of the required assessment or consent process was found in the resident's electronic medical record.
Failure to Accurately Document Oxygen Administration
Penalty
Summary
The facility failed to maintain accurate medical records regarding the administration of oxygen for a resident with a tracheostomy. The physician's order specified that the resident should receive 4 liters of oxygen per minute via tracheostomy to maintain oxygen saturation above 90%. However, repeated observations over several days showed the resident was receiving oxygen at 3 liters per minute via nasal cannula, not via tracheostomy as ordered. The resident was not in respiratory distress during these observations and confirmed that the correct rate should be 4 liters. Documentation in the Medication Administration Record (MAR) by the assigned nurse indicated that the resident was receiving 4 liters per minute via tracheostomy, consistent with the physician's order, even though the actual administration was 3 liters per minute via nasal cannula. The nurse acknowledged that she documented the ordered method and rate rather than the actual method and rate being used. Both the Director of Nursing and the Administrator confirmed that the nurse should have contacted the medical provider to update the order to reflect the resident's preference and actual practice, rather than inaccurately documenting compliance with the original order.
Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy during high-contact care activities for residents with tracheostomies. According to the facility's policy, EBP requires the use of both gowns and gloves for residents with indwelling medical devices, such as tracheostomies, during activities like transfers and hygiene care. However, observations revealed that staff did not consistently adhere to these requirements. In one instance, a nurse performed tracheostomy care for a resident without wearing a gown, despite EBP signage and the availability of gowns outside the resident's room. The nurse performed hand hygiene and donned gloves but omitted the gown. She later acknowledged forgetting to wear the gown, even though she had previously received education on EBP and typically followed the protocol. In another case, two nurses provided skin care and assisted with a transfer for a resident with a tracheostomy, again without wearing gowns. Both nurses wore gloves and performed hand hygiene, but neither donned a gown, even though PPE supplies were available and EBP signage was present. One nurse stated she did not usually wear a gown for this resident, citing the resident's discomfort, while the other admitted to not thinking about it at the time. The Director of Nursing confirmed that all staff had been educated on the EBP policy and that the observed actions did not align with facility protocols.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer oxygen (O2) in accordance with the physician's order for Resident #44, who was admitted with a diagnosis of dependence on supplemental oxygen. The physician's order dated 3/15/24 specified that Resident #44 should receive O2 at 3 liters per minute via nasal cannula (NC). However, observations on 3/19/24 and 3/21/24 revealed that Resident #44 was receiving O2 at 4 liters per minute via NC. Despite documentation on the Medication Administration Record (MAR) indicating that Resident #44 was receiving O2 at the prescribed rate of 3 liters per minute, the actual flow rate was consistently observed to be higher. Interviews with staff, including Nurse #3 and Nurse Aide (NA) #6, indicated that they were aware of the physician's order but failed to ensure the correct administration of O2. Nurse #3 admitted that she might have checked another resident's O2 flow rate instead of Resident #44's. The Director of Nursing (DON) confirmed that the nurse should have verified the O2 flow rate to ensure compliance with the physician's order. The Administrator also acknowledged that physician's orders should be followed for the administration of O2, highlighting a lapse in adherence to prescribed medical care for Resident #44.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to secure resident medications stored in an unattended medication cart on the 700-hall. On two separate occasions, the medication cart was observed with the lock not engaged, indicating it was left unlocked. The first observation occurred on 03/21/24 from 8:32 AM to 9:01 AM, during which several staff members, residents, and visitors walked past the unattended cart. Nurse #7 returned to the cart at 8:44 AM and realized it was left unlocked. She admitted that she usually locks her cart. The second observation took place on 03/22/24 from 8:45 AM to 8:54 AM, with similar circumstances where the cart was left unlocked and unattended. Nurse #7 returned at 8:52 AM and acknowledged that the cart should have been locked when she was not in front of it. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the medication cart should be secured and locked unless the nurse is present at the cart. Both the DON and the Administrator stated that the nurse assigned to the medication cart is responsible for ensuring it is secured throughout their shift. The failure to lock the medication cart as required was identified as a deficiency in the facility's medication management practices.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that were previously put in place following multiple surveys. This resulted in repeated deficiencies in several areas, including the accuracy of assessments, development and implementation of comprehensive care plans, provision of ADL care for dependent residents, ensuring a hazard-free environment, proper labeling and storage of drugs and biologicals, and infection control. Specific instances included inaccurate coding of the Minimum Data Set (MDS) assessments for preadmission screening, falls, and hospice status, as well as failures in developing person-centered care plans for residents with respiratory services and a history of wandering. Additionally, the facility did not adequately assist dependent residents with eating, provide incontinence care, or offer alternate meal choices when necessary. There were also lapses in investigating and analyzing falls to implement appropriate interventions, securing resident medications, and following hand hygiene protocols during meal delivery service. The deficiencies were observed during various surveys, including recertification and complaint surveys. For example, during one survey, a nurse aide failed to perform hand hygiene after handling an overbed table and bed control, which could lead to cross-contamination. In another instance, the facility did not secure medications stored in an unattended medication cart. The facility also failed to comprehensively assess residents for fall risk and implement interventions to reduce the risk of falls. These repeated failures indicate a pattern of the facility's inability to sustain an effective Quality Assurance Program, as evidenced by the recurrence of similar issues across multiple surveys.
Failure to Implement Hand Hygiene Protocols During Meal Delivery
Penalty
Summary
The facility failed to implement their hand washing and alcohol-based hand sanitizer procedures as part of their infection control policies. During a meal delivery service, a nurse aide (NA) did not perform hand hygiene after moving an overbed table and handling a bed control in one resident's room before proceeding to deliver a meal to another resident. This lapse in protocol was observed despite the availability of hand sanitizer dispensers in the hallway and the NA's acknowledgment of the requirement to perform hand hygiene after such activities. The Director of Nursing confirmed that the NA should have performed hand hygiene after touching items in the resident's room. The NA admitted to being aware of the hand hygiene protocol but stated that she had been moving quickly and forgot to sanitize her hands. The Administrator also confirmed that hand hygiene should be performed after contact with a resident's environment to prevent the spread of germs. The NA had previously received infection control training, including hand hygiene, in May 2023.
Failure to Offer Flu Vaccine During Flu Season
Penalty
Summary
The facility failed to offer the flu vaccine during the flu season for two residents, Resident #56 and Resident #69, who were both assessed as cognitively intact. Resident #56 was admitted to the facility and had no documentation of being offered the flu vaccine. The Director of Nursing confirmed that the resident's health record lacked documentation of the flu vaccine being offered, and Resident #56 stated he was not offered the vaccine until a later date. Nurse #8, responsible for offering the flu vaccines, could not recall if she had offered the vaccine to Resident #56 and did not document it. Similarly, Resident #69 was admitted to the facility and also had no documentation of being offered the flu vaccine. The Director of Nursing noted the absence of documentation in Resident #69's health record, and the resident could not remember if she was offered the flu shot. Nurse #9, who was responsible for offering the flu vaccine to Resident #69, believed she had offered it but could not remember when and did not document it. Both residents were in the facility during the flu season, and the staff should have documented consent or refusal in their charts.
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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) |
|---|---|---|---|---|
| Carolina Rivers Nursing And Rehabilitation Center | 2.6 mi | — | 0 | 0 |
| Brook Stone Living Center | 19 mi | — | 0 | 0 |
| Woodbury Wellness Center Inc | 29 mi | — | 1 | 0 |
| Croatan Ridge Nursing And Rehabilitation Center | 29.4 mi | — | 0 | 0 |
| Cherry Point Bay Nursing And Rehabilitation Center | 29.6 mi | — | 0 | 0 |
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