Jacksonville Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Jacksonville Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689May 1, 2025

  Based on observation, record review, interviews, and a review of facility policies and procedures, the facility failed to ensure that the residents' environment was as free of accident hazards as was possible for one (Resident #108) of 34 residents in the total survey sample. Razors were discovered at Resident #108's bedside. The findings include: On 04/29/25 at 13:52 PM, medication (an oral inhaler) was observed at the bedside of Resident #108. (Photographic evidence obtained). […]

• No harm, potential for more than minimal, isolatedF695May 1, 2025

  Based on observation, record review, interviews, and a review of the facility's policies and procedures, the facility failed to provide respiratory care consistent with professional standards of practice for one (Resident #33) of four residents reviewed for oxygen administration. Resident #33 was receiving oxygen without a physician's order. The findings include: On 04/29/25 at 11:13 AM, an interview was attempted with Resident #33. He offered no verbal response to interview questions, and instead covered his head. Oxygen was observed infusing at 3.5 L/min (liters per minute) via nasal cannula (NC). […]

• No harm, potential for more than minimal, isolatedF584Jun 2, 2023

  Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, affecting one (Resident #73) of 103 residents, by failing to eliminate pests from the resident's room. Failure to ensure the necessary housekeeping and maintenance services are provided for residents can increase the risk of disease-causing organisms within the facility. The findings include: On 5/30/23 at 10:28 a.m., Resident #73's room was observed with small roaches crawling on the floor at the doorway entry and on the side of the trash can in the resident's bathroom. […]

• No harm, potential for more than minimal, isolatedF684Jun 2, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Residents #47, #102, and #237) of [NAME]-seven sampled residents. The findings include: 1. On 5/31/2023 at 12:02 p.m., Certified Nursing Assistant (CNA) C was observed in Resident #47's room with the door ajar. From the hallway, the CNA could be seen transferring the resident to bed using a mechanical lift (Hoyer lift) by himself. Upon seeing the surveyor in the hallway, the CNA immediately pulled the privacy curtain preventing further observation. CNA C was then observed exiting Resident #47's room at 12:08 p.m. […]

• No harm, potential for more than minimal, isolatedF688Jun 2, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure that two (Residents #57 and #85) of two residents reviewed for limited range of motion, from a total of 37 residents in the sample, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The findings include: 1. On 5/31/23 at 11:29 AM, Resident #57 was observed in bed. His right upper extremity was contracted to his chest. When the resident was asked if he was able to extend his arm, he held it with the left hand as he tried to stretch it, then shook his head no. He was then asked if he was attending any therapy and again he shook his head no. He stated he had a splint but staff were not consistent with applying it. […]