Jacksonville Rehabilitation and Nursing

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 6, 2021

  Based on interviews, record review, and a review of the facility's policies and procedures titled, Abuse Prevention and Reporting and Investigation of Sexual Misconduct, the facility failed to provide vulnerable residents protection from sexual abuse. This resulted in unwanted sexual contact for one (Resident #9) of four residents reviewed for abuse, from a total of 18 residents in the sample. The facility failed to develop and implement interventions necessary to protect Resident #9 from unwanted sexual contact by Resident #2, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This created a likelihood that Resident #9 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial harm from Resident #2. […]

• Immediate jeopardy, isolatedF835Aug 6, 2021

  Based on interviews and record reviews, the facility's administration failed to provide appropriate services and adequate supervision to ensure the protection of vulnerable residents from sexual abuse for one (Resident #9) of 18 residents in the sample. The facility failed to develop and implement interventions necessary to protect Resident #9 from unwanted sexual contact by Resident #2, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This created a likelihood that Resident #9 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial harm from Resident #2. Resident #2 was assessed, and care planned on 3/20/2020 for inappropriate touching related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no guidance for supervision. […]

• Immediate jeopardy, isolatedF867Aug 6, 2021

  Based on interviews, record reviews, and a review of the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #9) out of four residents reviewed for abuse, from a total of 18 residents in the sample. It also placed all other vulnerable female residents at risk for serious adverse outcomes related to potential sexual abuse from Resident #2. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based on observations, interviews, record review, and a review of facility in-service training, the facility failed to follow proper dish sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents receiving food from the facility's kitchen. The facility also failed to log proper temperatures for the dish machine. Sanitation is important in health care settings serving nursing home residents. The findings include:On 04/27/2026 at 9:50 AM, during an interview with Dietary Aide (DA) C, she was asked if she was the person responsible for cleaning the residents' dishes and operating the facility's low-temperature dishwasher. She replied yes. She was asked to demonstrate her process for cleaning the dishes. She ran the dishwasher. […]

• No harm, potential for more than minimal, widespreadF801Jul 25, 2024

  Based on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, by failing to employ either a certified dietary manager or a certified food service manager when a registered dietitian was not employed on a full-time basis. This had the potential to affect all of the residents in the facility. The findings include: A tour of the kitchen was conducted on 7/22/24 at 10:35 AM. The surveyor was greeted by Kitchen Manager O, who was asked if she was the Certified Dietary Manager (CDM). She stated she was the Kitchen Supervisor, not the CDM. She stated she would go get the CDM. She left and returned with Registered Dietitian (RD) P. […]