Legacy at Jacksonville

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents environment remained as free of accident hazards as is possible for 1 of 5 residents (Resident #1) reviewed for accident hazards. The facility failed to serve coffee at an appropriate temperature resulting in Resident #1 acquiring burns to his left and right inner thighs from a coffee spill. The noncompliance was identified as PNC. The past noncompliance began on 5/22/26 and ended on 5/23/26. The facility had corrected the noncompliance before the survey began. […]

• No harm, potential for more than minimal, patternF755Apr 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 of 5 residents (Resident # 63), and 5 of 5 medication carts (LVN Cart N#100/200, LVN Cart N#200/300, LVN Cart S#400, RN Cart S#500, and LVN Cart S#600), reviewed for pharmacy services. *LVN D failed to use the proper technique for administration of eye drops for Resident #63 on 4/28/2026. *LVN E signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart N#100/200 on 04/29/2026. *LVN D signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart N#200/300 on 04/29/2026. […]

• No harm, potential for more than minimal, patternF585Feb 5, 2025

  Based on interview and record review, the facility failed to ensure residents were informed of how to file a grievance for 8 of 8 confidential interviews reviewed for grievances. Residents were not informed of their right to file a grievance during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their rights and decreased execution of their rights. Findings included: During a record review of resident council meeting minutes from the past four months (January 2025, December 2024, November 2024 and October 2024) they revealed a grievance form had not been explained to them or how to use the form. […]

• No harm, potential for more than minimal, patternF695Sep 15, 2021

  Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 3 of 9 residents reviewed for respiratory care (Resident #271, #2 and #41). The facility did not ensure Resident #271, #2 and #41's oxygen concentrator filters were clean for 3 days. The facility did not ensure Resident #271's oxygen tubing was dated. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings Included: 1. Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF880Sep 15, 2021

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 11 staff observed for infection control. (Housekeeper G, RN A and LVN B) The facility did not ensure Housekeeper G were screened for signs and symptoms of COVID-19 prior to entering the facility. Housekeeper G, RN A and LVN B did not utilized appropriate PPE (personal protective equipment) use throughout the facility. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. […]