Pavilion at Jacksonville, The

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF803Mar 12, 2026

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that menus met the nutritional needs of residents in accordance with established national guidelines (S483.60) which included not following menu recipes. This has the potential to affect all residents that consume their meals prepared by the facility. There were 60 residents in the facility at the time of the survey. The findings include:A tour of the kitchen was conducted on 3/9/2026 at 10:05 AM. Employee L, a Cook/Dietary Aide, was observed preparing the meal. The menu posted: Meatloaf Homestyle, Parsley Mashed Potatoes, Seasoned [NAME] Beans, Dinner Roll and Brownies.Two (2) unidentifiable loaves were observed covered in a dark red sauce on top of charred paper on a flat pan. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based on observations, interviews, and record review, the facility failed to properly store, prepare, distribute and serve food in accordance with professional standards for food service safety. The ice machine had a buildup of a dark fuzzy residue on the seams and edges of the lid, food processor had dried yellowish food residue with buildup, meat slicer had miscellaneous debris in the crevices/seams under the blade, milk cooler's seal was detached, onions in storeroom were soft and slimy, no pots in the kitchen, and nourishment room had debris and staining on cabinet floor surface. This could potentially affect the 60 residents residing in the facility. […]

• No harm, potential for more than minimal, widespreadF804May 2, 2024

  Based on interviews, record review, and policy and procedure review, the facility failed to ensure food served was prepared by methods that conserved nutritive value and flavor, by failing to follow standardized recipes to provide palatable and appetizing food in accordance with professional standards for food service. This practice can result in decreased food consumption by residents who consume foods from the facility's kitchen. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. The findings include: During a follow-up tour of the kitchen on 5/1/24 at 11:50 a.m., Employee D was asked to provide the recipes used for today's menu. […]

• No harm, potential for more than minimal, widespreadF812May 12, 2022

  Based on observations, interviews, and record review, the facility failed to 1) Ensure food items had not expired, 2) Document food items' use by dates, 3) Keep thermometers in cooling units that contained food, 4) Use sanitizer in the three-compartment sink every time it was used, and 5) Keep food temperature logs for every meal. This deficient practice could potentially affect all residents receiving food from the facility's kitchen. The findings include: On [DATE] at 10:35 AM an observation of the kitchen was made revealing the following: A bag of hotdog buns with a green/yellow substance on them was observed on the bread rack. Also observed were two bags of hamburger buns with a green substance on several of the buns. The bags were dated [DATE]. […]

• No harm, potential for more than minimal, isolatedF842Mar 12, 2026

  Based on record review, observation, interview, and facility policy review, the facility failed to maintain residents' medical records that were complete and accurately documented for one (Resident #6) of four residents reviewed for indwelling catheter, from a total survey sample of 24 residents. The findings include:A review of the medical record for Resident #6 revealed she was originally admitted to the facility on [DATE], and most recently readmitted to the facility from the hospital on 1/16/26. Her primary diagnosis is quadriplegia, C5-C7. Secondary medical diagnoses included neuromuscular dysfunction of bladder and presence of urogenital implantsA review of the facility's Resident Matrix on 3/9/2026, listed resident #6 as having an indwelling catheter. […]