Terrace of Jacksonville, The

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 18, 2021

  Based on observation, interviews, and record review, the facility failed to ensure one of three residents (Resident #57) reviewed for falls was free from neglect in a total sample of 64 residents. Resident #57 attempted to reach the grab bar and fell in the shower trying to transfer to the shower chair. Employee H watched without assisting the resident. Resident #57 had self care deficit related [MEDICAL CONDITIONS] and required assistance with Activities of Daily Living (ADLs). Failure to provide the necessary care and services to Resident #57 resulted in the resident sustaining a [MEDICAL CONDITION] wrist. The findings include: During the tour on 02/17/21 at 2:30 pm, Resident #57 was observed lying in bed with a hand splint on the left hand. […]

• Actual harm, isolatedF610Feb 18, 2021

  Based on observations, interviews, and record review, the facility failed to report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action could be taken for one of three residents reviewed for falls in a total sample of 64 residents (Resident #57). Failure to review incidents of neglect may potentially result in missed opportunities for corrective action to prevent future incidents for all residents. The findings include: During the tour on 02/17/21 at 2:30 pm, Resident #57 was observed lying in bed with a hand splint on the left hand. […]

• Actual harm, isolatedF697Feb 18, 2021

  Based on observation, staff interview, clinical record review, and facility policy and procedure review, the facility failed to manage pain for one (Resident #147) of one resident sampled for pain management out of a total of 64 sampled residents. Lack of treatment can cause worsening of condition, health complications, and inhibits the resident from reaching his/her highest practicable level of wellbeing. The findings include: Resident #147 was observed on 02/14/2021 at 12:25 PM. She was lying in bed with her eyes closed. No cervical (C-Collar) was observed to be applied to her neck. Her heels were not floated on a pillow or cushion but were resting directly on the mattress. She did not arouse when her name was called. She appeared to grimace in pain and moan. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based on food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure food items were properly labeled and dated in both the main kitchen and nourishment rooms. This deficient practice prevents staff from determining appropriate use and increases the risk of pathogen exposure.The findings include:On 05/04/2026 at 10:47 AM, an observation of the kitchen's dry storage room revealed one basket of onions, two loaves of bread, one bag of hamburger buns, one bag of pasta noodles, and one bag of sugar frosted flakes cereal with no labels or dates. […]

• No harm, potential for more than minimal, widespreadF812Feb 18, 2021

  Based on the kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff implemented the facility policy for the proper procedures for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen when staff failed to change gloves when they became contaminated, and to wash their hands between glove changes during the lunch meal service. […]