Health inspection·July 14, 2022

F 0693 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 7/14/22 at 11:20 AM with the Registered Dietitian (RD). She reported that she based the resident's tube feeding rate on her specific needs. She calculated 30 to 35 per kilogram for residents who needed to gain weight. The RD stated if she needed to change the resident's tube feeding, she would put an order in and verbally tell the unit manager and physician or leave a note. She stated she checked the accuracy of the tube feedings monthly. Residents Affected - Some She had Resident #100 on 60 for 22 hours a day and water flushes four times a day at 250 ml per flush. An interview was conducted with Licensed Practical Nurse (LPN) A at 12:34 PM on 7/14/22. She was asked to look up Resident #100's tube feeding order in the electronic medical record. LPN A reported the resident's order stated 60 ml every hour for 22 hours a day and flush with water every six hours. At this time, she was asked to observe the pump in Resident #100's room. She was asked whether the pump matched the order. She stated, No it does not match. The tube feeding pump was set at 50 ml per hour with water flushes every four hours. 2. An observation was made of Resident #70 on 7/12/22 at 4:30 PM. A tube feeding pump was observed and the resident's tube feeding rate was set at 50 ml per hour. On 7/14/22 at 12:00 PM, Resident #70 was observed. His tube feeding rate was set at 50 ml per hour. On 07/14/22 at 12:27 PM, an observation of the tube feeding pump in Resident #70's room was made with LPN G. The pump was set at 50 ml per hour. At the time of the observation, LPN G confirmed that the rate was set at 50 ml per [NAME]. She was asked to verify the order in the electronic medical record. She returned to the nurses' station to verify order and stated the tube feeding rate was ordered for 56 ml per hour for 22 hours a day. A record review conducted for Resident #70, revealed an admission date of 4/29/22. His diagnoses included diabetes mellitus due to underlying condition with diabetic kidney complications, altered mental status, gastrostomy, hemiplegia and hemiparesis following cerebral infarction, and dysphagia, oropharyngeal phase. A review of the resident's MDS assessment, dated 5/12/22, revealed a BIMS score of 6 out of a possible 15 points, indicating severe cognitive impairment. The resident was totally dependent for eating. A review of the resident's physician's orders revealed a tube feeding order with a start date of 7/8/22 for Glucerna 1.5 at 56 ml per hour for 22 hours a day with an on time of 10:00 AM and an off time of 8:00 AM. The accompanying order for water flushes was for 150 ml every four hours. A review of the July 2022 MAR revealed the nursing staff had not initialed the form indicating the feedings had been administered from 7/8/22 through 7/12/22. (Photographic evidence obtained) A Nutrition Note authored by the RD on 7/7/22 revealed a tube feeding order change. Body weights were recorded with no weight gain from May 2022 to July 2022. Weights included 99.6 lbs. (pounds) on 5/2/22 and 98.8 lbs. on 7/11/22. The resident's active Care Plan was reviewed and documented Resident #70 required tube feeding via (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105138 If continuation sheet Page 2 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Rehabilitation and Nursing 5377 Moncrief Road Jacksonville, FL 32209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 a feeding tube due to dysphagia. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 7/14/22 at 11:20 AM with the Registered Dietitian (RD). She was asked what rate Resident #70's tube feeding should be set at and she reported she had changed it on 7/8/22 to 56 ml per hour for 22 hours a day. She stated Resident #70 should be weighed monthly. She was trying to get him to an ideal body weight and the rate ordered was for weight gain. She stated, I am not sure why he has not gained weight. She reported his current tube feeding order should be for a total of 1848 calories daily. Residents Affected - Some An interview was conducted with LPN G on 7/14/22 at 12:17 PM. She stated the registered nurses or licensed practical nurses were responsible for the tube feedings. She was asked about Resident #70's tube feeding rate and she reported it was 50 ml per hour. A review of the facility's policy titled Enteral Nutrition was reviewed. The policy stated, Adequate nutritional support through enteral feeding will be provided to residents as ordered. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105138 If continuation sheet Page 3 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Rehabilitation and Nursing 5377 Moncrief Road Jacksonville, FL 32209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to identify resident preferences consistent with residents' food allergies to meet the needs of one resident (#36) reviewed from a total sample of 20 residents. The findings include: During an interview with Resident #36 on 7/11/22 at 12:52 PM, she reported she was allergic to apples and pineapples but the kitchen kept sending pineapples and apples on her meal trays. At the time of the interview, a pineapple cup was observed on Resident #36's lunch tray. (Photographic evidence obtained) On 7/11/2022 at 12:54 PM, observation of Resident #36's lunch meal ticket, dated 7/11/2022 read, Note: no apple, no pineapples. (Photographic evidence obtained) On 7/11/2022 at 2:24 PM, a Medical Nutrition Therapy note revealed Resident #36's current diet consisted of: Pureed diet, honey-thickened liquids; Allergies: pineapple, apple; Food preferences (likes): banana, macaroni and cheese. On 7/13/2022 at 4:01 PM during an interview with Certified Nursing Assistant E, she stated she verified resident plates and tray tickets before passing the meals to the residents. If there were foods on the tray the resident was allergic to, the resident would not receive the tray and the nurse would be notified. On 7/14/2022 at 11:46 AM during an interview with the registered dietitian, she confirmed that food allergies/preferences were identified on admission during the resident interview. They were added to the resident's chart under the nutrition note, and they were printed on each meal ticket. The the kitchen staff were responsible for checking each meal ticket for allergies, likes and dislikes prior to sending the food to the resident. A review of Resident #36's active Care Plan, revised 3/19/2022, revealed the resident had a nutritional problem or potential nutritional problem related to gastrointestinal hemorrhage, type 2 diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, anemia, schizoaffective disorder, bipolar disorder, Parkinson's disease, acute kidney failure, hyperlipidemia, hypertension, cardiac murmur, coronary artery disease, and required a mechanically altered diet. Interventions included: food allergy: pineapple and apple. A review of the facility's policy and procedure titled, Food Allergies and Intolerances (undated), revealed: Residents with food intolerances and allergies will be offered appropriate substitutions for foods that they cannot eat. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105138 If continuation sheet Page 4 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Rehabilitation and Nursing 5377 Moncrief Road Jacksonville, FL 32209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by 1) Failing to ensure the dishwashing machine reached appropriate temperatures, 2) Failing to ensure the refrigerator and freezer maintained appropriate temperatures, 3) Failing to ensure food temperatures were recorded daily, and 4) Failing to ensure the facility's nourishment rooms were maintained per requirements. The findings include: 1. On 7/11/22 at 10:54 AM, a tour of kitchen was conducted. At 11:07 AM, Dietary Aide H was observed using the dishwashing machine and was asked what type of machine it was. Dietary Aide H stated it was a high-temperature machine. She was asked what temperature it should reach when washing dishes and she stated, The final rinse should be 180 º F (Fahrenheit). When asked about the wash cycle temperature, Dietary Aide H stated, I'm not sure. I don't know. During this time, an observation was made of the dishwashing machine. It was run three separate times with a wash temperature of 110 ºF and rinse temperature of 150º F. The Dietary Manager (DM) was nearby and was asked about the machine. She was asked three times what type of dishwashing machine it was, low-temperature or high-temperature, and she reported both. Temperature logs for June 2022 and July 2022 were observed with high temperatures written on them. June temperature logs documented several days with a wash temperature below 160 ºF. The July 2022 log had six days of missing temperatures during the lunch meal, and several days with temperatures below the 160 ºF wash cycle standard temperature. (Photographic evidence obtained) The Dietary Manager was asked about the unacceptable dishwasher temperatures and what her plan was at this time. She stated, You're putting me in hard place. I guess we will use Styrofoam. At this time the Dietary Manager said nothing about the dishwashing machine being under repair or not meeting temperatures prior to the abovementioned observations. On 7/11/22 at 11:45 AM, the dishwasher technician reported the temperatures should be hotter. The rinse water should reach 185 ºF. The Maintenance Director, who was present at the time, asked the dishwasher technician, Isn't 120 ºF okay?, at which time the technician stated, It needs to be higher. On 7/11/22 at 3:09 PM, the Administrator was interviewed. She stated the Dietary Manager informed her of issues in the kitchen during the morning meetings, and that Two weeks ago, the Dietary Manager told me about a company coming to work in the kitchen but that is all. An interview with Maintenance Assistant J was conducted on 7/11/22 at 3:18 PM. He reported that he tested the water in the kitchen water heater three times a day for temperatures. He confirmed that he did not test the water after it went through the booster. He stated he was told by the Maintenance Director to check the temperatures. He reported that the temperature of the water heater was 155 ºF and the booster on the machine should be reaching 185 ºF to 190 ºF. During an interview with the Administrator on 7/11/22 at 3:25 PM, she reported she was not aware of anyone telling them to check the temperature of the dishwasher or the water heater. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105138 If continuation sheet Page 5 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Rehabilitation and Nursing 5377 Moncrief Road Jacksonville, FL 32209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Maintenance Assistant J was interviewed again on 7/11/22 at 3:33 PM. He was asked who tested the two temperatures and who recorded the two temperatures needed. He stated, The first temp is the one I give to the dietary worker, and the rinse is the second one. The dietary staff write that one down. A review of the facility's policy on Sanitization (Revised in December 2008), revealed: The high-temperature dishwashing machine must be operated using the following specification: wash temperature (150ºF to 165ºF) for at least forty-five seconds; Rinse temperature 165ºF to 180ºF for at least twelve seconds. On 7/11/22 at 11:00 AM, an observation of the kitchen's refrigerator and freezer were made. The refrigerator thermometer read 46 ºF and the freezer read 20 ºF. On 7/13/22 at 11:15 AM, a second observation was made of the kitchen's refrigerator and freezer. The refrigerator thermometer read 42 ºF and the freezer thermometer read 30 ºF. (Photographic evidence obtained) The milk cartons on the tray line were tested on [DATE] at 12:19 PM. The Dietary Manager was asked to test milk cartons with the thermometer for appropriate temperatures. Two of three milk cartons were above 41 ºF. The first was 45 ºF and the second was 42 ºF. On 7/14/22 at 1:37 PM, an interview was conducted with the Dietary Manager who reported that the freezer had been broken since March or April 2022 and the part was ordered on 6/30/22. There was no date scheduled for repair. (Photographic evidence obtained) On 7/13/22 at 11:33 AM, observations of the Food Temperature logs were noted with several days of missing documentation for the dinner service. The dates missing food temperatures included: 7/7/22, 7/6/22, 7/9/22, 7/10/22, and 7/11/22. (Photographic evidence obtained). The Dietary Manager reported at 1:37 PM on 7/14/22 that food temperatures were taken every two hours while on the tray line steam table. Food temperatures were taken during the breakfast, lunch and dinner service. A review of the facility's policy titled Preventing Foodborne Illness-food Handling, stated functioning of the refrigeration and food temperatures would be monitored at the designated intervals throughout the day and documented according to state-specific requirements. On 7/13/22 at 9:53 AM, the nourishment room on the 3rd floor was observed with no thermometer in the refrigerator area. The refrigerator had stains and food residue inside and outside. The temperature log was filled out for everyday but there was no thermometer in the device. On 7/13/22 at 10:01 AM, the 2nd floor nourishment room was observed. There was a thermometer in the refrigerator, but it was broken. (Photographic evidence obtained) Temperature logs were posted on the refrigerator with no temperature filled out on the form. The microwave had soiled paper towels in it with crumbs and stains inside. (Photographic evidence obtained) It was also observed that soiled plastic containers were on top of the microwave. (Photographic evidence obtained) An interview was conducted with the Dietary Manager at 1:37 PM on 7/14/22. She reported that the nourishment rooms were checked by the dietary aides and dietary manager two times a day. She reported that the nursing staff also cleaned them. When asked who wrote temperatures down on the logs, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105138 If continuation sheet Page 6 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Rehabilitation and Nursing 5377 Moncrief Road Jacksonville, FL 32209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 reported that the nursing staff was responsible for that task. Level of Harm - Minimal harm or potential for actual harm No facility policy related specifically to nourishment rooms was provided at the time of the survey. . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105138 If continuation sheet Page 7 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Rehabilitation and Nursing 5377 Moncrief Road Jacksonville, FL 32209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interviews and record reviews, the facility failed to maintain resident medical records that were complete and accurately documented for one (Resident #36) of five residents reviewed for nutrition and hydration services from a total sample of 20 residents. (Residents #36). The findings include: A review of the Nutrition Consult, dated 7/6/22, found that Resident #36 was documented as currently receiving the following supplement: House supplement 180 ml (milliliters) two times daily by mouth for meals and recommendation to increase house supplement to 180 ml three times daily. A review of the resident's Physician's Orders found that on 7/6/22, she was ordered a house supplement three times a day: Readycare 2.0, 180 ml and add thickening powder to reach a honey-thickened consistency. A review of Resident #36's July 2022 Medication Administration Record (MAR), revealed: House Supplement three times a day, Readycare 2.0 180 ml TID (three times daily) and add thickening powder to reach a honey-thickened consistency. Start date 7/6/2022 at 5:00 p.m. Documentation verifying the supplement was provided to the resident was missing for dates 7/7/22, 7/8/22, 7/9/22, 7/10/22, and 7/11/22. (Copy obtained) During an interview with Licensed Practical Nurse (LPN) A on 7/13/22 at 12:17 PM, she confirmed that the house supplement Readycare twice a day order for 6/6/2022 was increased to three times a day on 7/6/22. When the electronic MAR was reviewed with LPN A, she stated she was not sure why there was no documentation for 7/7/22 through 7/11/22 to verify the supplement had been given. During an interview with LPN B on 7/13/22 at 12:22 PM, the nurse confirmed the new supplement order for three times a day started on 7/6/2022. The nurse was not sure why the medication administration record was blank for 7/7/22 through 7/11/22, indicating the supplement had not been provided on those days. During an interview with the Assistant Director of Nursing (ADON) on 07/13/22 at 12:25 PM, she stated she did not know why the July 2022 MAR was not signed from 7/7/22 through 7/22/11 for for the house supplement that was to have been provided three times a day. She further stated that no documentation meant the task had not been done. During an interview with Registered Nurse (RN) D on 07/13/22 at 1:10 PM, she confirmed that the supplement order for twice a day was discontinued on 7/6/2022 and increased to three times a day on the same day, 7/6 2022. She confirmed staff should have continued providing the house supplement twice a day and documenting same until it was discontinued on 7/6/22, they they should have begun documenting administration of the supplement three times a day per the new order. A review of the facility's policy and procedure titled, Supplement Policy and Procedure (Undated), revealed: Supplements will be provided in accordance with the MD (Medical Doctor) order and amount consumed will be documented on the MAR (Medication Administration Record). (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105138 If continuation sheet Page 8 of 8