Health inspection·May 8, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, document review, and facility policy and procedure review, the facility failed to maintain the physical environment in a safe, functional, sanitary and comfortable environment in 16 resident rooms (#201, #208, #209, #210, #214, #219, #302, #304, #305, #307, #308, #309, #310, #313, #315, and #321) affecting 40 out of 117 residents in the facility, as well as an industrial size fan running in the hallway on the second floor with dirt and dust stuck to it, and a wheelchair in disrepair with food particles in the hallway on the third-floor. These concerns could negatively impact residents' enjoyment of their environment as well as their safety. The findings include: A tour of the facility conducted on 05/08/2025 at 10:15 am revealed the following observations. 1. room [ROOM NUMBER] had black biological growth under the toilet rim. 2. room [ROOM NUMBER] had a dark stain inside the toilet bowl. 3. room [ROOM NUMBER] had a black biological film on the rails around glass of the window. There was a dead cock roach on the floor near bathroom. The floor mat was dirty and torn next to the B-bed. The vent in the bathroom had a buildup of dust on it. The ceiling above the door appeared to have bubbled up paint from water damage and white biological growth on the paint. Two dead cockroaches were stuck to the wall in the bathroom. There was a large brown stain on the bathroom wall near the sink. There was dirt and debris on the floor. The threshold of the door into the room from the hallway was missing, leaving exposed screws. 4. room [ROOM NUMBER] had dark stains inside the toilet bowl. The floor around the base of the toilet were stained and the grout around the base of the toilet was dark black. 5. room [ROOM NUMBER] had stains on the cabinets The drawers to the cabinets did not close properly. There were brown stains on the wall. A cock roach was on the wall above the bathroom door. The toilet bowl had stains inside. There was a large brown stain on the wall in the bathroom. There was a hole in the wall around the plumbing under the bathroom sink. There were two dead roaches on the walls in the bathroom. There was a used urinal on the floor next to the toilet. 6. room [ROOM NUMBER] had black grout around the base of the toilet and the floors in the bathroom had dirt and stains. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105138 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 05/08/2025 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)