Inspection·June 9, 2022

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with Certified Nursing Assistant (CNA) B on 6/8/22 at 12:25 p.m., she was asked if she was caring for Resident #63 today. She replied yes. She was asked if the resident had been observed attempting to eat non-food items, and she stated, Yes, she likes to eat paper. She was asked what type of paper she had observed the resident attempting to eat. She stated, Anything, like the paper napkins, tissues, meal tickets, any paper she finds. She was asked what she did when she observed the resident exhibiting this behavior. She stated, I take it away from her. I try to keep paper away from her. I'll take it off her meal tray, like her meal ticket and her napkin. In an interview on 6/8/22 at 4:45 p.m., LPN C was asked if she was caring for Resident #63 this evening. She stated, Yes, I am. She was asked if she had observed this resident attempting to eat any non-food items, and she replied, Yes, she will grab any paper items she finds and chew them. She was asked to describe the paper items. She stated, Like papers, meal tickets, napkins, tissue. She was asked if she had observed the resident trying to eat any other type of non-food items, and she replied, No, it's just paper items. I don't know if she is trying to eat them, but she will chew them like gum. She was asked what she did when she observed this behavior. She stated, I will take it away from her and redirect her. She was asked if the resident was monitored for this behavior, and she stated, We just try to keep an eye on her and not leave paper stuff near her, but if she finds something like tissues or paper in the bathroom, we tell her to spit it out and take it away. She was asked if there interventions in place to help prevent these behaviors, and she replied, We just take it away from her. In an interview on 6/8/22 at 4:55 p.m., CNA D was asked if she was caring for Resident #63 this evening. She replied yes. She was asked if she had observed the resident attempting to eat non-food items. She stated, Yes, she will put paper in her mouth, like tissue or napkins, or any paper she finds. She was asked what she did when she observed this behavior. She stated, All staff will try to take it away if we see it happening. She tries to keep it, and we will tell her to spit it out. Usually, she'll listen and she will spit it out. She was asked if there were any interventions used by staff to help prevent this behavior. She stated, We try to keep paper away from her. Sometimes she'll get it from the bathroom. We just have to always keep an eye on her. She was asked how long she had observed these behaviors, and she replied, Well, I'd say a few months now since I've been taking care of her. Resident #63 was observed sitting in the TV/dining room area on 6/7/22 at 9:00 a.m., 6/8/22 at 8:35 a.m., and 6/8/22 at 4:40 p.m. She was greeted by name each time. She did not respond. She was asked how she was doing each day. She pointed at the television and did not answer. A review of Resident #63's medical record revealed diagnoses including unspecified dementia with behavioral disturbance, dysphagia, schizophrenia, type two diabetes, pseudobulbar affect, anxiety disorder, major depressive disorder, and cognitive/communicative deficit. A review of the comprehensive Minimum Data Set (MDS) assessment, dated 4/13/22, revealed the following: Section C: Brief Interview for Mental Status (BIMS) score = 03 (on a scale of 00-15, with 03 indicating severe cognitive impairment) A review of the resident's active care plan revealed the following: Initiated 9/16/19 (Last revision 4/15/22) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105287 If continuation sheet Page 2 of 3 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 105287 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westside Oaks Rehabilitation & Nursing Center 2061 Hyde Park Rd Jacksonville, FL 32210 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 0744 Focus: Behavior problem: verbally abusive, wandering, resists care. Level of Harm - Minimal harm or potential for actual harm Goals: Resident will not harm themselves or others secondary to their behaviors through the next review. Residents Affected - Few Interventions: Administer and observe the effectiveness and side effects of medications as ordered. Intervene as needed to protect the rights and safety of others. Approach in calm manner. Divert attention, remove from the situation and take to another location as needed. The care plan did not reveal any focus area, goals, or interventions for the behavior of eating/chewing non-food items. A review of the medical record revealed the following active orders: 2/15/22: Depakote 125 mg (milligrams) twice a day by mouth (for diagnosis: schizophrenia) 12/22/20: Activity level: Up as tolerated unless otherwise specified. 5/11/22: Target behavior: Observe for exit-seeking behaviors each shift. 12/22/20: Target behavior: Observe resident for paranoia and other challenging behaviors each shift. 6/26/21: Diet order: Regular 1/17/21: Consult psych (psychiatry/psychology) for eval (evaluation) and treatment. A review of progress notes from 12/21/21 through 6/8/22 revealed no notes regarding the resident attempting to eat non-food items. There were no notes regarding interventions to assist in preventing this behavior. A review of the Psychiatric Consults, which occurred on a monthly basis, revealed no indication of the psychiatry provider having been made aware of behaviors related to eating or attempting to eat non-food items. A review of the facility's policy/procedure titled Dementia Care (last revised 7/11/18) revealed: Concern identified: Individualized approaches to care will be utilized to focus on the residents' needs in an attempt to reduce behavioral expressions of distress. Behavioral interventions are individualized approaches provided as a part of a supportive physical and psychosocial environment directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities. Care not only focuses on meeting the physical needs of the resident but also the social, emotional, and spiritual, and/or assisting the resident to maintain optimal quality of life through respect, gentleness, and understanding. Thus the following aims of care are foremost: Promotion and maintenance of a safe environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105287 If continuation sheet Page 3 of 3