Inspection·September 2, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in regard to 1) call light not properly working in Resident #6's room, and 2) water dripping from a vent in the ceiling going into a trash bin in Resident #5's room, out of 8 resident rooms sampled. The findings include:1.During a tour of the Memory Care unit in the facility on 9/2/2025 at 10:05 am, a flashing red light making an audible sound was observed above room [ROOM NUMBER]. Two (2) staff members were at the nurses' station approximately 5 feet away room as well as several residents in the lounge area approximately 3 feet away from the room. Several staff members were observed walking on the unit. None of them made an effort to respond to the flashing red call light or the audible sound that it was making. Further observation revealed a housekeeper was cleaning the room. The light remained flashing, making an audible sound after the housekeeper exited the resident's room. The housekeeper was asked about the observation of the illuminated light. She stated that she believed the light was broken and needed to be fixed. She reentered the room, without knocking, and examined the call light box affixed to the wall and said it was broken. Employee C, a Licensed Practical Nurse (LPN) and Unit Manager of the Memory Care unit, entered the room and intervened. He asked if he could provide additional information. He explained that the room with the flashing light belonged to Resident #6.An interview was conducted on 9/2/2025 at 10:11 am with Employee C. He was advised of the observation of the flashing light and the audible sound it was making. When asked about the observation, he stated that a contractor had been in and attempted to repair the issue. He explained that a repair order had been submitted through the facility's electronic maintenance reporting system. When asked how long the issue had persisted, he stated that it had been about 2 days, possibly longer. He stated that initially there were two call lights in need of repair. One was repaired, and this one had remained broken. He explained that the light located in the resident's restroom needed repair. He confirmed that Resident #6 used the restroom and was assisted with toileting. When asked what would happen if the aide assisting the resident with toileting required assistance. He stated, The aide would have to verbally call for help. An interview was conducted on 9/2/2025 at 10:25 am with Employee D, a Certified Nursing Assistant (CNA) who was assigned to Resident #6. She was asked about the observation of the flashing call light. She stated that it had been broken for less than a week. She stated that she reports repairs to the Memory Care Director or Unit Manager who then reports it to the Maintenance Director. She confirmed she had not reported the call light issue. 2. On 9/2/2025 at 1:50 pm, a trash bin collecting water dripping from a vent in the ceiling was observed in room [ROOM NUMBER] (Resident #5's room). The resident was observed sitting up in bed with a yellow wrist band labeled fall risk on her left wrist. A wooden cane and wheelchair were located near the bed. An interview was conducted with Resident #5 on 9/2/2025 at 1:54 pm. The resident confirmed the wheelchair and cane belonged to her. She was able to stand (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 2 Event ID: 105358 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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)