Inspection·March 17, 2022

F 0695 concentrator to 2 LPM. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled Oxygen Therapy read: Initiation of Oxygen: 1) Verify physician order; 7) Apply device to patient. Oxygen Devices: 1) Nasal cannula: e. Change out weekly and PRN. (Photocopy obtained) Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 2 of 7 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 105429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Coast Health and Rehabilitation Center 7723 Jasper Avenue Jacksonville, FL 32211 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interview, and facility policy and procedure review, the facility failed to ensure drug regimen was reviewed at least once a month by a licensed pharmacist for two (Residents #44 and #58) of five residents reviewed for unnecessary medication, from a total of 39 residents in the sample. The findings include: 1. A review of Resident #44's medical record revealed he was admitted on [DATE] with a readmission date of 10/7/20. Resident had orders for Depakote 275 milligrams (mg) twice daily for mood stabilization; Remeron 7.5 mg at bedtime for depression; Buspirone 15 mg three times daily for anxiety; Fluvoxamine 50 mg once daily for obsessive compulsive disorder; and Sertraline 25 mg once daily for major depression. A review of the monthly pharmacy reports from October 2021 to March 2022 revealed Resident #44 was not reviewed during the months of November 2021, December 2021, January 2022, and February 2022. 2. A review of Resident #58's medical record revealed he was admitted on [DATE] with a readmission date of 2/8/22. Resident had orders for Lexapro 10 mg once daily for depression and Buspirone 5 mg three times daily for anxiety. A review of the monthly pharmacy reports from October 2021 to March 2022 revealed Resident #58 was not reviewed during the month of November 2021. During an interview with the Director of Nursing (DON) and the Regional Clinical Consultant (RCC) on 3/17/22 at 3:02 PM, the DON stated, they were responsible for making sure the monthly pharmacy reviews were conducted. The RCC explained the DON had received training on the pharmacy review process last week and due to identification of deficiency, they were developing a Performance Improvement Project to address the deficiencies. A review of the facility's policy and procedure titled Section 8.1 Medication Monitoring - Medication Regimen Review and Reporting (PharMerica Corp 2007, 9/2018), Procedures, Item 2-revealed, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. (Photocopy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 3 of 7 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 105429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Coast Health and Rehabilitation Center 7723 Jasper Avenue Jacksonville, FL 32211 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy and procedure review, the facility failed to monitor resident behaviors related to the use of psychotropic medication for one (Resident #58) of five residents reviewed for unnecessary medications from a total of 39 residents in the sample. Residents Affected - Few The findings include: A record review for Resident #58 revealed he was admitted on [DATE] with a readmission date of 2/8/22, with the following diagnoses: anxiety disorder, major depressive disorder, acute renal failure on dialysis, hemiplegia, and hemiparesis right side, and left below the knee amputation. A review of the physician orders on 2/8/22, revealed an order for Escitalopram Oxalate (Lexapro)10 milligrams (mg) once daily for depression and Buspirone (Buspar) 5 mg three times daily for anxiety. (Photocopy obtained) Further review of the physician's orders on 2/9/22, revealed an order for Lexapro (escitalopram) antidepressant behavior monitoring every shift for behavioral disturbances and Buspar (Buspirone) behavior monitoring sedative behavior every shift. (Photocopy obtained) A review of Resident #58's Medication Administration Record (MAR) for March 2022, found no behavior monitoring for the use of Lexapro and Buspar. (Photocopy obtained) A review of the resident's care plan revealed a focus area for psychotropic medication. Interventions included administer medications as ordered, observe and document for side effects and effectiveness. A second focus area for behaviors related to episodes of agitations during care revealed interventions that included administer meds as ordered; monitor side effects and effectiveness; approach in a calm manner; assist to develop more appropriate methods of coping and interacting; document behaviors and response to interventions. An interview was conducted with the Director of Nursing (DON) and the Regional Clinical Consultant (RCC) on 3/17/22 at 3:02 PM. They verified there was no documented behavior monitoring for Resident #58 related to the use of Lexapro and Buspar. A review of the facility's policy and procedure titled Section 8.4 Medication Monitoring - Medication Management (PharMerica Corp 2007, 11/2017) Policy, revealed Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug without adequate monitoring. The facility's medication management supports and promotes the monitoring of medications for efficacy and adverse consequences. (Photocopy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 4 of 7 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 105429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Coast Health and Rehabilitation Center 7723 Jasper Avenue Jacksonville, FL 32211 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. Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure food was properly labeled; dishwashing machine was operating at required temperatures; maintain dishwashing machine daily temperature logs; maintained food at safe temperatures; and document food temperatures on temperature log. The findings include: During a tour of the kitchen on 3/14/22 at 9:55 AM, the following concerns were identified: 1. The milk cooler door was observed with a black substance on the rubber trim and the rubber trim was disconnected from the door. (Photographic evidence obtained) 2. The dishwashing machine was observed with a brown debris, crumble-like substance on top of it. (Photographic evidence obtained) 3. The walk-in refrigerator had the following items with no dates: a) peaches in serving cups b) five, small Styrofoam boxes stacked up c) plastic container with an orange liquid, covered loosely with plastic wrap. (Photographic evidence obtained) 4. [NAME] peppers were observed in the walk-in refrigerator with a grayish white fuzzy substance on them. (Photographic evidence obtained) 5. The dishwashing machine manufacturer's sticker was observed under the machine and read minimum temperature for wash cycle was 150° F and minimum for rinse cycle was 180° F. The dishwashing machine temperature log for March 2022 was observed and revealed the following: (Photographic evidence obtained) a. 3/1/22 - 03/03/22 were blank b. 3/4/22 - 03/10/22 revealed only one meal period (breakfast) c. 3/11/22 - 03/14/22 were blank d. 3/7/22 recorded a wash temperature of 144° F and rinse at 150° F e. 3/8/22 recorded a wash temperature of 136° F and rinse temperature of 160° F f. 3/9/22 recorded a wash temperature of 146°F and rinse temperature of 170° F g. 3/10/22 it was recorded that the wash temperature was 138° F and rinse cycle temperature was 140°F An interview was conducted with Employee Q, [NAME] about the dishwashing machine. He reported that on 3/10/22, he was having problems with the dishwashing machine and notified maintenance, but stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 5 of 7 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 105429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Coast Health and Rehabilitation Center 7723 Jasper Avenue Jacksonville, FL 32211 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 he ended up fixing the problem himself. Level of Harm - Minimal harm or potential for actual harm During another visit to the kitchen on 3/16/22 at 11:00 AM, the following observations were made with Employee W, Consultant Certified Dietary Manager (CDM), and the RD present. Residents Affected - Many 6. The steam table was observed uncovered for more than 10 minutes. 7. Temperature of the meatballs were at 136° F and the mechanical soft meat was 137° F. At this time, cook proceeded to put the meatballs in warmer. Employee Q was asked what the temperature of the food should be on the steam table and Employee Q reported 135°F. 8. Employee Q, [NAME] was observed mixing hot water with instant mash potatoes. The cook was observed using water from unmarked bowl and adding water from that bowl to the mash potatoes mixture. Employee Q was asked how he knows how much water to add to mash potatoes. He reported, He just eyes it. He was asked if he tastes his cooking. He replied, Often. Employee Q was asked why he pureed ham and not today's menu choice which was meatballs. Employee Q reported that he was told not to puree ground beef by his superior. On 3/16/22 at 11:45 AM, the RD was asked what he thought about the pureed ham that Employee Q, [NAME] had pureed for lunch. The RD stated it was too watery and residents could choke if it is too watery. RD spoke to Employee Q, Cook, and told him that he should add thickener or more meat to make the puree less watery. On 3/16/22 at 11:52 AM, Employee W, Consultant CDM, was asked how the pureed food should be made. She reported that the cook should be adding thickener and juices from meat to make pureed items, not water. Employee Q was directed by Employee W to throw out the pureed ham and make pureed meat from meatballs instead. At this time Employee Q was observed pureeing the meatballs in blender. Employee Q was asked to take the temperature of the pureed meatballs and it was 135°F. Employee Q put the pureed meatballs back in warmer. The food temperature log was observed and reviewed with Employee W. Employee W stated, the cook should be recording all food items cooked in this book. At this time, Employee W confirmed that there were several days in the food temperature logbook missing. (Photographic evidence obtained) On 3/16/22 at 12:30 PM, Employee R, Dietary Aide was observed touching the large garbage can to throw away her gloves. She opened the walk-in refrigerator to open, stepped in and came out moments later. She was then observed putting new gloves on without washing her hands. Shortly thereafter, Employee R was observed touching the air conditioner vent with her new gloves on. After she was made aware of her actions, Employee R removed her gloves and washed hands before putting on new gloves. During another visit to the kitchen on 3/17/22 at 2:19 PM, Employee T, Dietary Aide, was observed stacking trays and plastic domes directly from the washer on top of each other without letting them air dry. (Photographic evidence obtained) On 3/17/22 at 2:21 PM, the dishwashing machine wash temperature was observed below the recommended 150° F. During this time, the RD was asked what the staff should do if the temperature for dishwashing machine is lower than recommendations. He stated, the dishwashing machine should be paused, and temperatures should be observed that they are back up to correct temperature before starting wash again. Before exiting the kitchen, the dishwashing machine had reached 150° F after resting for 10 minutes or more. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 6 of 7 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 105429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Coast Health and Rehabilitation Center 7723 Jasper Avenue Jacksonville, FL 32211 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 An interview was conducted with the RD on 3/17/22 at 2:35 PM. The RD was asked how often the kitchen is cleaned. RD reported they have cleaning schedule for daily, weekly, and monthly duties. RD was asked what the [NAME] could do to keep the food at appropriate temperatures for tray line service. RD stated, Make sure the hot water at good level in the steam table, use smaller pans, and use metal lids when not being served. RD was asked what the [NAME] should being following when preparing foods. The RD answered, The [NAME] should be following the recipes and normally the CDM would go over the recipes with the Cook. The RD was asked if the [NAME] should know the recipes, he replied Yes. A review of the facility's policy and procedure titled Therapeutic Diet with effective date of 9/21 revealed foods requiring texture modification will be prepared using standardized recipes. (Photocopy obtained) A review of the facility's policy and procedure titled Cleaning and Sanitation with effective date of 9/21 stated to wash dishes in high temperature dish machine per manufacturer guideline plate or at 150 to 165° F wash and 180° F final rinse and record dish machine temperatures 3 times a daily. (Photocopy obtained) A review of the facility's policy and procedure titled Cooking with effective date of 1/21 stated to cook food to a proper internal temperature to prevent foodborne illness. Follow recipes for proper cooking times and temperatures. Also record food temperatures prior to serving residents/patients in the food temperature log. Reheat foods to 165°F when food held on a steam table drops below 140 °F. (Copy obtained) A review of the facility's policy and procedure titled Food Temperature Record with effective date of 1/21 stated to take temperature of food items prior to meal service at breakfast, lunch, and dinner. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 7 of 7