Inspection·February 29, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review for oxygen therapy, the facility failed to ensure that one (Resident #44) of three residents reviewed for respiratory care, received the correct number of liters of oxygen ordered by the physician, in a total sample of 26 residents. This could result in the resident not receiving appropriate care and/or clinical complications. Residents Affected - Few The findings include: On 2/26/24 at 10:25 AM, Resident #44 was observed lying in bed without oxygen via nasal cannula. The oxygen concentrator was located away from the bed with nasal cannula wrapped around the concentrator handle. (Photographic evidence obtained) A review of Resident #44's medical record revealed an admission date of 2/17/20 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure with hypoxia, and unspecified asthma with (acute) exacerbation. A review of the annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental (BIMS) score of 15/15, indicating intact cognition. A review of the physician's orders dated 1/10/24 revealed Oxygen at 3 liters per minute (LPM) via nasal cannula continuously, every shift for shortness of breath. On 2/27/24 at 9:51AM, Resident #44 was observed lying in bed without oxygen via nasal cannula. The oxygen concentrator was positioned adjacent to the bed. The oxygen concentrator was turned off. The nasal cannula was rolled up and lodged under the concentrator handle. (Photographic evidence obtained) A review of Resident #44's care plan initiated on 2/18/20 and revised 1/5/24 revealed a focus for Emphysema/COPD related to smoking. Interventions included give oxygen therapy as ordered by the physician. On 2/28/24 at 2:07 PM, Employee A, Registered Nurse (RN) was interviewed in Resident #44's room. When asked if she was familiar with Resident #44, she replied, Yes. When asked what the oxygen order was for the resident. She did not respond, she in turn addressed the resident. Employee A RN then asked Resident #44 if he had been using his oxygen lately. Resident #44 stated, I'll use it if you start it up. Employee A RN asked Resident #44 if he was short of breath. He stated, Always. When Employee A RN was asked what the facility process is for administration of oxygen. She stated, First you gotta get the order, then get the concentrator, you see what the person is sating at, usually the desired oxygen saturation is 92% on room air, if its below 92% then we put on oxygen. On 2/28/24 at 2:14 PM, an interview was conducted with Employee B RN. She was asked to verify Resident #44's oxygen order. She reviewed the order in the electronic medication administration record and stated, It was supposed to be an as needed (PRN) order. When asked to recite the actual order as it appeared, Employee B RN stated, Oxygen at 3 liters per minute via nasal cannula, continuously, every shift for shortness of breath. She stated, the order was supposed to be PRN order but it's not. A review of the facility's policy and procedure titled: Oxygen Therapy read: Policy: Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 2 of 6 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 02/29/2024 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 0695 Procedure: Level of Harm - Minimal harm or potential for actual harm 1. Verify physician order. Education 2. Indications for oxygen use: Residents Affected - Few a. Obstructive pulmonary disease c. Hypoxemia e. shortness of breath (dyspnea) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 3 of 6 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 02/29/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain sufficient nursing staff at all times to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being for three (Residents #50, #71, and #289) of three resident requiring one on one supervision, from a total of 26 residents in the sample. This had the potential to negatively impact all 90 resident in the facility at the time of the survey. The findings include: 1. A review of Resident #50's clinical record revealed an admission date of 8/4/20 with diagnoses that included encephalopathy, seizures, anxiety, depression, and schizoaffective disorder. A quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident has a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition. A review of the physician's orders dated 2/9/24 revealed Resident #50 was to have one to one (1:1) supervision every shift. 2. A review of Resident #71's clinical record revealed an admission date of 1/18/24 with diagnoses that included dementia and depression. A MDS assessment dated [DATE], indicated the resident has a BIMS score of 5/15, indicating severely impaired cognition. A review of the physician's orders dated 2/9/24 revealed the resident was to have 1:1 to one supervision every shift. 3. A review of Resident #289's clinical record revealed an admission date of 2/14/24 with diagnoses that included mild cognitive impairment of unknown etiology, anorexia, muscle weakness, history of falling, and schizophrenia. A MDS assessment dated [DATE], indicated the resident has a BIMS score of 3/15, indicating severely impaired cognition. A review of the physician's orders dated 2/24/24 revealed the resident was to have 1:1 monitoring every shift due to elopement risk. On 2/26/24 at 7:50 AM, an interview was conducted with Employee C, Licensed Practical Nurse (LPN). She stated that she worked overnight from 7:00 PM on 02/25/24 to 7:00 AM on 02/26/24. She was waiting on her relief to show up so she could go home and there were staff call outs last night. The facility census was 90 and she was assigned 45 residents for her entire shift. There were two LPNs on the entire night shift, and both had 45 residents assigned. She stated there were only two Certified Nursing Assistants (CNA) that worked over night and each of them had 45 residents to take care of. When asked about Residents #50, #71, and #289, 1:1 supervision, Employee C, LPN confirmed there were no staff to provide their 1:1 supervision. She explained that staffing had been an ongoing issue for about three months. On 2/26/24 at 10:30 AM, an interview was conducted with the Director of Nursing (DON) and the Administrator. Both were aware of the insufficient staffing overnight from 2/25/24 to 2/26/24. The Administrator stated he was informed by staff that there were call outs. The DON also confirmed he was made aware of the insufficient staffing and that he made calls to staff that were not working to get staff to work. The DON stated he was unable to find anyone to work. The Administrator stated that the staffing coordinator resigned without notice on 2/19/24. Leadership took on the responsibility of the staffing coordinator. Both the DON and the Administrator confirmed that the facility census was 90 overnight. They also confirmed that there were only two LPNs and each of them had 45 residents assigned to them. The DON and administrator also confirmed that there were only two CNAs and that each of them also had 45 residents assigned to them. The Administrator confirmed that there were three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 4 of 6 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 02/29/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many residents with a 1:1 supervision order and that those three residents were not able to supervised 1:1 due to insufficient staffing. A review of the facility's policy titled Staffing with an effective date of 01/24, was conducted. Page one stated Each nursing center has sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by federal law, and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). The projected staffing plans are re-evaluated on an on-going basis in response to changes in the facility, resident population or other circumstances. Staffing is monitored on an ongoing basis. Page one, #3, stated Adjust staffing throughout the day based on census and resident special care needs changes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 5 of 6 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 02/29/2024 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on employee record reviews and staff interviews, the facility failed to provide the required in-service training for nurse aides, to ensure the continuing competence of nurse aides, no less than 12 hours per year, which includes dementia management training and resident abuse prevention training to 3 Certified Nursing Assistants (CNAs) (CNA Staff D, E, and F) of 5 staff reviewed. This has the potential to jeopardize continued conpetence of CNAs. The finding include: A record review of training files revealed the following: CNA D was hired on 2/10/21. Further review revealed no evidence a current 12 hours of in-service education was provided. CNA E was hired on 9/25/06. Further review revealed no evidence a current 12 hours of in-service was provided. CNA F was hired on 2/9/23. Further review revealed no evidence a current 12 hours of in-service was provided. On 2/29/24 at 1:01 PM, the Administrator, Director of Nursing (DON) and Regional Nurse Consultant were requested to provide the CNA competence records for CNA D, E, and F. On 2/29/24 at 2:00 PM, the Administrator stated, We are getting them for you right now. On 2/29/24 at 2:15 PM, the Regional Nurse Consultant stated, We are looking for the documents now. On 2/29/24 at 2:40 PM, the Administrator was once again asked to provide the competencies documentation for CNA D, E, and F. On 2/29/24 att 3:17 PM, the facility failed to provide CNA D, E, and F's annual competencies. On 2/29/24 at 3:30 PM, the facility failed to provide CNA D, E, and F's annual competencies. During the exit conference on 2/29/24 at 3:50 PM, the facility acknowledged the documentation was not available. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 6 of 6