Inspection·November 6, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some issue to anyone. She denied awareness of any ongoing plumbing issues. She stated she would report any concerns to the nurse. She added that the facility does have a system where work orders can be submitted, however, she had not been trained on how to do it. On 11/6/2024 at 11:48 am, an interview was conducted with Employee C. She stated the restroom on the [NAME] Wing had been out of order intermittently for approximately two weeks. She confirmed the restroom was for resident use only. When asked if the restroom was currently out of order. She replied, normally there would be a sign on the door if it was out of order, so I guess they're [the residents] using it. When asked about the repairs needed in the restroom, she stated that the toilet was broken and that water was coming up from the tiled floor. On 11/6/2024 at 12:29 pm, an interview was conducted with the Maintenance Director. He stated that all work orders should be submitted into the TELS system which sends alerts to his personal phone. He stated that a work order could be submitted by any staff member and he had a list of vendors used for maintenance services. He explained that once a maintenance issue had been identified, he had to contact the corporate office to provide an estimate for repairs verses the estimate to replace. He stated he hadn't seen anyone come in to repair the sinks since he'd been employed at the facility nor had he seen any estimates. He stated he was not aware of any current concerns with the plumbing or water leaks at the time. A tour of the facility was then conducted with the Maintenance Director. During a visit of the East Wing, he stated he wasn't aware of any concerns on this wing. Upon entering the shower room on this wing, he observed the sink present and stated that it needed to be repaired. After turning on the shower and observing the leak from the neck of the shower connected to the wall, he stated that it also needed to be repaired. Upon entering the [NAME] Wing, he stated that restroom was repaired on Monday [11/4/2024]. The towels and blanket were observed once again on the floor outside of the restroom door. He stated he was not aware that it was broken again. He was taken to the resident rooms (#107, #200, and #308) where he observed the sinks hanging from the walls. He commented that he had not inspected the entire facility and that he would repair the sinks. He referred to the building as dated and stated that it would take time to make all of the necessary repairs. On 11/6/2024 at 1:39 pm, a follow up interview was conducted with Employee A. She stated she typically worked on the [NAME] Wing. She stated maintenance issues were reported in the TELS system, an electronic reporting system. If something needed to be done immediately, she would report it in TELS and also send a group text message to the department heads, which included the Administrator. She confirmed her knowledge of the leak/flooding in the restroom on the [NAME] Wing. She stated that the area was usually wet adding, especially when it rains. She stated someone came in on Monday [11/4/2024] to repair the toilet and that she had not seen the toilet replaced. She stated the issue was not resolved and that all residents were able to use that restroom not just the residents on that wing. On 11/6/2024 at 2:05 pm, an interview was conducted with Employee F, Licensed Practical Nurse (LPN). She stated she contacted the Maintenance Director when there were maintenance issues. She used the computer reporting system for maintenance requests, however, she had been having issues logging into it. So, it was easier for her to call the Maintenance Director. She was aware of the issues with the resident restroom on the [NAME] Wing and was advised that it had been repaired, and that now it was broken again. She stated she had not reported this and said, This is an old building. There are always problems. A record review of Plumbing/Electric invoices provided by the facility revealed the following. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 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 105429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0921 10/03/24: Toilet tank rebuild Level of Harm - Minimal harm or potential for actual harm 10/04/24: Customer had a toilet with an old worn-out stud that came detached . 10/07/24: Two toilets that were not draining and a shower that needed to be rebuilt Residents Affected - Some . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105429 If continuation sheet Page 3 of 3