Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observations, interviews, and record review, the facility failed to give residents with limited
mobility appropriate services, equipment, and assistance to maintain or improve mobility with maximum
practicable independence unless a reduction in mobility was demonstrably unavoidable. This impacted one
resident (#23) reviewed for care and services out of 18 residents with contractures, and from a total sample
of 34 residents. Failure to provide appropriate range of motion (ROM) and splinting can result in increased
pain and worsening of contractures.
The findings include:
A review of Resident #23's medical record revealed an admission date of 8/22/22 and diagnoses including
nontraumatic intracerebral hemorrhage, pancreatitis, cirrhosis of liver w/o ascites, cardiomyopathy,
polyneuropathy, history of falling, spondylolisthesis, ataxic gait, major depressive disorder, and spinal
stenosis with fusion of spine.
A review of the resident's minimum data set (MDS) assessment, dated 8/26/22, revealed a brief interview
for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. The resident's
functional status indicated impairment on both upper and lower extremities with total dependence and
two-person assistance for bed mobility and transfers.
A review of the resident's physician's orders included tizanidine every eight hours, started on 8/28/22
(muscle relaxant); buspirone, one tablet every eight hours, started on 8/28/22 (anxiety); oxycodone HCL
(hydrochloride) tablet, one every six hours for subluxation (partial dislocation) of C7/T1 cervical vertebrae,
started on 8/29/22; and gabapentin, one tablet three times a day, started on 10/24/22 (neuropathy).
Occupational therapy was ordered three to five times a week for 30 days, started on 10/24/22; Speech
therapy three to five times a week for 30 days, started on 10/24/22. No orders for restorative nursing were
found. (Photographic evidence obtained).
A review of Resident #23's care plans revealed a focus area for an alteration in musculoskeletal status
related to contractures to bilateral lower extremities. Interventions included: Perform passive range of
motion (PROM) to bilateral (both) extremities as tolerated daily and as needed. Another focus area was
noted for a risk for falls with interventions that included: Continue therapy to continue to improve trunk
controls/stability, initiated on 9/16/22. (Photographic evidence obtained)
On 11/07/22 at 1:48 PM, Resident #23 reported that he had a contracted right leg and currently received
no physical therapy (PT) or restorative program care. At this time, an observation revealed no splint on the
resident's right leg contracture. The resident then pointed to a splint in chair that he said was for his leg.
(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 6
Event ID:
105470
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
105470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fernandina Beach Rehabilitation and Nursing Center
1625 Lime Street
Fernandina Beach, FL 32034
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 11/09/22 at 4:48 PM, Resident #23 reported that he would love to have physical therapy, and that he did
not refuse therapy. He was observed at this time with no splint on his right leg contracture.
The Therapy Director was interviewed by telephone on 11/09/22 at 5:10 PM. She reported that Resident
#23 had physical therapy (PT) from August 23 to October 16, 2022. She also reported that Resident #23
was discharged from PT to the Restorative Program. She stated, If there is a decline or improvement with
resident mobility, then they can revisit starting therapy again. She reported that the restorative program staff
were responsible for applying and removing residents' splints. Therapy would educate staff on splint
placement and when the resident could wear the splint.
A review of the Physical Therapy Discharge Summary that was signed by Physical Therapy on 10/17/22
revealed the following: The discharge status and recommendations were as follows: 24-hour care and
continue with restorative nursing program (RNP). For RNP and functional maintenance program (FMP),
continue passive range of motion (PROM), bracing with pillow, knee brace, multi podus boot. (Photographic
evidence obtained)
An interview with the Restorative Program Nurse (RPN) was conducted on 11/09/22 at 5:38 PM. He
reported that any certified nursing assistant (CNA) could do restorative therapy; the facility did not have
designated restorative nursing assistants (RNAs). When asked how he tracked the restorative care and
splinting being provided to ensure it was done, he replied, The nurses on the floor should be monitoring it.
When the RPN was asked if Resident #23 was on the restorative nursing program, he reported, No, not
that I'm aware of. He stated, PT gives me a copy of the restorative orders in person, and the therapy
department educates the CNAs (certified nursing assistants) about the restorative care needed for a
resident. He did not know of any reason why Resident #23 would not be on a restorative program.
An interview was conducted with the Director of Nursing (DON) on 11/09/22 at 6:53 PM. When asked her
expectations for the restorative program, she stated, If a resident needs more range of motion, or if they are
on a toileting program, they are put on the restorative program. She reported that the therapy department
referred residents to the RNP. Therapy is the one that sets goals and the RNP implements the exercises.
When asked if Resident #23 was on the RNP, she reported that he was getting speech therapy but was not
on the RNP. I don't see any RNP orders. As far as I know he has no splint or contractures.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105470
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
105470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fernandina Beach Rehabilitation and Nursing Center
1625 Lime Street
Fernandina Beach, FL 32034
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 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
Based on interviews and record review, the facility failed to ensure that all licensed nurses and certified
nursing assistants demonstrated competencies and skills sets necessary to care for residents' needs, as
identified through resident assessments and described in the plan of care. There were 107 residents in the
facility at the time of the survey who were at risk of receiving substandard care and services.
The findings include:
On 11/08/22 at 11:00 AM, Resident #564 stated he thought his blood sugar was high maybe 441 this
morning. He could not recall if he had received any insulin coverage. He further stated he still felt like his
blood sugar was high because he didn't feel well.
In an interview on 11/08/22 at 11:40 AM, Licensed Practical Nurse (LPN) A (Agency) was asked about
Resident #564's blood sugar reading. She looked it up in the electronic medical record and stated that it
was 445 milligrams per deciliters (mg/dL) at 9:59 AM and that she had administered 22 units of insulin.
When asked if she had notified the physician, she stated that there was no order to call the physician. She
further stated that if a resident normally ran high, then she wouldn't necessarily call the physician. When
asked if the resident normally had a high blood sugar reading, she stated that she was from an Agency and
that this was only the second time she had worked at this facility; she didn't really know the resident. When
asked about the facility's policy for a circumstance like this, she stated she did not know. She added, At
some facilities when a resident's blood sugar is above 400, the physician is notified. She confirmed that she
had not notified the physician or rechecked the resident's blood sugar level.
In an interview with Licensed Practical Nurse (LPN) B (Agency) on 11/09/2022 at 3:10 PM, she was asked
about her training and competencies. She stated she had not received any training at this facility.
On 11/09/22 at 9:00 AM, the facility Administrator was provided a list of 10 randomly selected employees
and was asked to provide their personnel files and include competency skill checks.
On 11/09/22 at 11:00 AM, personnel files were provided without the competencies.
In an interview on 11/09/22 at 5:06 PM, the Assistant Director of Nursing (ADON) confirmed that she was
responsible for employee training and competencies. She mentioned that the training competencies were
conducted upon hire, annually, and as needed. She added that Corporate conducted the orientation training
and she and the unit managers were responsible for the competencies. When asked for the competencies
for the randomly selected employees, she said,They are done annually, I still have time. She was then
asked the process for Agency staff training. She stated the Agency staff were supposed to get a check list
with specific training before providing direct care at the facility. When asked for this information for
Employees A and B, she said, To be honest, it has not been happening.
A review of the facility's Education Plan revealed: Purpose - To provide guidance by which to follow to
ensure State, Federal, and OSHA education requirements are met consistent with the resident needs
based on the comprehensive assessment and care plans as well as the facility assessment. The procedure
read, The facility will ensure that the education plan includes both pre-service, annual and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105470
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
105470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fernandina Beach Rehabilitation and Nursing Center
1625 Lime Street
Fernandina Beach, FL 32034
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 0726
Level of Harm - Minimal harm
or potential for actual harm
other recurring requirements. The facility will ensure that nursing staff are able to demonstrate competency
in skills and techniques necessary to care for residents' needs, as identified through resident assessments,
described in the plan of care and based on the facility assessment.
.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105470
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
105470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fernandina Beach Rehabilitation and Nursing Center
1625 Lime Street
Fernandina Beach, FL 32034
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 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
Based on interviews and record review, the facility failed to 1) Maintain an effective system to obtain and
use feedback and input from direct-care staff, other staff, residents, and resident representatives, including
how such information would be used to identify problems that are high risk, high volume, or problem-prone,
and opportunities for improvement; 2) Maintain an effective system to identify, collect, and use data and
information from all departments, including but not limited to the facility assessment, and include how such
information would be used to develop and monitor performance indicators; 3) Develop, monitor, and
evaluate performance indicators, including the methodology and frequency for such development,
monitoring, and evaluation; and 4 ) Conduct distinct performance improvement projects that reflected the
scope and complexity of the facility's services and available resources, as reflected in the facility
assessment.
The findings include:
In an interview on 11/09/22 at 5:58 PM, the Administrator was asked about the facility's Quality Assurance
and Performance Improvement (QAPI) program and was asked for the facility's current performance
improvement plans (PIPs). He stated he could not find them. He added that he would contact the Director of
Nursing (DON) to see whether she had them in her office. Shortly thereafter, the DON entered the
Administrator's office and began reading the PIPs she was holding. She confirmed that the PIPs she was
reading were initiated during this survey through the problems identified. When asked for the PIPs that the
facility was working on prior to the survey, the DON stated she did not know of any. She left the
Administrator's office.
On 11/09/22 at 6:10 PM, the DON returned to the Administrator's office accompanied by the Unit Manager.
The DON stated the Unit Manager had been working on some PIPs and asked if she would state what she
was working on. When asked if the issues the Unit Manager was working on were discussed by the QAPI
committee meetings, she stated no. At this time the Administrator was observed perusing through a stack
of papers on his desk. The DON and the Unit Manager left the room.
On 11/09/22 at 6:15 PM, the Administrator began reading from the stack of papers on his desk. He stated
the PIPs the facility was working on included:
Physician progress notes: Progress notes should be current per with the facility policy. This was initiated on
4/21/22 and was ongoing. Care plan audit to ensure that vision, antipsychotics and pain were captured in
the care plan. This was initiated on 9/15/22. Advanced Directives to ensure that they were updated. This
was initiated in August 2022 (no specific date) and was ongoing. When asked long the Quality Assurance
(QA) committee monitored an issue that had been corrected, he stated three months minimum. He could
not explain why the PIP on physicians' progress notes was still open since April 2022. He was then asked
how the QAPI committee identified which issues to work on. He said, Corporate flags areas of concern that
may come up. We also use [electronic medical records] audits.
A record review of the facility's QAPI plan 2021-2022, revealed the following goals:
1.
Reduce the re-hospitalization rate by 13% or below on an consistent basis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105470
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
105470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fernandina Beach Rehabilitation and Nursing Center
1625 Lime Street
Fernandina Beach, FL 32034
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 0867
2.
Level of Harm - Minimal harm
or potential for actual harm
Reduce the alarm use in the facility.
3.
Residents Affected - Many
Reduce quality measure rates for falls with major injuries , urinary tract infections , pain, pressure ulcers, to
below the state and federal rates.
4.
Maintain the antibiotic stewardship program.
The QAPI plan further indicated that the organization utilized Quality Assurance and Performance
Improvement to make decisions and guide the daily operations, and that the Administrator and the Director
of Nursing were responsible for the QAPI process. The Director of Nursing, the Assistance Director of
Nursing and the Unit Managers would ensure that consistent, appropriate, and just-in-time training was
provided to facility employees. Quality topics were covered at general orientation sessions with ongoing
training. (Copy obtained)
A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy (revised
February 2020), revealed that the policy read, This facility shall develop, implement and maintain an
ongoing, facility-wide data-driven QAPI program that focused on indicators of the outcomes of the care and
quality of life of our residents. The objectives of the QAPI programs were identified as:
1.
Provide a means to measure current and potential indicators for outcomes of care and quality of life.
2.
Provide means to establish and implement performance improvement projects to correct identified negative
or problematic indicators.
3.
Reinforce and build upon effective systems and processes related to the delivery of quality care and
services.
4.
Establish systems through which to monitor and evaluate corrective actions.
(Copy obtained)
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105470
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
FAQ · About this visit
Common questions about this visit
What happened during the November 9, 2022 survey of FERNANDINA BEACH REHABILITATION AND NURSING CENTER?
This was a inspection survey of FERNANDINA BEACH REHABILITATION AND NURSING CENTER on November 9, 2022. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FERNANDINA BEACH REHABILITATION AND NURSING CENTER on November 9, 2022?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, u..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.