Inspection·June 23, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 6/23/22 at 2:23 PM, Resident # 23 stated she was aware that she had breast cancer and she was supposed to have surgery, but every time she tried to go to her appointments there was no transportation, therefore, she missed most of her appointments. She added that she believed her condition had worsened since she was pain and had discharge from her left breast. She lifted her blouse and revealed an allevyn foam dressing on the left nipple. The dressing was dated 6/20/22. She stated she had spoken to her physician regarding the need to get assistance scheduling her oncology appointment, but she had not received any feedback. In an interview with Licensed Practical Nurse (LPN) D on 6/23/22 at 2:27 PM, she was asked to explain the process for making resident appointments. She stated the person who received the appointment order, entered it in the resident's electronic medical record. After the order was entered, the individual responsible for scheduling made the appointment. When asked if Resident #23 had any appointments, she stated this resident normally made her own appointments. LPN D was asked who/which staff member was responsible for following up to ensure that the resident scheduled the appointments as ordered. LPN D stated, I am not sure. I will ask the unit manager. She checked the resident's record and stated, There are no orders for appointments. She was asked to review Resident #23's physician's progress note. LPN D confirmed that the nurse who was informed of the issue should have entered the order in the electronic medical record. When asked about the drainage and the dressing on the resident's breast, LPN D stated,I am not aware of any drainage. The resident has orders for Neosporin under her breast, and I have not put it on today. There is no dressing order. She added that she would get with the physician and the unit manger for order clarification and then schedule the appointment. In an interview with LPN C/Unit Manager on 6/23/22 at 2:30 PM, he confirmed that there were no appointment orders or appointments scheduled for Resident #23. He stated he would follow up as soon as possible. When asked about the dressing on the resident's breast, he stated he was not aware that the resident had any drainage from her breast. He added that he would follow up with the resident. In an interview with the Director of Nursing (DON) on 6/23/22 at 2:46 PM, she was asked who was responsible for reviewing residents' charts. She stated the 11:00 PM - 7:00 AM shift nurses were expected to review the progress notes nightly and transcribe/carry out the orders if they had not been completed. When asked about Resident # 23, The DON stated this resident made her own appointments. When asked if there was a process in place to ensure that the resident scheduled the appointments as ordered, she stated she would follow up with the unit manager since she did not see any orders in the electronic medical record. On 6/23/22 at 4:04 PM, a follow-up interview was conducted with the DON. She stated Resident #23 was agreeable to having the facility book her an appointment. She confirmed that there was no order for the allevyn dressing, but the resident wanted it on. New orders were obtained for the dressing. A Nursing Progress Note, dated 6/23/22, read,Per physician progress note dated 6/19/22, discussed with the nurse to arrange follow-up for patient due to bleeding from the breast with history of breast cancer. I called the physician and order given for patient to have oncology consult for the left breast nipple drainage as well as in-house wound care nurse to evaluate. (Copy obtained) 2. A review of Resident #73's clinical record revealed an admission on [DATE] with a re-entry on 2/27/16. Her primary diagnosis was hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified cite. Her secondary diagnoses included muscle weakness, anxiety disorder, pathological fracture, history of falls, contracture of muscle, and major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 2 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 0684 Level of Harm - Minimal harm or potential for actual harm A review of the June 2022 Physician's Order Sheets revealed active physician's orders for the following: Lexapro 20 mg (milligrams) QD (daily) for depression, Eliquis 2.5 mg every 12 hours for deep vein thrombosis (DVT - blood clot), megace 400 mg one time a day for poor appetite, and Dextromethorphan-quinidine 20-10 mg every 12 hours for pseudobulbar affect (PBA - sudden episodes of uncontrollable and inappropriate laughing or crying), and buspirone 15 mg BID (twice daily) for anxiety. Residents Affected - Few A review of the Care Plan revealed that Resident #73 required extensive to total assistance with Activities of Daily Living (ADL). Resident #73 was being followed by a psychiatry services with the most recent visit conducted on 6/16/22. Plan: Continue medication Lexapro for depression, buspirone for anxiety, dextromethorphan-quinidine for PBA, and megace for poor appetite. A Nursing Progress Note, dated 6/3/22, indicated that a CNA reported vaginal bleeding in brief, writer checked the brief and resident had slight bleeding coming from the vaginal area. Writer notified the physician and order given for vaginal ultrasound. Writer was informed that the mobile imaging company did not perform those ultrasounds. Physician notified of updates. Physician mentioned to just monitor area. An Internal Medicine Progress note, dated 6/18/22, read , Resident is stable. Lab work Monday. In an interview with LPN B on 6/23/22 at 1:55 PM, she was asked for the recent laboratory results for Resident #23. She provided results dated 1/25/22. She checked the physician's orders and stated there were no new orders. When asked about the physician's progress note dated 6/18/22, she stated the night shift nurses were supposed to conduct chart audits and enter any orders in the electronic medical record. She stated the laboratory orders were also entered in the lab requisition book for the laboratory staff to sign after obtaining a specimen. LPN B proceeded to check the lab requisition book and stated there were no lab draws requested for Resident #73 on 6/20/22. In an interview with the DON on 6/23/22 at 3:06 PM, she was asked about Resident #73's labs indicated in the physician's progress note. She stated the physician would have put the orders in the electronic medical record. She added that at times physicians also gave verbal orders to the nurses. She mentioned that she would contact the physician to follow up. On 6/23/22 at 4:08 PM, a follow-up interview was conducted with the DON. She stated the physician stated he thought he had put the order in the electronic medical record. She added that new orders were received to have the labs carried out on 6/23/22. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 3 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to review gradual dose reduction recommendations for one (Resident #73) of five residents selected for psychotropic drug review from a total sample of 25 residents. The findings include: A review of Resident #73's clinical record revealed an admission on [DATE] with a re-entry on 2/27/16. Diagnoses included hemiparesis following unspecified cerebrovascular disease affecting unspecified cite, anxiety disorder, and major depressive disorder. A review of the June 2022 Physician's Order Sheets revealed active physician's orders for the following: Lexapro 20 milligrams (mg) every day (QD) for depression, Eliquis 2.5 mg every 12 hours for Deep Vein Thrombosis (DVT - blood clot), megace 400 mg one time a day for poor appetite, Dextromethorphan-quinidine 20-10 mg every 12 hours for pseudobablor affect PBA (sudden episodes of uncontrollable and inappropriate laughing or crying), and buspirone 15 mg BID (twice daily) for anxiety. A review of the active care plan revealed that the resident was demonstrating generalized dissatisfaction with life, depressed mood, anxious feelings toward surroundings including staff and other residents, and often being short-tempered and frustrated with staff. [Resident #73] also has the potential for complications related to psychotropic drug use. A review of the pharmacy recommendations, dated 3/29/22, revealed a recommendation for: Antidepressant gradual dose reduction attempt for Lexapro 20 mg QD since February, 2016. The guideline further read, All agents falling within the psychoactive category (without regard to indication) fall under gradual dose reduction guidelines. This includes agents within the antidepressant category. (Copy obtained) Another recommendation, dated 5/29/22, read, Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in two different quarters with one month between attempts, then annually thereafter when used to manage behavior, stabilize mood, or treat psychiatric disorders. This resident has been taking the following anxiolytic without GDR: Buspirone 15 mg twice a day (BID) since 3/24/2017. (Copy obtained) A review of Resident #73's Medication Administration Record (MAR) for April 2022 through June 2022, revealed Lexapro 20 milligrams (mg) and buspirone 15 mg BID for anxiety, were administered every day. (Copy obtained) In an interview with the Director of Nursing (DON) on 6/23/22 at 4:00 PM, she confirmed that Resident #73 received Lexapro 20 milligrams (mg) and buspirone 15 mg BID for anxiety. She also confirmed that the GDR recommendations were not reviewed by the physician. A reviewed the facility's policy and procedure titled Psychotropic PRN (As Needed) Medication (Effective May 2017 and last Reviewed on May 2022), revealed, In accordance with State and Federal Guidelines, revised regulation 483.45 (e) Psychotropic Drugs states that based on a comprehensive assessment of a resident, the facility must ensure that: Residents who use psychotropic drugs receive gradual dose reductions, and behavior interventions, unless clinically contraindicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 4 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 0758 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 5 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to ensure proper sanitation and food storage practices were adhered to in order to prevent the outbreak of foodborne illnesses. Residents Affected - Many The findings include: During a tour of the kitchen on 6/21/22 at 10:52 AM with Certified Dietary Manager (CDM) E, he stated he had been employed at the facility for approximately one year. At this time, he identified Food Service Utility Worker F as the primary dishwasher. He stated he completed weekly kitchen audits and all outdated and damaged food should be discarded. An observation of one of the kitchen freezers revealed an open pack of ground turkey labeled use by 6/15/2022. When asked about this, the CDM acknowledged it was out of date and stated, It's not on the menu. There was also an unopened package of veggie burgers labeled use by 6/18/2022. The CDM stated the burgers weren't open and were there just in case a vegetarian was admitted into the facility. As the tour of the kitchen continued, a box labeled red potatoes was observed sitting on a shelf in the kitchen. Upon opening the top of the box, small flying insects immediately exited the box into the air. Several of the flying insects were covering some of the potatoes inside of the box and some of the potatoes were rotten. The CDM looked into the box, observed the conditions, reached into the box, retrieved the rotten potatoes, and discarded them in a nearby garbage can. During an observation of the dishwasher on 6/21/22 at 11:37 AM, a sign was observed posted next to the dishwasher identifying it as a low-temperature machine. Food Service Utility Worker F was asked to test the sanitation level of the dishwasher. He stated he had never done this before and was unsure of how to perform the test. When asked for the sanitation log and who was responsible for performing this test, he replied there was no log, and no one had been performing the test. At this time the CDM interjected and stated the dishwasher was a high-temperature machine and did not require sanitation testing. He stated the rinse temperature should reach 180 degrees. Food Service Utility Worker F began testing the dishwasher running a few items through. Initially, the rinse temperature did not register, so he restarted the process. Again, the rinse temperature did not register. (Photographic evidence obtained) Food Service Utility Worker F stated this had happened in the past. He was asked what he did when this occurred. He replied, I wait until it starts working. After he waited a few more minutes, he attempted to test the dishwasher again by running through more items. This time the rinse temperature registered at 158 degrees Fahrenheit (F). (Photographic evidence obtained) At 11:46 AM, the CDM was asked what should be done. He stated he should call maintenance, as they were responsible for the dishwasher, but neither he nor Food Service Utility Worker F contacted anyone at that time. Food Service Utility Worker F stopped using the dishwasher and turned it off. The tour of the kitchen continued. At 11:56 AM, flying insects were observed near the prep station next to the fryers. The CDM denied seeing the insects. Again, insects were observed in the area and again the CDM denied the observation. While checking the coolers in the kitchen, 19 expired cartons of chocolate milk were observed in the stand-up cooler near the serving station. The CDM confirmed the observation, acknowledging that the items were all expired. During an interview with the CDM on 6/21/22 at 12:06 PM, he was asked about the expired chocolate milk and who was responsible for ensuring that items in the cooler were within the appropriate date range. He stated it should be checked nightly by the nighttime staff. As the tour of the kitchen continued, the surveyor returned to the dishwasher. Food Service Utility Worker F turned on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 6 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 dishwasher and ran through more items. At this time the rinse temperature registered at 160 degrees F. (Photographic evidence obtained) The CDM stated he would contact maintenance. At this time he was advised to discontinue use of the dishwasher and not use items that were washed while the rinse temperature was not registering. On 6/21/22 at 12:13 PM, Maintenance Director H and Food Service Utility Worker F were observed at the dishwasher. They began testing the dishwasher and again the rinse temperature did not register. On 6/21/22 at 3:03 PM, the CDM advised that he had contacted the dishwasher service company to diagnose and repair the dishwasher. At this time he was again advised that he could not use the dishwasher or anything previously washed when the rinse temperature was not registering. He was advised at this time that he would need to use disposable dishware for meals until the repairs had been made. He nodded and replied, Oh, okay. On 6/21/22 at 4:37 PM, the kitchen staff were observed preparing dinner using regular dishware. The CDM was immediately notified of this and asked why disposable dishware was not being used. He stated he didn't understand, and he assumed the surveyor was referring to the dishes that would be used for breakfast the next day. At 4:44 PM, the kitchen staff were observed preparing meals on black paper plates. The plates were uncovered and were being placed on the counter before being transferred to the meal delivery cart. (Photographic evidence obtained) At 4:48 PM, after observing several plates on the counter, the CDM was asked about the black paper plates with no covers. He was specifically asked how the food would hold its temperature until it was received by the residents. He initially asked what he should do, then he asked if he could use the tray domes on the rack. When asked whether they had been washed in the dishwasher after lunch, he replied that they had. Again, he was advised that for sanitation purposes, items that had been washed in the dishwasher while the rinse temperature was not registering could not be used for food service. On 6/22/22 at 9:33 AM, the facility provided a service order receipt for the dishwasher repair dated 6/21/22 at 6:37 PM. The notes on the service order receipt read, Found bad Final Rinse temperature sensor. The receipt also advised that the unit was to operate at set point of booster heater to 180 degrees plus 10 degrees F during final rinse operation. (Photographic evidence obtained) A review of the instruction manual on the CLe-Series Dishwashers F44127 Rev. C (November 2012) revealed the machine could be operated as a low- or high-temperature machine. Per page 25, the minimum temperature for the final rinse cycle using high temperature sanitizing was 180 degrees F (82 degrees C). (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 7 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, resident and staff interviews, and resident and facility record reviews, the facility failed to maintain complete and accurate medical records for one (Resident #74) of two residents reviewed for non-pressure skin conditions, from a total of 25 residents in the sample. The findings include: An observation was conducted of Resident #74 on 06/21/22 at 1:29 PM. Multiple bruises were present on both forearms, and he had a dime-sized skin tear on the right forearm above his wrist. When he was asked what happened, Resident #74 replied he did not know; perhaps it was from his hospital bracelet. Observation confirmed a plastic snap-on medical identification bracelet secured loosely around his right wrist. On 06/22/22 at 11:07 AM, Resident #74 was observed in an activity on the 300 hall. The skin tear to his right forearm was visible and open to the air. The identification bracelet was still on the same wrist. Resident #74 reported the nurses were applying a salve to the area, and he would ask them to place the next bracelet on his left arm. An interview was conducted with Certified Nursing Assistant (CNA) A on 06/23/22 at 9:39 AM. She confirmed Resident #74 was assigned to her today on the 7:00 AM to 3:00 PM shift. She reported CNAs looked at residents' skin daily and reported any issues such as redness, discoloration, blisters, etc., to the nurse. CNA A stated Resident #74 was cognitively intact and pretty mobile but sometimes had involuntary movements due to his diagnosis of Parkinson's disease. When asked about the skin tear, CNA A said she was unaware of it but would go look. She confirmed that the bruising and the skin tear should have been reported to the nurse. CNA A went to Resident #74, looked at the area, returned and confirmed its presence. She said she would tell the nurse and proposed removing the wrist band and placing it on his bed and place another one on his wheelchair to prevent further skin tears. Resident # 74 was observed again on 06/23/22 at 11:54 AM. The skin tear was still visible, and the medical identification bracelet was now on the arm of his wheelchair. Resident #74 had a quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 6/11/22. He had a brief interview for mental status score (BIMS) of 14 out of a possible 15 points, reflecting that he was cognitively intact. He had diagnoses including anemia, diabetes mellitus and Parkinson's disease. Section M reflected Resident #74 had no skin issues. Resident #74 was care planned on 6/13/22 for the potential for impaired skin due to his immobility with a goal to have no skin impairment though the next review period. The interventions included to inspect his skin during bathing and to notify the nurse immediately of any new areas. Notify the resident or responsible party of any new areas. (Photographic evidence obtained) Resident #74 had a physician's order, dated 8/25/21, for weekly skin checks on Wednesdays during the 3:00 PM to 11:00 PM shift for skin assessment. Complete a skin note. If skin is not intact, complete a change in condition-skin form. (Photographic evidence obtained) A review of the Treatment Administration Record (TAR) for May 2022 and June 2022 found the weekly skin checks were checked off as having been performed as ordered on June 1, 8 and 15, 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 8 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 0842 (Photographic evidence obtained) Level of Harm - Minimal harm or potential for actual harm Corresponding nursing progress notes were authored on 6/1/22 and 6/15/22. Each noted Resident #74 presented with no new skin issues identified. There was no note for 6/8/22. Progress notes for the months leading up to June were reviewed with no mention of the area. (Photographic evidence obtained) Residents Affected - Few A Skilled Nursing Facility Daily Nursing Documentation note, dated 6/21/22, found section C. #2 Integumentary (skin) asked if the patient had any skin impairment. The answer was No. (Photographic evidence obtained) An interview was conducted with Licensed Practical Nurse (LPN) B, assigned to Resident #74 on the 7:00 AM to 3:00 PM shift at 2:53 PM on 06/23/22. She stated she believed Resident #74 was on a blood thinner. The bruising to his forearms was fairly normal as he had very thin, fragile skin. Skin checks were performed daily on the evening shift for this resident. Any open or reddened areas, skin tears or bruises were to be recorded on the skin report. Skin checks were also noted on the Treatment Administration Record (TAR). Anything significant was written in a skin note. LPN B was told about the skin tear. She stated she did not know about it; when it occurred, or why it was not documented. CNA A had just reported it to her, but she had not gotten to Resident #74 yet, as she was passing medication. LPN B said she would always make a note for any new skin issue, clean it up, notify the physician and follow protocols. She confirmed a note should have been authored when the injury occurred. An interview was conducted with Unit Manager C on 06/23/22 at 4:00 PM. He was asked about resident skin assessments. He pointed out the posted schedule and explained they were to be conducted and documented weekly for every resident per the assigned schedule. All new issues were to be documented. Unit Manager C was asked if he was aware of Resident #74's skin tear, and if he knew when it may have occurred. He replied that he did not know when it occurred. He had seen the wound today and recognized it was not new. He said it should have been documented when it was identified. He acknowledged the highly visible wound was overlooked on multiple shifts by multiple licensed staff over an undetermined period of time. He had no explanation as to why the area was not documented. A review of the facility's policy and procedure Skin Care Protocol (#BC NUR-039 revised 05/2022) revealed: Purpose: The purpose of this policy is to: 1. Maintain optimal skin integrity . 2. Protect skin and tissue against adverse effect of external mechanical force . Policy: Skin of all individuals at risk is systematically inspected upon admission and daily . Procedure: .4. Document wound assessment and interventions daily in the medical record . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 9 of 10 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 105645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258 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 0842 The policy did not address the facility's weekly skin sweep protocol. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105645 If continuation sheet Page 10 of 10