Health inspection·April 6, 2023

F 0582 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105666 If continuation sheet Page 2 of 5 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 105666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lanier Rehabilitation Center 12740 Lanier Road Jacksonville, FL 32226 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment as well as housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the 94 residents in its census, facility staff and visitors. The findings include: During a tour of the facility on 4/3/2023, multiple walls and flooring tiles in the halls on the units were observed to be in need of repair. Chipped paint, broken baseboards, stained floors, and broken tile were also observed. Resident rooms were in need of repair and/or cleaning, with resident room doors observed to be splitting and in need of repair as follows: At 11:34 a.m., the bathroom in room [ROOM NUMBER] was observed. The faucet was loose from the sink during water temperature testing. The the wall behind the sink had been patched with a thick substance, which had not been sanded down prior to being repainted. A large watermark stain was observed above the resident's toilet. A thick white substance was observed around the resident's toilet. The toilet was not secured to the floor. A dried dark brown liquid was observed on the floor extending out from the thick white substance and space between the toilet. The step leading to the resident's walk-in shower had been covered with a thick substance then repainted without proper sanding. The paint was peeling and separated from that step. During an interview at the time of these observations, the resident stated the bathroom had been like this for some time. He could not provide an exact timeframe. He stated the toilet leaked from the bottom. The resident stated in the past, repairs were attempted but the toilet continued to leak. He stated they came in and patched up some things in the bathroom, however, repairs were still needed. He stated he was told everything would be fixed but there was no follow through. (Photographic evidence obtained) At 12:08 p.m. in room [ROOM NUMBER], the baseboards behind and on the side of the resident's bed (Bed B) were broken and the paint was chipped. Further observation revealed spider webs containing several small, round, white objects. The floors were not clean. Dried substances, empty pill cups, food wrappers, and miscellaneous debris were observed on the floor. Chipped, discolored, and bubbling paint was observed on the wall above the air conditioning unit. The resident in Bed B was asked about the observations. The resident was alert and oriented but was nonverbal. The resident was asked if housekeeping cleaned her room. She nodded her head and mouthed yes. She was asked if she saw any bugs in her room. She nodded her head and mouthed sometimes. (Photographic evidence obtained) At 1:22 p.m. in room [ROOM NUMBER], broken and missing base boards were observed. The paint on the room walls was chipped. A broken piece of base board with an unidentifiable object (blue in color) was pushed down between the wall and baseboard. Miscellaneous debris was behind the broken baseboards. A dried substance was located next to Bed B. The resident was not interviewable and was unable to answer questions regarding the observations. (Photographic evidence obtained) At 2:01 p.m., in room [ROOM NUMBER], the resident in Bed B was receiving enteral feeding. A dried, dark beige substance was splattered on the pole holding the feeding bottle and device, the feeding device used to monitor/administer the feeding, the wall behind the pole, the floors around the pole, and on the resident's privacy curtain. The resident was non-interviewable and was unable to answer questions regarding the observation. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105666 If continuation sheet Page 3 of 5 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 105666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lanier Rehabilitation Center 12740 Lanier Road Jacksonville, FL 32226 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During subsequent tours of the facility, conducted on 4/4/2023, the environmental concerns observed during the initial tour on 4/3/2023 were again observed. On 4/5/2023 at 12:01 p.m., after a tour of the facility with Maintenance Director A, the Life Safety Surveyor confirmed the observations made by the survey team on 4/3/2023 and 4/4/2023. He advised that the concerns related to the bathroom in room [ROOM NUMBER], the walls in rooms [ROOM NUMBERS], the baseboards, and the walls and broken tiles in the hallways were addressed with the Administrator and Maintenance staff. On 4/5/2023 at 3:50 p.m., staff were observed in room [ROOM NUMBER]'s bathroom with miscellaneous tools and supplies. There was no actual observation of repairs. A tour of the facility was conducted on 4/6/2023 at 1:25 p.m., Maintenance Director A. He advised that he had been in his position since October 2021. He stated he was aware of the repairs needed in the facility. He stated the cracks in the floor tiles were being filled with grout in an effort to decrease fall hazards. He stated there was new maintenance department staff. He advised that he was making the repairs as he was able. He acknowledged repairs were actively being made to the bathroom in room [ROOM NUMBER]. He advised that facility repairs would be an ongoing process. A tour of the facility was conducted on 4/6/2023 at 3:27 p.m., Interim Housekeeping Supervisor E. She advised that previously she had occupied the role for approximately nine years and recently returned until the facility could hire someone for the position. She stated there were currently four housekeepers, four laundry workers, and a floor tech. The housekeepers were scheduled from 7:00 a.m. to 3:00 p.m. seven days a week. They were responsible for emptying the trash, cleaning the residents' bathrooms, wiping surfaces with any food particles, and sanitizing and polishing furniture at least once a week and as needed in the residents' rooms. She stated the certified nursing assistants (CNAs) were responsible for changing the residents' linens. She stated the housekeepers were to inspect the privacy curtains in order to determine which ones need to come down to be cleaned. She stated either herself or the floor tech was responsible for taking the curtains down, and she typically took down four to five curtains per day. She stated the housekeepers should be inspecting the curtains. She stated sweeping and mopping was done every day seven days a week. She stated the housekeepers informed her of any repairs needed. She added, they also had a maintenance log at the nurses' station and Maintenance checked the log books throughout the day, so they could go in and fix the problem. During the tour, the housekeeping supervisor was directed to room [ROOM NUMBER]. The trash, pill cup, and stains remained under Bed B. She was advised of the initial observation of the room in this condition on 4/3/2023. She shook her head and stated this should have been cleaned by housekeeping. She was then directed to room [ROOM NUMBER] Bed B. The dried, dark beige substance previously observed was still present on the floor near the resident's bed as well as the wall, on the pole holding the enteral feeding device as well as on the device itself. She confirmed that the dried, dark beige substance was the resident's enteral feeding. She advised that the enteral feeding liquid would always leak. She stated she was working with nursing and the CNAs to make it a team effort to keep the area clean. She acknowledged the liquid was dried and stated it's easier to clean when it's wet. She was advised of the initial observation on 4/3/2023 and stated, They'll just have to work to find a way to make sure it stays clean. She confirmed that the privacy curtain was stained and should have been taken down. A review of the facility's Maintenance Report Log revealed the initial report regarding the toilet in room [ROOM NUMBER] was made on 12/4/2022 by an employee who reported, Water seeps from under toilet in room [ROOM NUMBER]. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105666 If continuation sheet Page 4 of 5 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 105666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lanier Rehabilitation Center 12740 Lanier Road Jacksonville, FL 32226 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 0584 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105666 If continuation sheet Page 5 of 5