Health inspection·July 16, 2021

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few plastic knife was observed on the resident's bedside table. A hairbrush was observed on his bed which had a metal fork tied to one end and a metal spoon tied to the other end. The item was within the resident's reach. When asked about the object, the resident picked it up, held it in his hand, and stated, This? Oh, this is nothing. Upon further questioning, Resident #28 stated, This is the good stuff. It's metal. The Director of Nursing (DON) was in a room nearby and was motioned to come into the resident's room. Upon entering the room, she noticed the item in the resident's lap. She confirmed that the resident shouldn't have had the item and attempted to retrieve it. The resident immediately refused. The DON asked the resident for the item again and offered to bring him another set of utensils, but the resident refused. The DON then offered to take the item to the kitchen to have it washed. The resident refused and stated, I've got a sink in there while pointing to his restroom. The DON exited the room after being unsuccessful in removing the item. During an interview with Employee A, Licensed Practical Nurse (LPN) on 7/15/21 at 10:54 AM, the nurse explained that she was familiar with the resident. She identified him as being independent, schizophrenic, and with a grumpy attitude. She explained that he liked to walk around the facility and that he could be verbally aggressive. She further explained that he had a history of behaviors such as physical aggression, anger, agitation, and being a threat to himself or others. During an interview with the DON on 7/15/21 at 2:42 PM, she explained that Resident #28 was ordered to have plastic utensils as a result of an incident on 2/16/21 where he stood in the hall with a metal fork threatening to hurt someone if they didn't give him food. Review of the nursing progress notes revealed an entry dated 1/13/21 1:08 AM which indicated the resident threatened to kill someone if they don't get me some food. The note also indicated the resident overturned the meal tray cart and grabbed the left arm of a nurse and an arm of a CNA. Hospice was notified and, while waiting for Hospice to arrive, the resident exited the room several times threatening to kill people. Continued review of the nursing progress notes revealed an entry dated 2/16/21 1:57 AM which indicated the resident came out of his room yelling and screaming. He had a fork and a knife from the kitchen in his pocket. When an employee attempted to redirect him, the resident started yelling that he was not in prison and that he wanted food. The resident then began cursing and yelling that if the employee didn't get him some food, he was going to hurt someone. Continued review of the medical record revealed that ten days after the incident on 2/16/21, the resident's care plan was updated to reflect an intervention which read, provide plastic utensils at each meal for safety measures. During an interview with Employee M, Nursing Supervisor on 7/15/21 at 4:32 PM, she explained that Resident #28 had an incident with another resident. While she was trying to intervene, the resident shoved her. She described the resident as cycling and explained that he often refused his medications. She stated, I think everybody is fearful because he is a big guy and he has informed everybody that he used to be a bouncer. When he has gotten aggressive, it's just bad. His triggers aren't consistent. There have been staff members that have advised me that they are afraid of him. She added, The facility does need to look for more suitable surroundings for him. An interview was conducted with the Administrator on 7/15/21 at 1:45 PM. The Administrator was asked about the incident on 2/18/21 where Resident #28 struck another resident, causing injury. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 2 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few explained that Resident #28 did hit the resident in the face and stated the report should have been substantiated. The Administrator was then asked what the facility's plan was for managing Resident #28's ongoing behavior and the weapons. He stated, No one was aware until about 15 minutes ago and that the facility was going to provide closer monitoring. He explained that the facility would check for metal cutlery each time staff went into the room and check the room before and after meals. During an interview with Employee A, LPN on 7/15/21 at 2:44 PM, she explained that the resident had a habit of taking utensils off the meal carts and that he walks around and takes things. She stated that staff would attempt to remove the silverware from his possession, but that if the resident became anxious or aggressive, staff would just leave him alone. During an interview with Employee B, Certified Nursing Assistant (CNA) on 7/15/21 at 2:48 PM, she explained that she was familiar with Resident #28. She explained that the resident didn't like people in his room and that he rejected care. She stated she was fearful of the resident. When asked whether she had reported her concern to anyone, she stated, They know. I heard stories about him when I got here. She also stated she observed the resident earlier in the day scraping the floor with a metal spoon. She explained that she asked him for the spoon, but he refused. She further explained that she did not attempt to approach the resident or report the incident to anyone. During an interview with the dietician on 7/15/21 at 2:49 PM, she explained that she had heard in the morning meeting that the resident was removing utensils from the meal carts. She also stated she heard that the resident was chasing a staff member with a fork. She was not able to recall an approximately date of occurrence. During a follow up interview with the dietician via phone on 7/16/21 at 1:30 PM, she again explained that she recalled discussing the incident in the morning meeting and that she recommended the resident be offered plastic utensils. During an interview with Employee C, CNA on 7/15/21 at 3:00 PM, she explained that Resident #28 often refuses care and that he didn't like staff in his room at all. She stated she had observed the resident earlier in the day scraping the floor with a metal spoon. She stated she attempted to retrieve the item from the resident, but that he refused and became aggressive. When asked whether she had reported the incident to anyone, she stated, everyone knows how he is. During an interview with the Hospice Nursing on 7/15/21 at 3:00 PM, she explained that the resident has always been aggressive, irritable, and hard to manage. She explained that Hospice had prescribed a cream to reduce the resident's anxiety and behaviors, but that the primary care provider discontinued it. She added that she was unable to complete a visit with the resident on 7/15/21 because the resident was violent and repeatedly stated the robbers were coming. Review of a psychology therapy assessment, dated 1/27/21, revealed descriptions of the resident's mood being angry/hostile and irritable. The assessment and recommendations section read, He states that he does not trust anyone, and he has bound his eating utensils in the form of a weapon. Explore whether he may benefit from brief in-patient psychiatric admission where he can be monitored in a more secure setting. Review of the medical record revealed no evidence that this was done. Review of a Medication Management Assessment, dated 4/1/21 by the psychiatric Advanced Practice Registered Nurse (APRN) revealed Resident #28 had become combative and aggressive toward residents and staff. The assessment identified the resident as confused but with a concrete thought process. It also identified the resident as a current potential threat to himself or others, and indicated the DON had been notified of the threat. The assessment revealed recommendations that the resident would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 3 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0607 better suited for a memory care unit. (Photographic Evidence Obtained) Level of Harm - Immediate jeopardy to resident health or safety Review of a Medication Management Assessment, dated 4/28/21 by the psychiatric APRN indicated the resident continued with aggressive behaviors, and again indicated he would be better suited for a memory care unit. The assessment identified the resident as a potential threat to himself or others, and that the threat was communicated to a facility staff member. (Photographic Evidence Obtained) Residents Affected - Few An interview was conducted with the Social Services Director on 7/15/21 at 3:50 PM regarding the psychiatric provider notes, dated 4/1/21 and 4/28/21, recommending the resident be transferred to a memory care unit. She explained that she was not aware of the recommendations because she started working at the facility around the same time the recommendations were made. She confirmed that there had been no attempts by the facility to transfer the resident to a memory care unit. During an interview with Employee A, LPN on 7/16/21 at 1:38 PM, she was asked who was responsible for reviewing provider notes such as the ones from psychiatric providers. She stated, That is above my pay grade. I guess the Nurse Managers. Review of a psychiatry note, dated 7/14/21 revealed the resident was very irritable and angry. (Photographic Evidence Obtained) Review of a psychiatry note, dated 7/15/21 revealed the resident was assessed due to being unstable. The report indicated there was a significant history of agitation and making threats to harm others, and that the resident was found to be making a sharp weapon to harm others. The report further indicated that staff were feeling afraid of Resident #28, that he presented an acute threat to harm others, and that he lacked insight. The assessment indicated the resident appeared to be unstable and the physician felt the symptoms were occurring due to exacerbation of underlying depressive and mood disorder. The physician ordered transfer via [NAME] Act on 7/15/21. (Photographic Evidence Obtained) On 7/16/21 at 12:48 PM, a telephone interview was conducted with APRN #1. He stated he was familiar with Resident #28 and had cared for the resident for about two years. The APRN explained that the resident was a wanderer but was cooperative with care when he started providing care for the resident. He further explained that around February 2021, the resident started to be aggressive and violent. The APRN added that the resident was not benefiting from psychological behavioral therapy as he was not cooperative. Therefore, the APRN made the recommendation for memory care for more supervision. When asked whether the resident was a threat to himself or others, the APRN stated he had been notified of a situation where Resident #28 had threatened a staff member with a fork, and that he had an altercation with another resident. At that time, the APRN recommended the facility [NAME] Act the resident but that was not done. He also mentioned that upon making recommendations, the progress notes are available immediately in the resident's record and that the nurse on duty is notified. During an interview with the DON on 7/16/21 at 2:37 PM, she explained that she had recently started working at the facility and that, in that time, no one had reported any aggressive behaviors to her. She explained that the CNAs had the ability to report any behaviors in the electronic kiosk and that the expectation would be to notify the nurse immediately as well. During an interview with the Administrator and DON on 7/16/21 at 3:37 PM, both parties acknowledged that they were unaware of the resident's behaviors or his care plan interventions to receive plastic utensils. Both parties confirmed that they were not aware of any monitoring in place by facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 4 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few administration to ensure Resident #28 did not obtain silverware. Regarding psychiatric notes, the Administrator explained that each provider note is reviewed in the stand-up meeting. However, the DON intervened and stated not all notes were reviewed in morning meetings because some providers upload them directly to the system while other providers hand write them. The DON acknowledged the nursing leadership team was responsible for reviewing the notes and that a system needed to be developed to ensure they were being reviewed. Both the DON and Administrator denied being aware of recommendations to transfer Resident #28 to a memory care unit. The facility's abuse policies and procedures titled; Abuse Prevention Program (no effective date) were reviewed. The policy read, As part of the resident abuse prevention, the facility's administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. Section B of the abuse policy read, Facility staff will monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. (Photographic Evidence Obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 5 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to review the Pre-admission Screening for individuals with a mental disorder and individuals with intellectual disability to ensure that because of the physical and mental condition of the individual, the individual required the level of services provided by a nursing facility; and if the individual required such level of services, whether the individual required specialized services; that, because of the physical and mental condition of the individual, the individual required the level of services provided by a nursing facility; and if the individual required such level of services, whether the individual required specialized services for intellectual disability for one of 43 residents sampled, Resident #28. Residents Affected - Few The findings include: Record review revealed that Resident #28 was admitted into the facility on [DATE] with his last re-admission on [DATE]. The diagnoses included Unspecified Dementia without Behavioral Disturbance; Major Depressive Disorder; Other Psychotic Disorder not due to a Substance or known physiological Condition; Heart Failure, Chronic Kidney Disease, Stage 2 (Mild); Repeated Falls. Orders included Psychiatrist Evaluation and Treatment; Behavior Evaluation; Hospice for palliative care; Furosemide 20 mg by mouth daily; Trazodone HCL 50 mg by mouth three times a day; Acetaminophen 325 mg 2 tablets daily twice a day; and Seroquel 50 mg by mouth three times a day. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status score of 7 out of 15. He had little interest or pleasure in doing things 12-14 days, trouble falling or staying asleep 12-14 days, and felt tired or had little energy 12-14 days. Verbal behavioral symptoms directed towards others occurred 1 to 3 days and rejections of care occurred daily. He was independent in most activities of daily living; however, he required supervision with locomotion on and off the unit. Review of the most recent Care Plan revealed - Focus: Resident has potential to be physically aggressive related to dementia, anger, and prior homelessness. Interventions: communication, consult psych, larger name on door to identify his room, notify Hospice of any change in condition, notify MD of any change in condition, provide plastic utensils with each meal for safety measures. Focus: Psychotropic drug use. Interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness, Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly, Monitor/ document/ report as needed any adverse reactions of psychotropic medications. Focus: Behavioral problems related to cognitive loss and prior homelessness as evidence by going into other rooms, washing his clothes in the sink and toilet and throwing food and tray and other items on the floor. Interventions: staff to frequently monitor whereabouts throughout the facility, monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Intervene as necessary to protect the rights and safety of others. Review of Pre-admission Screening and Resident Review (PASRR), completed 7/14/2020 revealed Section I of the form indicated Resident #28 had two mental illnesses or suspected mental illnesses. Per Section II of the PASRR: A. there was an indication the individual had or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 6 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few individual development stage; B. the individual had or may have had serious difficulty interacting appropriately and communicating with other persons, had a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or had been dismissed from employment; had serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work life structured activities occurring in home or school settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors or requires assistance in the completion of these tasks; C. The individual had serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness or withdrawal from the situation or requires intervention by the mental health or judicial system. Based on the screening results, a Level II PASRR evaluation should have been completed prior to admission. Observations included: on 7/13/2021 at 2:40pm, the surveyor observed multiple plastic knives in the resident's room; observed resident to have plastic knives in his bed and also held in his hand wrapped in a cloth, resident murmured when asked about the knives, he stated: I also have a fork then displayed a plastic fork to the surveyor. On 7/14/2021 at 2:43pm, there were four (4) plastic knives observed on a side table in the resident's room. On 7/15/2021 at 10:39am, surveyor observed the resident out of bed sitting in a wheelchair watching TV in his room. A broken plastic knife was observed on the resident's bed side table behind him, and a hair brush with a metal fork tied to one end and a metal spoon tied to the other lying on the bed next to him within his reach. The resident was questioned about the object, and he turned and picked it up from the bed, held it in his hand then responded: This? Oh this is nothing and began talking about several packs of unopened adult briefs in his room. The surveyor attempted to redirect resident to further question him about the object. He responded: This is the good stuff. It's metal and went back to talking about the unopened briefs. The surveyor motioned the Director of Nursing (DON), who was in a room near by, to come into the resident's room. Upon entering, she immediately noticed the object in the resident's lap. She confirmed that he should not have it and attempted to retrieve it from the resident. He immediately refused. She continued to ask for it and motioned for the object but the resident blocked her hand. She offered to take the object and bring him another set of utensils, again he refused. She offered to take it to the kitchen to be washed, the resident responded: I've got a sink in there pointing to the restroom in his room. The DON and the surveyors exited the room after the DON could not successfully remove the item from the resident. During an interview on 7/15/2021 at 10:54am with Employee A, a Licensed Practical Nurse (LPN), she stated that she was familiar with the resident. She identified him as being independent, schizophrenic, with a grumpy attitude. She stated that he took his medications whole and liked to walk around the facility. She stated that he refuses his showers and can be verbally aggressive. She stated that he had behaviors, i.e. physical aggression angry, agitation, threat to himself others, mood changes, and refusals. During an interview on 7/15/2021 at 2:42pm with the DON, she stated that Resident #28 was ordered to receive plastic utensils as a result of an incident on 2/16/2021 where he stood in the hall demanding food with a metal fork in his hand threatening to hurt someone if no one gave him food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 7 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/15/2021 at 2:48pm with Employee B, a Certified Nursing Assistant (CNA), she stated that she was familiar with Resident #28, that he doesn't like people in his room and rejects all care. She stated that she was fearful of the resident. On 7/16/2021 at 9:00am, the survey team was advised that Resident #28 had been [NAME] Acted on 7/15/2021 and was no longer in the facility. On 7/16/2021 at 4:11pm, when asked about the PASRR's, the Administrator stated that Director of Social Services is responsible for the PASRR's. On 7/16/2021 at 4:22pm, the DON advised the survey team that Director of Social Services does not review the PASRR's. She stated that since she's been with the facility, she had been reviewing them. When asked why no Level II was done based on the 7/14/20, she could not answer why it was not done. She stated that she would have to look into it. On 7/16/2021 at 4:38pm, the DON returned to the conference room and stated that she was waiting on a response from Kepro regarding the PASRR for Resident #28. On 7/16/2021 at 5:11pm, the DON returned with a PASRR dated for 7/16/2021. Signed electronically by Employee F, Registered Nurse (RN) as the screener. Section II had been changed to reflect no for all of the questions. The DON was questioned about this new PASRR and the changes. She stated that she was not able to contact Kepro. She stated that Employee F does not work in the facility. She works for the corporate office as a Regional DON. She was asked how the staff screened the resident if she nor he were in the building. She stated that she just updated the information. She was shown where the new documentation was altered and she stated that she would need to ask about this. On 7/16/2021 at 5:17pm, the DON returned with Employee G, Regional Nurse Consultant (RNC). She stated that she had knowledge of the PASRR process. She confirmed that the PASRR was updated by Employee, F, who she referred to as a Regional DON with the company. She confirmed that the staff was not present in the facility. She stated that the DON advised her that the survey team requested an updated PASRR. She was advised by the survey team that this information was not correct. As the surveyor was attempting to explain the question that was asked, the DON responded, they needed to know why the Level II wasn't done. She confirmed that the Level II was not done. She was asked how was the screening done on 7/16/2021 if the resident nor the screener were present. She stated that the information was just verified and updated for today. She was shown both of the documents and asked why/how they were altered. Initially she stated that the new document wasn't altered. When she was shown the variances in the documents, she agreed that the new form had been changed and she stated that she could not confirm why this was done. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 8 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement safety interventions per the comprehensive plan of care for 4 of 4 residents (Residents #67, #192, #28, and #22) reviewed for development and implementation of comprehensive care plans. The findings include: Record review revealed that Resident #28 was admitted into the facility on [DATE] with the last re-admission on [DATE]. His diagnoses included Unspecified Dementia without Behavioral Disturbance; Major Depressive Disorder; Other Psychotic Disorder not due to a Substance or known physiological Condition; Heart Failure, Chronic Kidney Disease, Stage 2 (Mild); Repeated Falls Orders included Psychiatrist Evaluation and Treatment; Behavior Evaluation; Hospice for palliative care; Furosemide 20 mg by mouth daily; Trazodone HCL 50 mg by mouth three times a day; Acetaminophen 325 mg 2 tablets daily twice a day and Seroquel 50 mg by mouth three times a day. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status score of 7 out of 15. He had little interest or pleasure in doing things 12-14 days, trouble falling or staying asleep 12-14 days, and felt tired or had little energy 12-14 days. Verbal behavioral symptoms directed towards others occurred 1 to 3 days, and rejections of care occurred daily. He was independent in most activities of daily living; however, he required supervision with locomotion on and off the unit. Review of the most recent Care Plan revealed: Focus: Resident has potential to be physically aggressive related to dementia, anger, and prior homelessness. Interventions: communication, consult psych, larger name on door to identify his room, notify Hospice of any change in condition, notify MD of any change in condition, provide plastic utensils with each meal for safety measures. Focus: Psychotropic drug use. Interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness, Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly, Monitor/ document/ report as needed any adverse reactions of psychotropic medications. Focus: Behavioral problems related to cognitive loss and prior homelessness as evidenced by going into other rooms, washing his clothes in the sink and toilet, and throwing food and tray and other items on the floor. Interventions: staff to frequently monitor whereabouts throughout the facility, monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Intervene as necessary to protect the rights and safety of others. Review of Pre-admission Screening and Resident Review (PASRR), completed 7/14/2020 revealed Section I of the form indicated Resident #28 had two mental illnesses or suspected mental illnesses. Per Section II of the PASRR: A. there was an indication the individual had or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual development stage; B. the individual had or may have had serious difficulty interacting appropriately and communicating with other persons, had a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or had been dismissed from employment; had serious difficulty in sustaining focused attention for a long enough period (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 9 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to permit the completion of tasks commonly found in work settings or in work life structured activities occurring in home or school settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors or requires assistance in the completion of these tasks; C. The individual had serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness or withdrawal from the situation or requires intervention by the mental health or judicial system. Based on the screening results, a Level II PASRR evaluation should have been completed prior to admission. Observations included: on 7/13/2021 at 2:40pm, the surveyor observed multiple plastic knives in the resident's room; observed resident to have plastic knives in his bed and also held in his hand wrapped in a cloth; resident murmured when asked about the knives, he stated: I also have a fork then displayed a plastic fork to the surveyor. On 7/14/2021 at 2:43pm, there were 4 plastic knives observed on a side table in the resident's room. On 7/15/2021 at 10:39am, the resident was observed out of bed sitting in a wheelchair watching TV in his room. A broken plastic knife was observed on the resident's bed side table behind him, and a hair brush with a metal fork tied to one end and a metal spoon tied to the other lying on the bed next to him within his reach. The resident was questioned about the object, and he turned and picked it up from the bed, held it in his hand, then responded: This? Oh this is nothing and began talking about several packs of unopened adult briefs in his room. The surveyor attempted to redirect resident to further question him about the object. He responded: This is the good stuff. It's metal, and went back to talking about the unopened briefs. The surveyor motioned the Director of Nursing (DON), who was in a room nearby, to come into the resident's room. Upon entering, she immediately noticed the object in the resident's lap. She confirmed that he should not have it and attempted to retrieve it from the resident. He immediately refused. She continued to ask for it and motioned for the object but the resident blocked her hand. She offered to take the object and bring him another set of utensils, and again he refused. She offered to take it to the kitchen to be washed, but the resident responded: I've got a sink in there pointing to the restroom in his room. The DON and the surveyors exited the room after the DON could not successfully remove the item from the resident. During an interview on 7/15/2021 at 10:54am with Employee A, a Licensed Practical Nurse (LPN), she stated that she was familiar with the resident. She identified him as being independent, schizophrenic, with a grumpy attitude. She stated that he took his medications whole and liked to walk around the facility. She stated that he refuses his showers and can be verbally aggressive. She stated that he had behaviors, i.e. physical aggression angry, agitation, threat to himself others, mood changes, and refusals. During an interview on 7/15/2021 at 11:10am with Employee J, LPN, she confirmed that Resident #28 was Care Planned for disposable cutlery with all meals. She did not the advise the surveyor when or why this was done. During an interview on 7/15/2021 at 11:46am, the DON confirmed that the facility did not have a policy on sharps and/or accident hazards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 10 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/15/2021 at 2:42pm with the DON, she stated that Resident #28 was ordered to receive plastic utensils as a result of an incident on 2/16/2021 where he stood in the hall demanding food with a metal fork in his hand threatening to hurt someone if no one gave him food. During an interview on 7/15/2021 at 2:48pm with Employee B, a Certified Nursing Assistant (CNA), she stated that she was familiar with Resident #28, that he doesn't like people in his room, and rejects all care. She stated that she was fearful of the resident. She stated that she saw the resident earlier on the day of the interview scraping the floor with a metal spoon. She stated that asked him for it but he refused, and that she did not attempt to approach him nor did she report the incident to anyone. During an interview on 7/15/2021 at 3:00pm with Employee C, CNA, she stated that Resident #28 often refuses care and doesn't like staff in his room at all. She stated that she also saw him scraping the floor with the metal spoon on the morning of the interview. She stated that she attempted to get it from him but he refused. She stated everyone knows how he is. On 07/15/21 04:40 PM, Employee H, a Nursing Supervisor advised the survey team that she was shoved by Resident #28 during an attempt to diffuse a situation between him and another resident. On 7/16/2021 at 9:00am, the survey team was advised that Resident #28 had been [NAME] Acted on 7/15/2021 and was no longer in the facility. During an interview on 7/16/2021 at 6:30pm with Employee I, CNA, she stated that she has brought the resident's meal tray several times. She denied knowledge of any special instructions. After multiple prompts, she stated that she was unaware if he received silver or plastic utensils. She stated that the kitchen puts the utensils on the tray. Resident #22 Accidents Review of the medical record for Resident #22 revealed an admission date of 2/15/21. His primary medical diagnosis was heart disease. Secondary diagnoses included diabetes and failure to thrive. A five day MDS assessment with an ARD of 3/27/21 indicated a BIMS of 14. The resident required extensive assistance with activities of daily living. On 07/14/21 at 01:59 PM, Resident #22 was observed sitting in his wheelchair on the smoking patio. Four other residents were on the patio. On 07/14/21 at 02:05 PM, an employee assisted Resident #22 to light a cigarette. The resident was not wearing a smoking apron. Smoking Assessment (Photographic Evidence Obtained) Care Plan (Photographic Evidence Obtained) On 07/16/21 at 12:16 PM during an interview with the Director of Nursing, she was asked about the facility's smoking processes. She confirmed that an assessment is conducted for each resident that smokes, and that the assessment findings are then used to develop interventions for the care plan. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 11 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON confirmed that if a resident is assessed as requiring the use of a smoking apron, the intervention should be reflected on the care plan. The DON was not aware that the employees responsible for supervision of smoking did not have access to each resident's safety interventions. On 07/14/21 at 11:40 AM, Resident #22 was observed sitting in his wheelchair on the smoking patio holding a lit cigarette in his right hand. There were no staff members on the patio. On 07/14/21 at 12:23 PM, the Director of Nursing reported that the residents were keeping their cigarettes from the morning time. Resident #33 Comm-Sensory Review of the medical record for Resident #33 revealed an admission date of 10/9/20. The primary medical diagnosis was sepsis. Secondary diagnoses included cataracts and diabetes. A quarterly MDS assessment with an ARD date of 4/16/21 indicated a BIMS of 15. Resident #33 required extensive assistance with most activities of daily living. The assessment indicated the resident's vision was impaired and that she wore corrective lenses. No vision consults or notes. No vision care plans. 07/14/21 at 11:25 AM - Resident #33 observed lying in bed. 07/14/21 at 01:54 PM - Resident #33 observed lying in bed. 07/15/21 at 10:45 AM - An interview was conducted with the resident's assigned nurse. 07/15/21 at 11:07 AM - Resident #33 observed lying in bed. 07/13/21 at 10:45 - An interview was conducted with Resident #33. She was wearing a pair of glasses that she explained were reading glasses. She stated she doesn't attend activities because she can't see the activity calendar. She explained that she hadn't seen an eye doctor since sometime last year and that she normally wore glasses but didn't have any. A review of the comprehensive care plans revealed no focus areas for vision impairment. Continued review of the medical record revealed no vision consults or notes. CNA Interview Nurse Interview SSD Interview Policy - Vision Consults/Care 07/14/21 at 10:37 AM An interview was conducted with the Activities Director regarding Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 12 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #33. She confirmed that she was familiar with the resident. She explained that Resident #33 likes to attend nail painting, but that she does not ever attend bingo. The Activities Director explained that the resident had never voiced any complaints about not being able to read the activities calendar. 07/14/21 at 10:44 AM - An interview was conducted with the Social Service Director. She explained that she has been employed in the facility since the first part of April, 2021. She stated, Eye care is non-existent. Since I've been here, they have not been in for eye care. Corporate is trying to secure local providers for eye care. All of the long term care residents need to be seen. Resident #67 Accidents Review of the medical record for Resident #67 revealed an admission date of 11/13/20. The primary diagnosis was HIV. Secondary diagnoses included cerebral infarction and hemiparesis affecting right dominant side. A quarterly MDS assessment with an ARD of 5/23/21 indicated a BIMS of 15. Resident #67 required extensive assistance with most activities of daily living. 07/14/21 at 11:32 AM - Resident #67 was observed in her wheelchair propelling herself in the hallway. 07/14/21 at 02:01 PM - Resident #67 approached surveyor near the smoking patio and asked whether it was 2 o'clock. She stated, now you see what we're talking about. She was referencing the fact that the facility's posted smoking times indicate 2:00 PM, but no staff members were present to supervise the smoking process. 07/14/21 at 02:03 PM - The Unit Manager entered the vending area to purchase a soda. She looked outside toward the smoking patio and stated, They are getting on my nerves with this smoking. 07/14/21 at 02:05 PM - An employee exited through the vending area to the smoking patio and assisted each resident in lighting a cigarette. A smoking safety acknowledgement signed by the resident and dated 11/13/20 indicated, it is the facility policy that smoking be directly supervised by a staff member. This is to protect both the individual smoking and the entire resident population and staff. (Photographic Evidence Obtained) The most recent smoking assessment ___ (Photographic Evidence Obtained) The comprehensive care plans were reviewed. A focus area was noted for smoking. (Photographic Evidence Obtained) The facility's smoking policy, titled Citadel Safe Smoking Policy & Procedure, was reviewed. Th policy indicated Residents who smoke are to smoke with direct staff monitoring. Interview with the DON revealed the facility's therapy department does not conduct smoking safety evaluations. 07/13/21 at 12:45 PM - An interview was conducted with Resident #67 on the smoking patio. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 13 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few explained that she tries to adhere to the facility smoking times, but that the staff member assigned to assist residents with smoking is usually 25-35 minutes late. 07/14/21 at 11:42 AM - An interview was conducted with Resident #67 on the smoking patio. Seven residents, including Resident #67, were observed on the patio. Resident #67 was holding a cigarette which she extinguished in the ashtray as soon as she noticed the surveyor was coming. Resident #192 Accidents Review of the medical record for Resident #192 revealed an admission date of 3/10/21. Her primary diagnosis was osteoarthritis. Secondary diagnoses included legal blindness and seizures. A quarterly MDS assessment with an ARD of 6/17/21 indicated a BIMS of 15. Resident #192 required extensive to total assistance with most activities of daily living. 07/14/21 at 01:58 PM - Resident #192 was observed sitting on the smoking patio in her wheelchair. Her eyes were closed. Music was playing on her phone. 07/14/21 at 02:05 PM - Resident #192 was assisted to light a cigarette by Employee. She was not wearing a smoking apron. Smoking Safety Education and Acknowledgement (Photographic Evidence Obtained) Smoking Assessment (Photographic Evidence Obtained) Care Plan (Photographic Evidence Obtained) 07/16/21 10:57 AM . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 14 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Assigned to [NAME] Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained free of accident hazards as is possible, and each resident received adequate supervision and assistance devices to prevent accidents for 4 of 43 residents sampled, Residents #22, #28, #67 and #192. The findings include: Record review revealed that Resident #28 was admitted into the facility on [DATE], with the last re-admission on [DATE]. The diagnoses included Unspecified Dementia without Behavioral Disturbance, Major Depressive Disorder, Other Psychotic Disorder not due to a Substance or known physiological Condition, Heart Failure, Chronic Kidney Disease, Stage 2 (Mild), and Repeated Falls Orders included Psychiatrist Evaluation and treatment; Behavior Evaluation; Hospice for palliative care; Furosemide 20 mg by mouth daily; Trazodone HCL 50 mg by mouth three times a day; Acetaminophen 325 mg 2 tablets daily twice a day; and Seroquel 50 mg by mouth three times a day. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status score of 7 out of 15. He had little interest or pleasure in doing things 12-14 days, trouble falling or staying asleep 12-14 days, and felt tired or had little energy 12-14 days. Verbal behavioral symptoms directed towards others occurred 1 to 3 days, and rejections of care occurred daily. He was independent in most activities of daily living; however, he required supervision with locomotion on and off the unit. Review of the most recent Care Plan revealed: Focus: Resident has potential to be physically aggressive related to dementia, anger, and prior homelessness. Interventions: communication, consult psych, larger name on door to identify his room, notify Hospice of any change in condition, notify MD of any change in condition, provide plastic utensils with each meal for safety measures. Focus: Psychotropic drug use. Interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness, Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly, Monitor/ document/ report as needed any adverse reactions of psychotropic medications. Focus: Behavioral problems related to cognitive loss and prior homelessness as evidence by going into other rooms, washing his clothes in the sink and toilet, and throwing food and tray and other items on the floor. Interventions: staff to frequently monitor whereabouts throughout the facility, monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Intervene as necessary to protect the rights and safety of others. Review of Pre-admission Screening and Resident Review (PASRR), completed 7/14/2020 revealed Section I of the form indicated Resident #28 had two mental illnesses or suspected mental illnesses. Per Section II of the PASRR: A. there was an indication the individual had or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual development stage; B. the individual had or may have had serious difficulty interacting appropriately and communicating with other persons, had a possible history of altercations, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 15 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or had been dismissed from employment; had serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work life structured activities occurring in home or school settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors or requires assistance in the completion of these tasks; C. The individual had serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness or withdrawal from the situation or requires intervention by the mental health or judicial system. Based on the screening results, a Level II PASRR evaluation should have been completed prior to admission. Observations included: on 7/13/2021 at 2:40pm, the surveyor observed multiple plastic knives in the resident's room; observed resident to have plastic knives in his bed and also held in his hand wrapped in a cloth; resident murmured when asked about the knives, he stated: I also have a fork, then displayed a plastic fork to the surveyor. On 7/14/2021 at 2:43pm, there were 4 plastic knives observed on a side table in the resident's room. On 7/15/2021 at 10:39am, the resident was observed out of bed sitting in a wheelchair watching TV in his room. A broken plastic knife was observed on the resident's bed side table behind him, and a hair brush with a metal fork tied to one end and a metal spoon tied to the other lying on the bed next to him within his reach. The resident was questioned about the object, he turned and picked it up from the bed, held it in his hand, then responded: This? Oh this is nothing, and began talking about several packs of unopened adult briefs in his room. The surveyor attempted to redirect resident to further question him about the object. He responded: This is the good stuff. It's metal and went back to talking about the unopened briefs. The surveyor motioned the Director of Nursing (DON), who was in a room nearby, to come into the resident's room. Upon entering, she immediately noticed the object in the resident's lap. She confirmed that he should not have it and attempted to retrieve it from the resident. He immediately refused. She continued to ask for it and motioned for the object, but the resident blocked her hand. She offered to take the object and bring him another set of utensils, and again he refused. She offered to take it to the kitchen to be washed, but the resident responded: I've got a sink in there pointing to the restroom in his room. The DON and the surveyors exited the room after the DON could not successfully remove the item from the resident. During an interview on 7/15/2021 at 10:54am with Employee A, a Licensed Practical Nurse (LPN), she stated that she was familiar with the resident. She identified him as being independent, schizophrenic, with a grumpy attitude. She stated that he took his medications whole and and liked to walk around the facility. She stated that he refuses his showers and can be verbally aggressive. She stated that he had behaviors, i.e. physical aggression angry, agitation, threat to himself others, mood changes, and refusals. During an interview on 7/15/2021 at 11:10am with Employee L, LPN Care, she confirmed that Resident #28 was Care Planned for disposable cutlery with all meals. During an interview on 7/15/2021 at 11:46am, the DON confirmed that the facility did not have a policy on sharps and/or accident hazards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 16 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 7/15/2021 at 2:42pm with the DON, she stated that Resident #28 was ordered to receive plastic utensils as a result of an incident on 2/16/2021 where he stood in the hall demanding food with a metal fork in his hand threatening to hurt someone if no one gave him food. During an interview on 7/15/2021 at 2:48pm with Employee B, a certified nursing assistant (CNA), she stated that she was familiar with Resident #28, that he doesn't like people in his room, and rejects all care. She stated that she was fearful of the resident. She stated that she saw the resident earlier on the day of the interview scraping the floor with a metal spoon. She stated that asked him for it but he refused, and that she did not attempt to approach him nor did she report the incident to anyone. During an interview on 7/15/2021 at 3:00pm with Employee C, CNA, she stated that Resident #28 often refuses care and doesn't like staff in his room at all. She stated that she also saw him scraping the floor with the metal spoon on the morning of the interview. She stated that she attempted to get it from him but he refused. She stated, everyone knows how he is. On 7/16/2021 at 9:00am, the survey team was advised that Resident #28 had been [NAME] Acted on 7/15/2021 and was no longer in the facility. During an interview on 7/16/2021 6:30pm with Employee H, CNA, she stated that she has brought the resident's meal tray several times. She denied knowledge of any special instructions. After multiple prompts, she stated that she was unaware if he received silver or plastic utensils. She stated that the kitchen puts the utensils on the tray. Based on observations, interviews, and record reviews, the facility failed to: (A) Assess resident behaviors that precluded potential harm and failed to intervene appropriately for one of one residents reviewed for behaviors (Resident #28). (B) Appropriately supervise residents who smoke for three of three residents reviewed for smoking (Resident #22, Resident #67, and Resident #192). On 7/12/21, the facility's census was 89. All 89 residents were at risk for serious injury, serious harm, impairment, or death as a result of the deficient practice. Immediate Jeopardy (IJ) at a scope and severity of (J) isolated began on January 13, 2021, and was identified on July 15, 2021 at 1:30 PM, which was on-going. On July 15, 2021 at 8:45 PM, the Administrator was notified of the IJ determination. The findings include: Cross Reference to F607, F726, and F867 A. A review of the medical record for Resident #28 revealed an admission date of 11/11/18. Medical diagnoses included major depressive disorder, dementia, and psychotic disorder. He received hospice services for a diagnosis of cerebral atherosclerosis. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. The assessment also revealed the presence of verbal behavioral symptoms directed toward others, and that the resident was independently ambulatory. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 17 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety An abuse report dated 2/18/21 at 7:30 PM revealed Resident #28 entered the room of another resident and struck the resident on his legs and face. Following the incident, the victim was found with facial injuries. (Photographic Evidence Obtained) On 7/13/21 at 2:35 PM, surveyor was preparing to enter Resident #28's room. Resident #67 approached the surveyor in the hallway and stated, be careful because he is aggressive. Residents Affected - Few On 7/13/21 at 2:40 PM, multiple plastic knives were observed lying on the resident's bed. The resident was also holding one knife in his hand which was wrapped in a cloth. When asked about the knives, the resident stated, I also have a fork. He then displayed the plastic fork. On 7/14/21 at 2:43 PM, there were four plastic knives observed on a bedside table in the resident's room. On 7/15/21 at 10:39 AM, Resident #28 was observed in his room sitting in a wheelchair. A broken plastic knife was observed on the resident's bedside table. A hairbrush was observed on his bed which had a metal fork tied to one end and a metal spoon tied to the other end. The item was within the resident's reach. When asked about the object, the resident picked it up, held it in his hand, and stated, This? Oh, this is nothing. Upon further questioning, Resident #28 stated, This is the good stuff. It's metal. The Director of Nursing (DON) was in a room nearby and was motioned to come into the resident's room. Upon entering the room, she noticed the item in the resident's lap. She confirmed that the resident shouldn't have had the item and attempted to retrieve it. The resident immediately refused. The DON asked the resident for the item again and offered to bring him another set of utensils, but the resident refused. The DON then offered to take the item to the kitchen to have it washed. The resident refused and stated, I've got a sink in there while pointing to his restroom. The DON exited the room after being unsuccessful in removing the item. During an interview with Employee A, Licensed Practical Nurse (LPN) on 7/15/21 at 10:54 AM, the nurse explained that she was familiar with the resident. She identified him as being independent, schizophrenic, and with a grumpy attitude. She explained that he liked to walk around the facility and that he could be verbally aggressive. She further explained that he had a history of behaviors such as physical aggression, anger, agitation, and being a threat to himself or others. During an interview with the DON on 7/15/21 at 2:42 PM, she explained that Resident #28 was ordered to have plastic utensils as a result of an incident on 2/16/21 where he stood in the hall with a metal fork threatening to hurt someone if they didn't give him food. Review of the nursing progress notes revealed an entry dated 1/13/21 at 1:08 AM which indicated the resident threatened to kill someone if they don't get me some food. The note also indicated the resident overturned the meal tray cart and grabbed the left arm of a nurse and an arm of a CNA. Hospice was notified and, while waiting for Hospice to arrive, the resident exited the room several times threatening to kill people. Continued review of the nursing progress notes revealed an entry dated 2/16/21 at 1:57 AM which indicated the resident came out of his room yelling and screaming. He had a fork and a knife from the kitchen in his pocket. When an employee attempted to redirect him, the resident started yelling that he was not in prison and that he wanted food. The resident then began cursing and yelling that if the employee didn't get him some food, he was going to hurt someone. Continued review of the medical record revealed that ten days after the incident on 2/16/21, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 18 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident's care plan was updated to reflect an intervention which read, provide plastic utensils at each meal for safety measures. During an interview with Employee M, Nursing Supervisor on 7/15/21 at 4:32 PM, she explained that Resident #28 had an incident with another resident and that while she was trying to intervene, the resident shoved her. She described the resident as cycling and explained that he often refused his medications. She stated, I think everybody is fearful because he is a big guy and he has informed everybody that he used to be a bouncer. When he has gotten aggressive, it's just bad. His triggers aren't consistent. There have been staff members that have advised me that they are afraid of him. She added, The facility does need to look for more suitable surroundings for him. An interview was conducted with the Administrator on 7/15/21 at 1:45 PM. The Administrator was asked about the incident on 2/18/21 where Resident #28 struck another resident, causing injury. He explained that Resident #28 did hit the resident in the face and stated the report should have been substantiated. The Administrator was then asked what the facility's plan was for managing Resident #28's ongoing behavior and the weapon. He stated, No one was aware until about 15 minutes ago and that the facility was going to provide closer monitoring. He explained that the facility would check for metal cutlery each time staff went into the room and check the room before and after meals. During an interview with Employee A, LPN on 7/15/21 at 2:44 PM, she explained that the resident had a habit of taking utensils off the meal carts and that he walks around and takes things. She stated that staff would attempt to remove the silverware from his possession but that if the resident became anxious or aggressive, staff would just leave him alone. During an interview with Employee B, Certified Nursing Assistant (CNA) on 7/15/21 at 2:48 PM, she explained that she was familiar with Resident #28. She explained that the resident didn't like people in his room and that he rejected care. She stated she was fearful of the resident. When asked whether she had reported her concern to anyone, she stated, They know. I heard stories about him when I got here. She also stated she observed the resident earlier in the day scraping the floor with a metal spoon. She explained that she asked him for the spoon, but he refused. She further explained that she did not attempt to approach the resident or report the incident to anyone. During an interview with the dietitian on 7/15/21 at 2:49 PM, she explained that she had heard in the morning meeting that the resident was removing utensils from the meal carts. She also stated she heard that the resident was chasing a staff member with a fork. She was not able to recall an approximately date of occurrence. During a follow up interview with the dietitian via phone on 7/16/21 at 1:30 PM, she again explained that she recalled discussing the incident in the morning meeting and that she recommended the resident be offered plastic utensils. During an interview with Employee C, CNA on 7/15/21 at 3:00 PM, she explained that Resident #28 often refuses care and that he didn't like staff in his room at all. She stated she had observed the resident earlier in the day scraping the floor with a metal spoon. She stated she attempted to retrieve the item from the resident but that he refused and became aggressive. When asked whether she had reported the incident to anyone, she stated, everyone knows how he is. During an interview with the Hospice Nurse on 7/15/21 at 3:00 PM, she explained that the resident has always been aggressive, irritable, and hard to manage. She explained that Hospice had prescribed a cream to reduce the resident's anxiety and behaviors, but that the primary care provider discontinued it. She added that she was unable to complete a visit with the resident on 7/15/21 because the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 19 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 resident was violent and repeatedly stated the robbers were coming. Level of Harm - Immediate jeopardy to resident health or safety Review of a psychology therapy assessment, dated 1/27/21 revealed descriptions of the resident's mood being angry/hostile and irritable. The assessment and recommendations section read, He states that he does not trust anyone, and he has bound his eating utensils in the form of a weapon. Explore whether he may benefit from brief inpatient psychiatric admission where he can be monitored in a more secure setting. Review of the medical record revealed no evidence that this was done. Residents Affected - Few Review of a Medication Management Assessment, dated 4/1/21 by the psychiatric Advanced Practice Registered Nurse (APRN) revealed Resident #28 had become combative and aggressive toward residents and staff. The assessment identified the resident as confused but with a concrete thought process. It also identified the resident as a current potential threat to himself or others, and indicated the DON had been notified of the threat. The assessment revealed recommendations that the resident would be better suited for a memory care unit. (Photographic Evidence Obtained) Review of a Medication Management assessment dated [DATE] by the psychiatric APRN indicated the resident continued with aggressive behaviors, and again indicated he would be better suited for a memory care unit. The assessment identified the resident as a potential threat to himself or others, and that the threat was communicated to a facility staff member. (Photographic Evidence Obtained) An interview was conducted with the Social Services Director on 7/15/21 at 3:50 PM regarding the psychiatric provider notes, dated 4/1/21 and 4/28/21 recommending the resident be transferred to a memory care unit. She explained that she was not aware of the recommendations because she started working at the facility around the same time the recommendations were made. She confirmed that there had been no attempts by the facility to transfer the resident to a memory care unit. During an interview with Employee A, LPN on 7/16/21 at 1:38 PM, she was asked who was responsible for reviewing provider notes such as the ones from psychiatric providers. She stated, That is above my pay grade. I guess the Nurse Managers. Review of a psychiatry note dated 7/14/21 revealed the resident was very irritable and angry. (Photographic Evidence Obtained) Review of a psychiatry note dated 7/15/21 revealed the resident was assessed due to being unstable. The report indicated there was a significant history of agitation and making threats to harm others, and that the resident was found to be making a sharp weapon to harm others. The report further indicated that staff were feeling afraid of Resident #28, that he presented an acute threat to harm others, and that he lacked insight. The assessment indicated the resident appeared to be unstable and the physician felt the symptoms were occurring due to exacerbation of underlying depressive and mood disorder. The physician ordered transfer via [NAME] Act on 7/15/21. (Photographic Evidence Obtained) On 7/16/21 at 12:48 PM, a telephone interview was conducted with APRN #1. He stated he was familiar with Resident #28, and had cared for the resident for about two years. The APRN explained that the resident was a wanderer, but was cooperative with care when he started providing care for the resident. He further explained that around February 2021, the resident started to be aggressive and violent. The APRN added that the resident was not benefiting from psychological behavioral therapy as he was not cooperative. Therefore, the APRN made the recommendation for memory care for more supervision. When asked whether the resident was a threat to himself or others, the APRN stated he had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 20 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few notified of a situation where Resident #28 had threatened a staff member with a fork, and that he had an altercation with another resident. At that time, the APRN recommended the facility [NAME] Act the resident, but that was not done. He also mentioned that upon making recommendations, the progress notes are available immediately in the resident's record and that the nurse on duty is notified. During an interview with the DON on 7/16/21 at 2:37 PM, she explained that she had recently started working at the facility and that, in that time, no one had reported any aggressive behaviors to her. She explained that the CNAs had the ability to report any behaviors in the electronic kiosk, and that the expectation would be to notify the nurse immediately as well. During an interview with the Administrator and DON on 7/16/21 at 3:37 PM, both parties acknowledged that they were unaware of the resident's behaviors or his care plan interventions to receive plastic utensils. Both parties confirmed that they were not aware of any monitoring in place by facility administration to ensure Resident #28 did not obtain silverware. Regarding psychiatric notes, the Administrator explained that each provider note is reviewed in the stand-up meeting. However, the DON intervened and stated not all notes were reviewed in morning meetings because some providers upload them directly to the system while other providers hand write them. The DON acknowledged the nursing leadership team was responsible for reviewing the notes and that a system needed to be developed to ensure they were being reviewed. Both the DON and Administrator denied being aware of recommendations to transfer Resident #28 to a memory care unit. B. Review of the medical record for Resident #22 revealed an admission date of 2/15/21. His medical diagnoses included heart disease, diabetes, and failure to thrive. A five day MDS dated [DATE] indicated a BIMS of 14. The resident required extensive assistance with activities of daily living and was a smoker. Review of the medical record for Resident #67 revealed an admission date of 11/13/20. Her medical diagnoses included included cerebral infarction and hemiparesis affecting right dominant side. A quarterly MDS assessment dated [DATE] indicated a BIMS of 15. Resident #67 required extensive assistance with most activities of daily living and was a smoker. Review of the medical record for Resident #192 revealed an admission date of 3/10/21. Her medical diagnoses included osteoarthritis, legal blindness, and seizures. A quarterly MDS assessment dated [DATE] indicated a BIMS of 15. Resident #192 required extensive to total assistance with most activities of daily living and was a smoker. 07/13/21 at 12:45 PM - An interview was conducted with Resident #67 on the smoking patio. She explained that she tries to adhere to the facility smoking times, but that the staff member assigned to assist residents with smoking is usually 25-35 minutes late. On 7/14/21 at 11:40 AM, Resident #22 was observed sitting in his wheelchair on the smoking patio holding a lit cigarette in his right hand. Resident #67 was sitting in her wheelchair and was holding a lit cigarette. Resident #192 was sitting in her wheelchair and was holding a lit cigarette. No staff members were present on the patio. The Director of Nursing was notified immediately. On 7/14/21 at 12:23 PM, an interview was conducted with the Director of Nursing. She explained that all residents are required to be supervised while smoking, and explained that the residents who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 21 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 were discovered smoking independently must have kept cigarettes from the morning. Level of Harm - Immediate jeopardy to resident health or safety Continued record review for Resident #67 revealed a smoking assessment dated [DATE]. The assessment identified the resident as a smoker and indicated the resident should use a smoking apron while smoking. (Photographic Evidence Obtained) Residents Affected - Few A review of the comprehensive care plans for Resident #67 revealed a focus area for smoking. The care plan identified the resident's goal as the resident will not smoke without supervision through the review date. An intervention read, The resident requires supervision while smoking. (Photographic Evidence Obtained) Continued record review for Resident #22 revealed a smoking assessment dated [DATE]. The assessment identified the resident as a smoker and indicated the resident should use a smoking apron while smoking. (Photographic Evidence Obtained) A review of the comprehensive care plans for Resident #22 revealed a focus area for smoking. The care plan identified the resident's goal as The resident will be free from injury related to smoking. Interventions included close monitoring while smoking in the smoking area. (Photographic Evidence Obtained) Continued record review for Resident #192 revealed a smoking assessment dated [DATE]. The assessment identified the resident as a smoker and indicated the resident should use a smoking apron while smoking. (Photographic Evidence Obtained) A review of the comprehensive care plans for Resident #192 revealed a focus area for smoking. The care plan directed staff to supervise the resident during smoking activities, assure the resident could safely reach the ashtray, and assist the resident in making sure cigarettes were fully extinguished each time to avoid burns. (Photographic Evidence Obtained) On 7/14/21 at 2:01 PM, Resident #67 approached the surveyor near the smoking patio exit door and stated, Now you see what we are talking about. They are never on time. That's why we smoke on our own. On 7/14/21 at 2:03 PM, Employee K, LPN - Unit Manager entered the vending area near the smoking patio exit door. She looked outside at the smoking patio and stated, They are getting on my nerves with this smoking. On 7/14/21 at 2:05 PM, an employee entered the smoking patio area and assisted Residents #22, #67, and #192 with lighting their cigarettes. Resident #22 and Resident #67 were not wearing smoking aprons. During an interview with the Director of Nursing on 7/16/21 at 12:16 PM, she was asked about the facility's smoking processes. She confirmed that an assessment is conducted for each resident that smokes and that the assessment findings are then used to develop interventions for the care plan. The DON confirmed that if a resident is assessed as requiring the use of a smoking apron, the intervention should be reflected on the care plan. The DON was not aware that the employees responsible for supervision of smoking did not have access to each resident's safety interventions. The facility's smoking policy, titled Citadel Safe Smoking Policy & Procedure, was reviewed. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 22 of 23 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 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221 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 0689 Level of Harm - Immediate jeopardy to resident health or safety policy indicated Residents who smoke are to smoke with direct staff monitoring. (Photographic Evidence Obtained) . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 23 of 23