Health inspection·February 16, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/16/23 at 1:43 PM, Licensed Practical Nurse (LPN) C confirmed that Resident #28's room had no curtains. She stated she would notify housekeeping to put one up. In an interview with the Administrator on 2/16/23 at 2:00 PM, she stated her expectation was that staff should provide privacy at all times while providing care, by closing the door and pulling the privacy curtains including the window curtains. She stated a curtain would be put up as soon as possible. A review of the facility's policy and procedure titled Quality of Life/Dignity (revised February 2020), revealed that each resident would be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. The policy interpretation and implementation indicated that staff would promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to 1) Provide appropriate treatment and services for residents who were dependent on staff for activities of daily living (ADLs), and 2) Ensure that a resident's activities of daily living abilities did not diminish for one (Resident #39) of three residents reviewed for activities of daily living, from a total sample of 37 residents. Residents Affected - Few The findings include: On 2/13/23 at 2:36 PM, Resident #39 was observed lying in bed with right-sided weakness. His facial hair was long and his call bell was on the floor. (Photographic evidence obtained) In an interview on 2/13/23 at 2:37 PM, Resident #39 stated he would prefer to have his beard shaved. He said he had notified staff a number of times that he would like his beard shaved. He stated he never had a long beard. When asked how he summoned staff for assistance, he stated he used his call bell, and he started looking around for the call bell. On 2/15/23 at 9:42 AM, Resident #39 was observed lying in bed with his eyes closed. His call light was on the floor. (Photographic evidence obtained) On 12/16/22 at 12:00 PM, the resident's call light was observed clipped to the top of the bed on the right side (resident's weak side). Resident #39 stated there was water on the floor. When asked if he had called for help to have the water cleaned up, he said he could not reach the call light. He tried to push himself using his left foot with no success. There were no side rails on the bed to use as mobility aids. In an interview with Certified Nursing Assistant (CNA) A on 02/16/23 at 12:45 PM, he stated he was assigned to Resident #39. He said he had worked with the resident since he was admitted and he never had a long beard. He stated residents were supposed to be shaved on their shower days. Resident #39's shower days were Tuesdays, Thursdays, and Saturdays during the 3-11 PM shift. When asked where the call light should be for Resident #39, the CNA said, on the left side by the window because it's his good side. He added that the resident was able to help with some ADLs and move in the bed, but he had declined since the bed rail was removed. CNA A confirmed that the resident could not reach his call light. He also demonstrated how the resident would adjust himself/move in the bed. He stated it had been about three months since the side rails were removed, and that he had notified the unit manager about resident's decline in ADL function. On 2/16/23 at 1:15 PM, CNA B stated her regular schedule was working the evening shift and Resident #39's room was part of her permanent assignment. When asked about shaving the resident's beard, she stated it was supposed to be done on his shower days. She confirmed that Resident 39's shower days were Tuesdays, Thursdays, and Saturdays in the evening. She also confirmed that the resident liked a clean shave. When asked if she shaved the resident on 2/14/23, she replied, I did not do it because [CNA A] has been doing it for all male residents. I'm not sure why he stopped doing it, because he used to do a good job and he has safer clippers. She stated she would make sure the resident was shaved in the evening. When asked about the resident's functional status, she stated the resident was totally dependent with care since his side rails were removed. She added that the side rails helped the resident with bed mobility and transfers. She stated it had been almost three months since they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0676 were removed from his bed. Level of Harm - Minimal harm or potential for actual harm A clinical record review revealed that Resident #39 was admitted to the facility on [DATE] with diagnoses including hemiplegia, unspecified affecting right dominant side, dementia, epilepsy, anxiety disorder and major depressive disorder. Residents Affected - Few A review of the annual Minimum Data Set (MDS) assessment, dated 1/20/23, revealed that resident's Brief Interview for Mental Status (BIMS) score was not obtained. He required supervision for bed mobility, transfers, personal hygiene and toilet use. A review of the care plan (12/5/22) rvealed a focus area for ADL/Self-Care Deficit related to decreased physical functioning, health status and use of medication, history of cerebral vascular accidents (CVA) with right hemiplegia. On 2/16/23 at 2:30 PM, the Director of Rehabilitation (DOR) was asked about the side rail assessment. She stated the therapy department in collaboration with nursing did the assessment to ensure that residents were appropriately fitted with the right rails. When asked whether Resident #39 was assessed for side rails, she said, As far as I know, [Resident #39] was approved for quarter side rails to assist with bed mobility because he had right-sided weakness. She provided the screening tool (conducted 7/25/22) indicating that the resident had quarter side rails. (Copy obtained) She stated she was not sure why the rails were removed. In an interview with the Director of Nursing (DON) on 2/16/23 at 3:00 PM, she stated the side rails were removed because a nursing assessment was not completed on time. She said one was completed on 1/15/23 indicating that the resident required side rails (Copy obtained), therefore, the rails should have been in place. A reviewed the facility's policy and procedure titled Activities of Daily Living (ADLs), Supporting (revised March 2018), revealed the following: The policy statement indicated that residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Further review of the policy interpretation and implementation revealed: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. The existence of a clinical diagnosis or condition does not alone justify a decline in resident's ability to perform ADL. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene, mobility etc. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0676 with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Level of Harm - Minimal harm or potential for actual harm 7. Residents' responses to interventions will be monitored, evaluated and revised as appropriate. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #14) of six residents receiving oxygen therapy, received the correct oxygen flow rate as ordered by the physician, from a total of 37 residents in the sample. Residents Affected - Few The findings include: During a tour of the facility on 2/13/2023 at 1:10 pm, Resident #14 was observed lying in bed watching television and wearing a nasal cannula. Her oxygen concentrator, located at the bedside, was set to deliver oxygen at 3.5 Liters per minute (L/min). A hospital bag attached to the oxygen concentrator was dated 1/26/2023 at 12:10 pm. (Photographic evidence obtained) A review of Resident #14's physician's order, dated 12/05/2022, revealed she was to receive oxygen at 4 L/min continuously via nasal cannula for shortness of breath (SOB). On 2/16/2023 at 12:43 pm, an observation of Resident #14's oxygen concentrator, revealed it was set at 3.5 L/min and dated 2/14/2023. (Photographic evidence obtained) A review of the clinical record revealed the resident was admitted into the facility on [DATE]. Her diagnoses included chronic systolic heart failure and pulmonary hypertension. A review of the February 2023 Medication Administration Record (MAR) revealed that oxygen was to be administered at 4 L/min via nasal cannula continuously for SOB with nursing initials indicating the oxygen was provided per the order. The MAR revealed oxygen tubing changes were provided every week on Sundays per the order. (Photographic evidence obtained) A review of the quarterly Minimum Data Set (MDS) assessment, dated 1/13/2022, revealed that Resident #14 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact. The assessment also documented that she was receiving oxygen therapy. A review of the care plan, dated 2/14/2022, revealed she was at Risk for Altered Respiratory Status/Difficulty Breathing related to shortness of breath and obstructive sleep apnea. Interventions included: Administer oxygen as ordered. Monitor oxygen saturations as ordered/PRN (as needed). Change tubing per facility protocol/Medical Doctor order and PRN. On 2/16/23 at 1:00 pm, Certified Nursing Assistant (CNA) D confirmed that nursing provided ongoing monitoring of Resident #14's oxygen therapy and ensured that the resident received the correct oxygen flow rate per the physician's order. She stated the resident did not adjust/change her own oxygen flow rate, and she had not refused her oxygen therapy. On 2/16/2023 at 1:00 pm, Licensed Practical Nurse (LPN) E was accompanied to Resident #14's room. She observed the oxygen concentrator set to administer oxygen at 3.5 L/min. (Photographic copy obtained) LPN E confirmed that the resident's physician's order was for a flow rate of 4 L/min, and a weekly change of tubing was completed by nursing staff on the night shift. LPN E reported that nursing was responsible for ongoing monitoring of oxygen therapy, ensuring the resident was provided the correct oxygen flow rate per the physician's order, as well as weekly tubing changes. Correct oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0695 settings were communicated during the shift change report from one nurse to the next. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure for Oxygen Administration (dated October 2010), revealed that preparation included Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. (Copy obtained) Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assist one resident (#68) from a total sample of 37 residents, in obtaining routine and 24-hour emergency dental care. Failure to provide dental care could result in dental caries, infection, pain and loss of teeth. Residents Affected - Few The findings include: On 2/13/23 at 1:53 PM, Resident #68 was observed with missing and broken teeth. She stated she had issues with her teeth and would like them pulled out because they were affecting her ability to chew. She stated she was blind due to cataracts and staff assisted her with her meals. She had told them several times about her wishes and concerns as they assisted her with her meals. Resident #68 could not provid specific names of the staff she notified. A review of the resident's clinical record revealed that she was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia/hemiparesis following cerebral infarction (stroke) affecting her left non-dominant side. Other diagnoses included type 2 diabetes mellitus, chronic kidney disease, psychosis, major depressive disorder and recurrent anxiety disorder. A review of the admission Minimum Data Set (MDS) assessment, dated 11/21/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating that she was cognitively intact. She required extensive assistance bed mobility, transfers, and toilet use, and limited assistance with meals. She was documented with obvious signs of cavities or broken teeth. A review of the care plans revealed there was no care plan addressing dental concerns. On 2/15/23 at 9:59 AM, Resident #68 complained that her teeth were bothering her, they were painful, and she could not eat well. In an interview on 2/16/23 at 3:02 PM, the Social Services Director confirmed that she was aware that Resident #68 had dental concerns, and that she had been seen by a dentist on 2/13/22. When asked what the recommendation were, she stated she had not received the paperwork. When asked if she could obtain the paper work from the dental provider, she stated she was informed that the person who saw the resident was a hygienist and could not conduct an evaluation, therefore, no paperwork was available. When asked to provide the list of residents who were scheduled for a dental visit on 2/13/23, she confirmed that Resident #68 was not on the list. (Copy obtained) She added that she would contact the dental provider to conduct an emergency evaluation of the resident within the next day. A review of the facility's policy and procedure titled Dental Services (revised December 2016), revealed that routine and emergency dental services were available to meet the residents' oral health needs in accordance with the residents' assessments and plans of care. The policy interpretation and implementation indicated that the social services representative would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan if eligible. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to date mark numerous open food packages in the dry storage room, the refrigerator, and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 2/13/23 10:43 a.m. During the tour, no date markings were observed on an open jar of Real Mayo mayonaise, an open pan of vegetable lasagna, a green bin filled with open fresh cabbage, an open box filled with white potatoes, an open box of chicken, an open box filled with bananas, an open box filled with green peppers, an open box filled with cucumbers, or an open bag of onions on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of meat and frozen potatoes sitting on a shelf in the walk-in freezer. The bread rack next to the dry storage room had three open bundles of bread with no date markings. (Photographic evidence obtained) Another tour of the kitchen was conducted on 2/15/23 at 10:30 a.m. In the dry storage room, there was no date marking observed on one open bag of pasta. On the opposite side in the dry storage room, there was no date marking identified on one open bag of pink lemonade. The bread rack next to the dry storage room had one open bundle of bread with no date marking. No date marking was observed on the open bag of onions, open box filled with green peppers, or the open box filled with cucumbers on the shelf in the walk-in refrigerator. (Photographic evidence obtained) An interview was conducted with [NAME] G on 2/16/23 at 1:30 p.m., who confirmed that the facility's policy for date marking was to ensure open food was covered, labeled, and dated, and that leftover bread was wrapped and date marked. An interview was conducted on 2/16/23 at 1:41 p.m. with Dietary Aide H, who confirmed that open food items were to be wrapped and dated before going back into the refrigerator or dry storage shelf. Opened bread was to be wrapped and dated before placing it back on the rack. An interview was conducted on 2/16/23 at 2:00 p.m. with Dietary Manager F, who confirmed that the facility's policy for food storage and date marking was that opened foods should be labeled and dated. Opened bread was to be wrapped and dated. A review of the facility's policy and procedure entitled Food Storage (dated 1//152021), revealed: To ensure that all food served by the facility is of excellent quality and safe for consumption, all food will be stored according to the current Federal and State Food Code. Procedures: Dry storage rooms: To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Refrigerators: Date, label and tightly seal all refrigerated foods, including left-overs, using clean, nonabsorbent, covered containers that are approved for food storage. All items should include name of item and a use-by date. (Copy obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 10 of 10