Health inspection·January 12, 2024

F 0583 Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation: Residents Affected - Some 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. Privacy and confidentiality; 3. The unauthorized release, access, or disclosure of resident information is prohibited. (Photographic evidence obtained) A copy of Nursing Home Residents' Rights (undated) was provided and revealed: Section 400.002, Florida Statutes: Nursing home facilities shall adopt and make public a statement of rights and responsibilities of the residents and shall treat such residents in accordance with the provisions of that statement. Each resident shall have the right to: Privacy in treatment and in caring for personal needs. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 2 of 11 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 01/12/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and facility policy review, the facility failed to 1) ensure each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices regarding wound care for two (Residents #2 and #11) of three residents reviewed for wound care, from a total of 24 residents in the sample, and 2) failed to ensure quality of care, a fundamental principle that applies to all treatment and care provided to facility residents, by not performing regular control solution testing for five of five glucometers used for residents blood glucose monitoring. Residents Affected - Few The findings include: 1. On 1/11/24 at 10:50 am, Resident #2 was observed lying in bed awake, with a visitor at his bedside who identified herself as the resident's sister. His left foot was wrapped in a bulky ace wrap. When asked if he had a wound on his left foot. He stated, I had my toes amputated. When asked how often he has wound care performed to the area. He stated, It's supposed to be every day but they ain't doing it here. His sister stated, I don't think they've done it since he got here from the hospital on Monday night. They say a doctor is going to come look at it, but no one has looked at it. There was no date observed on the ace wrap. A review of Resident #2's medical record revealed an admission date of 1/8/24, with diagnoses that included ortho aftercare following surgical amputation, type 2 diabetes mellitus; peripheral vascular disease; reduced mobility. A review of Resident #2's admission nursing evaluation on 1/8/24 revealed: Surgical incision on the left foot with dressing and treatment in place. A review of Resident #2's current physician orders revealed an order written on 1/8/24: Wound care-surgical: cleanse left foot with normal saline, pat dry, apply non-adherent dressing, secure with tape and wrap with kerlix; change daily and as needed until healed: every day shift until WCN (wound care nurse) consult and as needed. A review of the eTAR (electronic treatment administration record) revealed the order for left foot wound care written as ordered, and the treatment was observed as not signed off as completed as ordered on 1/8/24, 1/9/24 or 1/10/24. On 1/11/24 at 3:30 pm, Resident #2 was asked for permission to observe his left foot wound care, which he agreed to. Employee A, Licensed Practical Nurse (LPN) identified herself as the wound care nurse for the facility, and stated she would be completing the wound care today for Resident #2. When asked if she had completed his wound care prior to today, since his admission on [DATE]. She said, No. When asked if she knew who had completed the wound care for Resident #2 since he was admitted on [DATE]. She said, It should be the floor nurse if I didn't do it, but I don't know. When asked what the order for Resident #2's wound care was. She said, It's cleanse the wound with normal saline, place a non-adherent dressing, and wrap it with kling daily. Employee A removed the current dressing which consisted of an ace wrap, kling wrap, an ABD (abdominal) pad, gauze pads, and xeroform. The xeroform and gauze pads had a moderate amount of red drainage on them, and the ABD pad had a small amount of red drainage. No date was observed on any part of the dressing removed. When Employee A was asked if she observed any date anywhere on the dressing as she removed it, she stated, No. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 3 of 11 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 01/12/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if she knew who may have placed the dressing on the resident, she stated, No. When Resident #2 was asked if he knew who changed his left foot dressing last, he said, I don't remember, it was so long ago. He was then asked if the dressing was changed yesterday at the facility. He said, No, absolutely not, it hasn't been changed by anyone since I've been here. Employee A was asked if the dressing should have been changed at the facility since the resident was admitted . She stated, They should have changed it. They should have looked at it and assessed it upon admission. I know I haven't changed it until today. A review of Resident #11's medical records revealed he was admitted on [DATE] and readmitted on [DATE], with diagnoses that including, but not limited to, type 2 diabetes mellitus, peripheral vascular disease and dementia. A review of the physician's orders for Resident #11 dated 12/4/23 read: to cleanse a right heel with wound cleanser, pat dry, apply Betadine to the wound bed and leave open to air (start 12/5/23). A review of the treatment administration record (TAR) for Resident #11 revealed this treatment was not signed off as completed on December 5, 7, 9, 11, 12, 14, 15, 18, 19, 21, 22 or 26, 2023 or on January 2, 5, 6 or 8, 2024. On 12/26/23 a new order was written for Resident #11 (started 12/27/23 and discontinued 1/5/24) to cleanse the right heel with Dakins solution, pat dry, apply Santyl and Gentamicin to the wound bed, cover with adhesive border dressing and rolled gauze daily and as needed (prn) every day for unstageable wound. Review of the TAR found this was not signed off as completed on January 2 or 4, 2024. An interview was conducted with the Director of Nursing (DON) on 1/12/24 at 12:25 pm. He was asked to review the order and TAR for Resident #11's heel treatments. Upon review of the TARs, the DON confirmed the overlapping orders and missing documentation for Resident #11's wound. He said his expectation was for nurses to enter new orders upon receipt, discontinue prior orders, then document all treatments provided. The Director of Nursing (DON) was asked for a wound care policy at entrance conference on 1/11/24. One was not provided. He was asked again to provide a wound care policy on 1/12/24 and stated he would get that. He was asked a third time on 1/12/24 for a wound care policy. On 1/12/24 at 9:00 am, in an interview with the DON, he stated the facility does not have a policy for wound care and they would be writing one today. On 1/12/24 at 9:55 am, the DON presented a facility policy titled Wound Care (revised 10/2010). He stated the Regional Nurse was able to access this policy. The facility's policy titled, Wound Care (revised 10/2010) was reviewed. Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 10. The signature and title of the person recording the data. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 4 of 11 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 01/12/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On 1/12/24 at 6:40 am, Employee C, LPN was observed on the Med Surg Unit (MSU) and asked how often the glucometers were tested for their control values. She stated, On the night shift, once a week on Sunday night. When she was asked where the results were kept, she stated, In the back of the narcotic book. She was then asked to show the most recent results. Employee C went through the narcotic book to a section in the back marked Accucheck Control Log. The Control Log revealed the last testing was completed in October 2023. When asked if there were any more recent results, she said, I don't know. When asked if she had performed any glucose meter control testing. She said, No. On 1/12/24 at 6:44 am, Employee B, LPN was observed on the MSU and asked how often the glucometers were tested for their control values. He stated, Every night on the night shift. He was asked where the results were kept. He stated, In the narcotic book, on the med cart. He was asked to show the most recent values recorded. He went to the back of the narcotic book on his medication cart and went to the tab marked Accucheck Control Log. The results revealed the last testing was completed in October 2023. When asked if there were any other testing results elsewhere. He stated, I don't know, this is where it's kept. When asked if he had performed the control testing on his shift last night, he did not answer the question. When asked if he has been testing the glucometers for control values while working on the night shift, he did not answer the question. On 1/12/24 at 6:50 am, the DON was asked when the glucometers were tested for their control values. He stated, They are supposed to be checked nightly. When asked if he could locate the current testing results on the Med Surg Unit (MSU). He proceeded to check the back of all three narcotic books, one on each medication cart, which only revealed the aforementioned October 2023 testing results. The DON was observed looking through the nurses' station for any testing documentation. He stated, I don't see any current testing. He was asked to check the Palms Unit for any evidence of current testing. Upon reaching the unit, he asked the nurses on the unit if they had any glucometer control testing. Three nurses were present, one answered him. He checked the back of each of the two narcotic books on each of the two medication carts which revealed the most recent testing was documented in October 2023. Employee D, the unit manager, was asked if she was aware of any glucometer control testing. She said, No, I don't think so. I haven't seen any since I've been here. Glucometer policies were requested. The DON provided the Assure Prism Glucometer manual. No facility specific policy was provided. The manual provided stated: Assure Prism Control Solution: The Assure Prism Control Solutions are for use the with Assure Prism multi Meter and Assure Prism multi Test Strips to check that the meter and test strips are working together properly and that you are performing the test correctly. Recommended Control Solution Use: You want to practice the test procedure using control solution instead of blood; You use the Assure Prism multi Meter for the first time; You begin using a new bottle or box of individually wrapped test strips; You suspect that the meter or the test strips are not working properly; You think the test results are inaccurate or they do not reflect how the patient feels; If the meter has been dropped or damaged. The manual further stated: Policy: Quality Control Testing on Assure Prism Multi Meter: Quality control testing using the Assure Prism Control Solution will be performed to examine the performance of the Assure Prism multi Blood Glucose Monitoring System. The Assure Prism Control Solution checks if the meter and test strips are working correctly as a system and if you are testing correctly. Important: Depending on state regulations, control solution testing may be required on a daily basis. Please check with your local inspectors regulations or facility procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 5 of 11 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 01/12/2024 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 0684 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 6 of 11 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 01/12/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, medical record review, and facility policy review, the facility failed to ensure the residents received adequate supervision to prevent accidents, by failing to supervise residents on the smoking patio for two (Residents #8 and #9) of fifteen residents identified as smokers, from a total of 24 residents in the sample. The findings include: On 1/12/24 at 6:05 am, two residents (Residents #8 and #9) were observed in the designated smoking area, each in a wheelchair, without staff present. Each of the two residents removed a pack of cigarettes and a lighter from their pockets and lit their respective cigarettes. Resident #8 was asked his name, he replied and also provided the name of Resident #9, stating, He can't talk. Resident #8 was asked if they usually come outside to smoke without staff. He stated, Yes. When asked if he was considered a safe smoker. He stated, Yes. When he was asked if the lady (Resident #10, who was observed outside but not smoking) also smoked with them. He stated, No, she needs staff out here, and she has to wear one of those aprons when she smokes. On 1/12/24 at 6:15 am, Employee D, Licensed Practical Nurse (LPN) was asked if any residents should be smoking in the designated smoking section, unsupervised by staff. She stated, No, they are not. They have scheduled smoking breaks with staff. When asked if she was aware that there were residents outside smoking without staff. She stated no and proceeded to walk to the smoking area. As she went outside, Resident #8 and Resident #9 were observed to have come back inside the building. She asked them if they were outside smoking. Resident #8 stated no. Resident #10 was observed to be still outside in the smoking area, not smoking. On 1/12/24 at 6:47 am, the Director of Nursing (DON) was asked if any residents are allowed to smoke outside unsupervised by staff. He stated, No. All smokers are monitored by staff. There are scheduled smoking breaks. The last one is at 9:30 pm and the first one is at 8:30 am. When asked if resident smoking was allowed on the night shift. He stated no. When asked if any resident's should be outside smoking unsupervised on the night shift. He stated no. A review of Resident #8's medical record revealed a Smoking Evaluation dated 1/11/24 which stated: The resident is a smoker and utilizes the following smoking products: cigarettes. The resident does need to be supervised while smoking and the following interventions have been placed: education on risk factors with smoking. Supervision with smoking. Supervised schedule. (Photographic evidence obtained) A review of Resident #8's person-centered care plan revealed: Focus (12/9/22, revised 2/13/23) The resident is risk for complications related to chronic tobacco use of cigarettes. Goal (revised 6/12/23) The resident will remain compliant with facility smoking program through the next review. Interventions: Notify charge nurse if resident is suspected to violate facility smoking policy. Provide physical assistance for smoking functions such as lighting, holding, and extinguishing the cigarette as needed. Smoke times as scheduled. (Photographic evidence obtained) A review of Resident #9's medical record revealed a Smoking Evaluation dated 1/11/24 which stated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 7 of 11 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 01/12/2024 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 - Minimal harm or potential for actual harm The resident is a smoker and utilizes the following smoking products: cigarettes. The resident does have impaired cognition. The resident does need to be supervised while smoking and the following interventions have been placed: education on risk factors with smoking. Supervision with smoking. Supervised schedule. (Photographic evidence obtained) Residents Affected - Few A review of Resident #9's person-centered care plan revealed: Focus (2/10/23, revised 5/23/23) The resident is risk for complications related to chronic tobacco use of cigarettes. Nicotine dependence. Goal: The resident will remain compliant with facility smoking program through the next review. Interventions (revised 2/13/23) Notify charge nurse if resident is suspected to violate facility smoking policy. Provide physical assistance for smoking functions such as lighting, holding, and extinguishing the cigarette as needed. Smoke times as scheduled. Monitor for compliance with smoking. (Photographic evidence obtained) A review of the facility policy titled, Resident Smoking Supervised and Unsupervised (revised 11/2022) revealed: Standard: The facility shall establish and maintain safe resident smoking practices. Guideline: Safety practices apply to smoking and non-smoking residents in accordance with State and Federal regulations. Procedure: 14. Residents who require supervision with smoking privileges may be supervised by facility staff, volunteers, and family during facility designated smoking times. (Photographic evidence obtained) A review of the Resident Council meeting minutes for October 2023 included an Adhock Smoking Meeting. (Ad hoc is an activity or organization done or formed only because a situation has made it necessary and is not planned in advance.) The minutes for this meeting revealed: (Acting Administrator) explained the smoking policy and the fact that at one of our other facilities we had a resident that caught themselves on fire while smoking. 1. All smokers must have a smoking assessment completed to determine if you're safe or if you need assistance smoking. 2. ALL smokers must be supervised while smoking and are only to smoke at allotted smoking times. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 8 of 11 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 01/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to provide medications as ordered by the physician to meet the needs for one (Resident #3) of three residents reviewed for compliance with medication administration, from a total of 24 residents in the sample. The findings include: On 1/11/24 at 3:15 pm, an observation of medication administration was conducted for Resident #3 with Employee E, Registered Nurse (RN). The nurse had a medicine cup with crushed medications and added a small amount of water. When asked what medication was in the cup. She stated, Quetiapine, Multivitamin, and Namenda. She then poured approximately 20 milliliters (ml) of water into the gastrostomy tube. The nurse then poured the contents of the medication cup into the gastrostomy tube, followed by pouring approximately 30 ml of water into the gastrostomy tube. When the nurse was asked if all three medications were in the same medication cup that she had poured into the resident's gastrostomy tube. She said, Yes. When asked if she usually administers each medication separately with a 5-10cc water flush in-between each medication. She stated, No, not really. A review of Resident #3's medical records, including the physician's orders revealed the following active orders: 11/13/23: Quetiapine Fumarate 50 milligrams (mg): give one tablet via gastrostomy tube two times day 11/23/23: Multivitamin Tablet: give one tablet via gastrostomy tube one time a day 11/23/23: Namenda 10mg: give one tablet via gastrostomy tube two times a day 11/13/23: Enteral Tube: flush with 30 milliliters (ml)-50ml of water before and after medication administration and 5ml-10ml of water between each medication. A review of the facility's policy titled, Administering Medication Through an Enteral Tube (revised 11/2018) revealed: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: 3. Administer each medication separately and flush between medications. Steps in the Procedure: 10. Administer each medication separately. 15. If administering more than one medication, flush with 15ml warm purified water (or prescribed amount) between medications. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 9 of 11 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 01/12/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to maintain standard precautions designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #2, #19, #7, and #3) of four residents reviewed for tube feeding, from a total of 24 residents in the sample. Residents Affected - Some The findings include: 1. On 1/11/24 at 10:51 am, Resident #2, a resident who receives gastrostomy tube feedings, had a tube feeding syringe observed in a Styrofoam cup with no date on syringe, cup, or packaging. This cup was observed next to a urinal on the bedside table, the cup and urinal were observed to be in physical contact with each other. (Photographic evidence obtained) On 1/12/24 at 8:43 am, Resident #2 was observed to have a tube feeding syringe on his nightstand table with no date on the packaging or the syringe. The packaging had do not throw away written on it. (Photographic evidence obtained) On 1/12/24 at 8:45 am, the Director of Nursing (DON) was asked to view the tube feed syringe and packaging and asked why it said do not throw away on the packaging. He stated, We recently changed suppliers and I think we might not have had enough syringes for some of the tube feed connectors. He was asked how often the tube feed syringes should be replaced. He stated, They should be dated on the package and changed daily. 2. On 1/11/24 at 10:46 am, Resident #19, a resident who receives gastrostomy tube feedings, was observed lying in bed, eyes closed. Jevity 1.2cal tube feed feeding formula, dated 1/10/24, was observed hanging from the tube feed pole, observed disconnected from resident. A tube feed syringe was observed in a packaging dated 1/9/24 hanging on the tube feed pole. (Photographic evidence obtained) On 1/12/24 at 8:44 am, Resident #19, was observed lying in bed, eyes closed. Jevity 1.2cal tube feed feeding formula, dated 1/11/24, was observed hanging from the tube feed pole, observed connected from resident with pump functioning. A tube feed syringe was observed in a packaging dated 1/9/24 hanging on the tube feed pole. (Photographic evidence obtained) 3. On 1/11/24 at 11:10 am, Resident #7, a resident who receives gastrostomy tube feedings, was observed lying in bed, awake, watching television. She was non-verbal. Nepro 1.8cal tube feeding formula dated 1/10/24 was observed on tube feed pole, not currently hooked up to resident. Tube feed syringe was observed set on night stand table with no bag/no date. (Photographic evidence obtained) On 1/11/24 at 2:25 pm, Resident #7 was observed lying in bed, eyes closed. There was no tube feeding formula observed on the tube feed pole. A tube feed syringe was observed set on the night stand table with no bag/no date. 4. On 1/11/24 at 1:15 pm, Resident #3, a resident who receives gastrostomy tube feedings, was observed lying in bed, eyes closed. Tube feed syringe observed on tube feed pole in bag, undated. On 1/11/24 at 3:15 pm, Employee E, Registered Nurse (RN) was observed administrating medications to Resident #3 via gastrostomy tube. She used a syringe which was undated on the packaging and undated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 10 of 11 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 01/12/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the syringe. During an interview with Employee E at 3:16 pm, she was asked if there was a date on the syringe or packaging she used. She stated, No, I opened it this morning. She was then asked if she puts a date on the syringes and packaging when she opens them. She stated, I usually do. She was asked how often she changes the tube feeding syringes. She stated, When I need to. The facility's policy titled, Infection Prevention and Control Program (revised 10/2018) was reviewed and revealed: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Director of Nursing (DON) was asked for an enteral tube feeding policy at entrance conference on 1/11/24 at 9:00 am. The policy was not provided by the end of that day. He was asked again to provide an enteral tube feeding policy on 1/12/24 at 7:10 am. He stated he would get it. He was asked a third time on 1/12/24 for a wound care policy. On 1/12/24 at 9:00 am, in an interview with the DON, he stated the facility did not have a policy for enteral tube feeding, and they would be writing one today. On 1/12/24 at 10:13 am, the DON presented a facility policy titled, Enteral Feedings- Safety Precautions (revised 12/2011). He stated the Regional Nurse was able to access this policy. The policy revealed: Purpose: To ensure the safe administration of enteral nutrition. General Guidelines: Preventing contamination: 1. Maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105707 If continuation sheet Page 11 of 11