Health inspection·January 16, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents' right to a safe, clean, comfortable and homelike environment, including but not limited to, receiving treatment and supports for daily living safely for five (Residents #64, #75, #14, #65, and #10) residents in five (rooms 204, 205, 208, 510, and 512) of 66 resident rooms, and in three (Halls 100, 500, and 200) of four hallways in the facility. The findings include: This is a single-story facility where the residents are housed on two units, MSU and Palms. A tour of the facility was conducted on 1/13/2025 at 10:30 a.m. During a tour of the MSU unit several of the baseboards were pulled away from the walls on the 100 and 500 hallways. Miscellaneous stains were observed on various areas of the laminated floors in the main hallways leading to resident rooms. Also, several walls in the hallways and in resident rooms were highly stained with chipped/tearing paint and/or in need of repair. Live roaches were observed in room [ROOM NUMBER]. (Photographic Evidence Obtained) The tour continued on the Palms Unit. On this unit live roaches were observed resident room numbers 204, 205, and 208. Live roaches, spider webs, and dead roaches were observed on the floor behind Resident #64's bed. Heavily stained privacy curtains (rooms [ROOM NUMBERS]) and miscellaneous stains and debris in the 200 hallway leading to residents' rooms and on resident room floors. (rooms 204, 205, 208, and 510). (Photographic Evidence Obtained) During an interview on 1/13/2025 at 11:41 a.m. with Resident #75, the privacy curtain hanging between the resident and her roommate was soiled. Random debris and dead pests were observed behind the resident's bed and in between and behind the dressers of both residents. Resident #75 stated, There are a lot of roaches. She stated that staff was aware of it. The resident advised that she had also seen roaches inside of her dresser drawers. She pulled out two of her drawers. Dark brown and black speckles and other miscellaneous debris was observed in the corner of the resident's dresser drawers. Dark brown and black speckles were observed on the walls behind the dresser and on a lamp on top of the dresser. (Photographic Evidence Obtained) During an interview with Resident #14 on 1/13/2025 at 1:29 p.m., Five to eight black gnats were observed flying around on the left side of the resident. She reported that she was blind. Her roommate, Resident #65, reported seeing gnats as well as live roaches in their room. During an interview on 1/14/2025 at 10:30 a.m. with Resident #10, a trail of a thick, black fuzzy Page 1 of 12 105707 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some substance was observed on the wall below the TV and behind a dresser. The wall had holes and torn paint in multiple areas. Also observed live roaches as well as dead roaches in this resident's room. Several speckles, dark brown and black in color were observed on several areas of the walls and the resident's equipment. During an interview with Resident #10 she stated there was heavy pest (roaches) activity in her room. She stated the facility was aware of it and there was someone who came to spray. She stated the treatment was not effective and she employed her own methods (isopropyl alcohol) to keep the roaches off of her. (Photographic Evidence Obtained) A tour of the facility was conducted with the facility's Housekeeping Supervisor and the Maintenance Director on 1/15/2025 at 12:33 p.m. The Maintenance Director stated he was responsible for pest control-related issues. He stated recently the Housekeeping Department had gotten involved. Staff should be reporting pest sightings in TELS, an electronic maintenance reporting system used by the facility. Once a report was submitted via this system, it sent an alert to his phone. He then contacted the pest control company to come out to treat the area. Both he and the Housekeeping Supervisor stated there was a breakdown in the reporting due to staff inconsistency. The Housekeeping Supervisor stated he had received verbal reports of pest activity from staff. He documented it so that it could be reported to the Maintenance Director; however, there were times when this had not been done. The Housekeeping Supervisor stated additional staff training was needed in this area. He stated they worked to keep things clean as best as they could. Further tour of the facility, the areas of concern previously observed by the survey team (detached base boards, floor stains, curtain stains, pest activity, etc.) were brought to the attention of the Housekeeping Supervisor and the Maintenance Director. The Housekeeping Supervisor confirmed that the issues were present. He stated he had been working with his staff to improve their cleaning methods. He stated each room was cleaned every day and there were random rooms scheduled daily for deep cleaning. He was shown the areas in the halls where the floors were stained. He stated he was responsible for cleaning the floors in the main areas. He stated he was behind and working to get all of the floors cleaned. The Maintenance Director was shown the walls in need of repair and the detached based boards. He acknowledged there were maintenance issues. He stated he was aware of many of the concerns; however, some of them had not been reported to him by other staff members. He did not provide an estimated time or plan to have these areas resolved. During the tour of the Palms Unit, the Housekeeping Supervisor was shown the areas of concern in Resident #10's room. He stated the trail of thick black fuzzy substance on the wall below the TV was mold. He stated it needed to be treated. He also stated that the wall needed to be repaired. While observing the wall in this resident's room, the surveyor and both facility staff members observed live roaches crawling on the resident's floor and wall. The Housekeeping Supervisor attempted to kill one of the roaches, but it crawled out of sight/reach. He stated the housekeepers should be pulling out the dressers and cleaning behind them in the residents' rooms. While touring Resident #75's room, the Housekeeping Supervisor was directed toward the soiled curtain. He stated his staff should have identified and pulled this curtain down to be cleaned. He stated the certified nursing assistants (CNAs) or housekeeping staff should be checking and reporting this so the curtains could be changed. He was also shown the random debris and dead roaches behind the resident's bed and in between and behind the dressers in the room. At the time of the observation, there was an additional observation of live roaches in Resident #75's room. He again stated his staff wasn't performing as they should and that he would address this. (Photographic Evidence Obtained) The Maintenance Director was asked about the repairs again. He stated if staff did not report the issues, they had no way of knowing. He again acknowledged that repairs were needed. He was asked about recommendations from pest control and whose responsibility it 105707 Page 2 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0584 Level of Harm - Minimal harm or potential for actual harm was to ensure that the recommendations were followed. He did not provide a verbal response; instead, he and the Housekeeping Supervisor acknowledged that there were major concerns with roaches in the facility. The Housekeeping Supervisor stated he planned to re-implement a system to follow-up with the housekeepers to ensure that they were performing their duties as they should. He did not provide a plan or timeframe for this. Residents Affected - Some A review of the facility's 5-Step Daily Room Cleaning policy and procedure (revised 10/25/2016), revealed: Purpose: To teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a healthcare facility. 2. Horizontal Surfaces-disinfected Using a solution of properly diluted germicide, sanitize all horizontal surfaces (allowing for appropriate solution dwell time. 3. Spot Clean Walls Vertical surfaces are not completely wiped down daily-but must be spot cleaned daily. Walls-especially by trash cans, light switches and door handles-will need special attention. 4. Dust Mop The entire floor must be dust mopped-especially behind dressers and beds. Move all furniture to dust mop. All corners and along baseboards must be dust mopped to prevent buildup. 5. Damp Mop The most important area of patient's room to disinfect is the floor. The Housekeeping Supervisor provided a copy of the in-services he conducted with his staff during 11/2024, 12/2024, and 1/2025. The documentation was reviewed. The facility's 5-Step Daily Room Cleaning was not reviewed in any of the in-services. Neither was pest control reporting. . 105707 Page 3 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of resident records, the facility failed to ensure the MDS (Minimum Data Set) assessment was completed accurately for one (Resident #14) of one resident reviewed for communication, from a total survey sample of 34 residents. Residents Affected - Few The findings include: On 1/13/2025 at 1:22 p.m., Resident #14 was observed lying in bed with her eyes closed with a blanket held up just below her chin. A nasal cannula (a device that provides additional oxygen through the nose) was in place, and the overhead light was on. She was greeted directly in a normal tone but did not respond. Speaking up, while standing closer, a second attempt to greet her was made with no response. Moving closer to Resident #14, by her left side, she was greeted a third time. She appeared startled and asked loudly, What? Who is that? You'll have to speak up. I'm blind and I can't hear well. When asked if she had hearing aids, she reported no but she would like them. When asked if she had spoken with anyone about obtaining hearing aids, she responded that she had, but no one had helped her. When asked if she could recall the last person she reported her concern to, she stated, Honey, they all know I'm blind and can't hardly hear. On 01/15/25 at 9:03 a.m., Resident #14 was observed lying in bed with a blanket pulled up over her face. When she was greeted, she moaned. When asked how her breakfast was and if she received a shower, she removed the covers from her face and asked, What? in a loud tone. She was asked again how her breakfast was and if she had a shower, to which she responded no, and apologized saying, I just can't see or hear, and I'm congested today. I'm sorry baby. I didn't hear you. On 1/16/2025 at 11:24 a.m., an interview with Certified Nursing Assistant (CNA) C revealed that she had only been working with Resident #14 for a few days, so she was not very familiar with the resident. She did confirm that she was compromised with her communication abilities and was hard of hearing. On 1/16/2025 at 3:27 p.m., an interview with Licensed Practical Nurse (LPN) G revealed that she was assigned to pass Resident #14's medications. She reported Resident #14 to be very hard of hearing and that she experienced challenges providing her care. She went on to state, I am constantly repeating myself because she can't hear me. LPN G reported that Resident #14 did not have hearing aids, but agreed she would benefit from wearing them and it would help staff when providing care. A medical record review for Resident # 14 revealed she was admitted to the facility 10/2/2023 with diagnoses including chronic respiratory failure with hypoxia, hypertensive heart disease without heart failure, diabetes mellitus with unspecified diabetic retinopathy without macular edema, overactive bladder, and unsteadiness on her feet. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 11/29/24, revealed that Resident #14 had adequate hearing and no difficulty with normal conversation, social interaction, or listening to the TV without the use of a hearing aid or other hearing appliances. A review of the resident's Comprehensive Annual MDS assessment, dated 8/29/2024, revealed that Resident #14 had adequate hearing and no difficulty with normal conversation, social interaction, or listening to the TV without the use of a hearing aid or other hearing appliances. 105707 Page 4 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/16/2025 at 3:08 p.m., an interview with the Registered Nurse MDS coordinator and LPN F, MDS Nurse, revealed both completed resident assessments and both scheduled and attended the resident care plan meetings. When completing the resident assessments, LPN F reported that the physicians' orders were checked, the Assessment Reference Date (ARD) was captured, documentation was reviewed for diagnoses, and the necessary assessments were activated. She reported meeting with the residents during the ARD to check their vision, hearing, and teeth/oral status. She completed care plans based on everything collected during her assessments. LPN F confirmed that she completed the most recent quarterly MDS assessment dated [DATE] for Resident #14, and denied that there were any communication challenges. On 1/16/2025 at 3:30 p.m., upon requesting the facility's policy for Resident Assessments and Care Plans, the Administrator reported that the Resident Assessment Instrument (RAI) manual was utilized for MDS assessments and care planning. . 105707 Page 5 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

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 Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #14) of four residents reviewed for ADLs, from 34 residents in the total survey sample, received necessary services to maintain grooming and personal hygiene. Resident #14 did not receive routine or scheduled showers, her hair was matted, and there was an offensive odor present. Residents Affected - Few The findings include: On 1/13/2025 at 1:22 p.m., Resident #14, whose room was located on the MSU unit, was observed lying in bed with her eyes closed and her blanket held up just below her chin. Her hair was matted down along her face and was greasy in appearance, and there was a strong, foul, tangy odor present. There were approximately five small, black gnats observed flying closely on the left side of her body. She was asked when she had her last bath/shower. Resident #14 reported that she had not had a shower in more than 10 days. When asked who assisted her with showers, she reported, the CNAs (certified nursing assistants). On 1/14/2025 at 10:14 a.m., the MSU unit shower binder located at the nursing station was reviewed. Resident #14's scheduled shower days were Wednesday and Saturday on the evening shift. (Photographic evidence obtained) Further review revealed no shower sheets were present in the shower binder for resident #14. On 01/14/2025 at 3:44 p.m., Resident #14 was observed lying in bed with her hair in the same matted, greasy condition, and the foul odor persisted. When asked if she was provided with a shower, she reported that her 7 a.m. - 3 p.m. CNA offered her a shower to which she agreed, but reported that the CNA never came back to give her the shower. She had still had no shower. On 01/15/2025 at 9:03 a.m., Resident #14 was observed lying in bed with the blanket pulled up over her face. When she was greeted, she moaned. When asked if she had a shower yet, she removed the covers from her face and asked, What?. She was asked again if she had a shower yet to which she replied, No. An interview on 1/16/2025 at 11:05 a.m. with CNA A, who worked on the MSU unit and was specifically assigned to the 500 halls, reported that showers were offered on the assigned shower days and shift. If a resident refused during the assigned shift, another attempt was made on the next scheduled shift. A shower sheet was completed and marked whether the resident refused or not with the nurse signing off in acknowledgment. An interview on 1/16/2025 at 11:22 a.m. with RN B, who reported being assigned to work with Resident #14, stated, It's rare for Resident #14 to refuse care and I know she was offered an extra shower yesterday, but she declined. Her CNA mentioned she refused her showers. RN B confirmed that the shower sheets with refusals were kept in the shower binder at the nursing station. An interview on 1/16/2025 at 11:26 a.m. with CNA C, who reported working with Resident #14 only recently, revealed she was uncertain of her shower schedule and was unable to report whether the resident had refused her scheduled showers or not, but stated the shower schedule was located at the nursing station. 105707 Page 6 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A medical record review for Resident #14 revealed diagnoses including chronic respiratory failure with hypoxia, hypertensive heart disease without heart failure, diabetes mellitus with unspecified diabetic retinopathy without macular edema, overactive bladder and unsteadiness on feet. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 11/29/24, revealed that Resident #14 required partial to moderate assistance from staff with showering/bathing. No behaviors, including refusal/rejection of care was indicated. (Photographic evidence obtained) A review of the person-centered Care Plan revealed the following focus area: 6/3/2024 - Resident has (ADL) Activities of Daily Living self -care deficit related to ADL needs, blind, and chronic medical conditions. Goal: Resident will maintain and/or improve ADL functioning through next review date, target date 3/12/2025. Interventions: Bathing: The resident needs assistance of limited to extensive of 1-2 staff members based on fatigue, weightbearing, weakness. No rejection of care or behaviors documented during review. During an interview on 1/16/2025 at 1:59 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), when asked about Resident #14's shower sheets for the last 30 days, the DON reported that the CNAs should be carrying around shower sheets and completing them daily, but there was no consistency with the sheets getting turned in. The DON confirmed that there were no completed shower sheets to view for Resident #14. When asked to confirm how many showers Resident #14 had received over the last 30 days, the DON confirmed that Resident #14 had received two out of approximately 14 scheduled showers. The DON reported they would talk to the corporate office, complete a 4-step plan with in-service training on showering residents that would include monitoring daily, weekly and monthly. A review of the facility's document titled MSU CNA Daily responsibilities (undated), revealed: CNAs are responsible for completing showers on assigned days, with shower sheets being completed and given to the nurse for review. (Photocopy obtained) A review of the facility's policy and procedure titled ADL Care and Services (revised 1/2024), revealed: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy interpretation and implementation indicated: 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, nail care and oral care. (Photocopy obtained) . 105707 Page 7 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of resident records, the facility failed to ensure that one (Resident #14) of two residents reviewed for vision/hearing/communication, from a total survey sample of 34 residents, received proper treatment and assistive devices to maintain hearing ability. Resident #14 was very hard of hearing, which compromised her ability to communicate. The facility had a visiting audiologist; however, the resident had not been referred for an evaluation. Residents Affected - Few The findings include: On 1/13/2025 at 1:22 p.m., Resident #14 was observed lying in bed with her eyes closed and a blanket held up just below her chin. A nasal cannula (a device that provides additional oxygen through the nose) was in place, and the overhead light was on. She was greeted directly in a normal tone, but did not respond. Speaking up, while standing closer, a second attempt to greet her was made with no response. Moving closer to Resident #14, by her left side, she was greeted a third time. She appeared startled and asked loudly, What? Who is that? You'll have to speak up. I'm blind, and I can't hear well. When asked if she had hearing aids, she reported no but she would like them. When asked if she had spoken with anyone about obtaining hearing aids, she responded that she had, but no one had helped her. On 1/15/2025 at 9:39 a.m., an interview with the Social Services Director (SSD) revealed that she had only been in her position for a few months and was unsure of the referral process for audiology treatment and services. She confirmed that the audiologist visited last week and any resident could have been seen. She reported that audiology was reviewed during the care plan meeting with the resident present, as well as members of the interdisciplinary team. She was familiar with Resident #14, agreed she had communication challenges, and reported that she was uncertain of the reason the resident was not seen by the audiologist last week. She further confirmed that Resident #14 had not been seen by an audiologist since her admission to the facility. On 1/16/2025 at 11:24 a.m., an interview with Certified Nursing Assistant (CNA) C revealed that she had only been working with Resident #14 for a few days, so she was not very familiar with the resident. She did confirm that the resident was compromised with her communication abilities and was hard of hearing. On 1/16/2025 at 3:27 p.m., an interview with LPN G revealed she was assigned to pass Resident #14's medications. She reported that Resident #14 was very hard of hearing and that she experienced challenges providing her care. LPN G went on to state, I am constantly repeating myself because she can't hear me. LPN G reported Resident #14 did not have hearing aids, but agreed she would benefit from wearing them and it would help staff when providing care. A medical record review for Resident # 14 revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, hypertensive heart disease without heart failure, diabetes mellitus with unspecified diabetic retinopathy without macular edema, overactive bladder, and unsteadiness on feet. A review of the resident's nursing home Quarterly Minimum Data Set (MDS) assessment, dated 11/29/24, revealed she had adequate hearing and no difficulty with normal conversation, social interaction, or listening to the TV without the use of a hearing aid or other hearing appliances. 105707 Page 8 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0685 Level of Harm - Minimal harm or potential for actual harm A review of the person-centered Care Plan for Resident #14 revealed there was no plan of care in place addressing hearing or communication. An active physician's order, dated 10/3/2023, documented consults, Resident may have consults with audiology providers as needed. (Photographic evidence obtained) Residents Affected - Few A review of the Interdisciplinary Plan of Care Meeting (IPOC), dated 12/5/2024, revealed that audiology treatment and services were not reviewed. (Photographic evidence obtained) On 1/16/2025 at 1:59 p.m., an interview with the Director of Nursing (DON) and Assistant Director of Nursing ADON) revealed that they were unaware that Resident #14 had a hearing impairment. The DON went on to state, I guess we're not out on the floor enough. We plan to review the ancillary processes to address the break in the process. Audiology is reviewed during the care plan meeting and documented on the same paper. Resident #14's last IPOC, dated 12/5/2024, was reviewed with the DON. She was asked to show where audiology having been discussed was indicated. She provided no response. When asked if Resident #14 had been screened by audiology at any time since her admission, she provided no response. A review of the facility's policy and procedure titled Social Services, Consults-Ancillary Services (revised 01/2024), revealed: Social Services personnel shall coordinate most resident referrals with contracted providers or external agencies as indicated. The policy interpretation and implementation indicated: 1. Social Services shall coordinate most resident referrals (i.e. podiatry, dental, vision, etc.) (Photocopy obtained) . 105707 Page 9 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program so that the facility was free of pests and rodents in five (rooms 204, 205, 208, 510, and 512) of 66 resident rooms. Failure to correct this concern in a timely manner could negatively impact the the entire census of 105 residents. Residents Affected - Some The findings include: This is a single-story facility where the residents are housed on two units, MSU and Palms. A tour of the facility was conducted on 1/13/2025 at 10:30 a.m. During a tour of the MSU unit, Live roaches were observed in room [ROOM NUMBER]. (Photographic Evidence Obtained) The tour continued on the Palms Unit. On this unit live roaches were observed resident room numbers 204, 205, and 208. Live roaches, spider webs, and dead roaches were observed on the floor behind Resident #64's (room [ROOM NUMBER]W) bed. (Photographic Evidence Obtained) During an interview on 1/13/2025 at 11:41 a.m. with Resident #75 (room [ROOM NUMBER]D), dead roaches were observed behind the resident's bed and in between and behind the dressers. The resident stated there were a lot of roaches. She stated staff were aware of them. The resident advised that she had also seen roaches in her dresser drawers. She pulled out two of the drawers. There were dark brown and black speckles and other miscellaneous debris in the corner of the resident's dresser. Dark brown and black speckles were also observed on the walls behind the dresser and on a lamp on top of the dresser. (Photographic Evidence Obtained) During an interview with Resident #14 (room [ROOM NUMBER]D) on 1/13/2025 at 1:29 p.m., five to eight gnats were observed flying around on the resident's left side. The resident reported that she was blind. Her roommate, Resident #65 (room [ROOM NUMBER]W), reported seeing gnats as well as live roaches in their room. During an interview on 1/14/2025 at 10:30 a.m. with Resident #10 (room [ROOM NUMBER]P), live and dead roaches were observed in the resident's room. Dark brown and black speckles were observed on several areas of the walls and the resident's equipment. Resident #10 stated there was heavy pest (roaches) activity in her room. She further stated the facility was aware of it and there was someone who came to spray. She stated the treatment was not effective and she employed her own methods (isopropyl alcohol) of keeping the roaches off of her. (Photographic Evidence Obtained) A tour of the facility was conducted with the facility's Housekeeping Supervisor and the Maintenance Director on 1/15/2025 at 12:33 p.m. The Maintenance Director stated he was responsible for pest control-related issues. He further stated recently the Housekeeping department had gotten involved. Staff should be reporting pest sightings in TELS, an electronic maintenance reporting system used by the facility. Once a report was submitted via this system it sent an alert to his phone. He then contacted the pest control company to come out to treat the area. Both he and the Housekeeping Supervisor stated there was a breakdown in the reporting due to staff inconsistency. The Housekeeping Supervisor stated he had received verbal reports of pest activity from staff. He stated he documented it so it could be reported to the Maintenance Director; however, there were times when this had not been done. The Housekeeping Supervisor stated additional staff training was needed in this area. He stated they worked to keep things clean as best they could. During the tour of the facility, the pest 105707 Page 10 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activity previously observed by the survey team was brought to the attention of the Housekeeping Supervisor and the Maintenance Director. The Housekeeping Supervisor confirmed the issues were present. He stated he had been working with his staff to improve their cleaning methods. He stated each room was cleaned every day and random rooms were scheduled daily for deep cleaning. During the tour of the Palms Unit in Resident #10's room, live roaches were observed crawling on the resident's floor and wall. The Housekeeping Supervisor attempted to kill one of the roaches, but it crawled out of sight/reach. He stated the housekeepers should be pulling out the dressers and cleaning behind them in the residents' rooms. While touring the room of Resident #75 the Housekeeping Supervisor was shown the random debris and dead roaches behind the resident's bed and in between and behind the dressers. At the time of the observation, live roaches were also observed. He again stated his staff wasn't performing as they should and that he would address this. (Photographic Evidence Obtained) The Maintenance Director was asked about recommendations from pest control and whose responsibility it was to ensure that the recommendations were followed. He did not provide a verbal response, instead he and the Housekeeping Supervisor acknowledged that there were major concerns with roaches in the facility. The Housekeeping Supervisor stated he planned to re-implement a system to follow-up with the housekeepers to ensure they are performing their duties as they should. He did not provide a plan or timeframe for this. A review of the facility's policy for Pest Management (undated), revealed the following: Policy: It is the policy of the facility to contract with a licensed exterminator for pest management and standard pest control. Procedure: The exterminator will visit the facility twice monthly and as needed to provide extermination services. The exterminator will inspect all areas of the building during the visit. Included are the kitchen, staff dining room, resident dining areas, day rooms, common areas, nursing stations, all resident rooms, and all mechanical areas. Log books are kept at the nursing stations. Staff are encouraged to log any pest sightings in the book to cue the exterminator for areas that need focus and concentration. The exterminator will check the log book on each visit. A review of the facility's Pest Control Plan (undated), revealed: Daily Observations and Interventions: CNA's, housekeepers, and all other staff will observe resident rooms for open containers of food, spills, anything that pests will go after and be sure these items are in sealed containers. Staff will document any pest sightings in the log books located at the nursing station (if there are no log books at your stations, the maint., Director will get them from [Pest Control provider] and make sure they are in place. Maintenance is to do a full audit of all resident rooms and document any areas that pest may come into the building or any areas that pests may breed (moist, dark areas). They will then address these areas and close up any opening or eliminate any areas that may encourage breeding. Be sure to in-services all staff on these processes and document. A review of the pest control service reports for services performed on 11/7/2024, 11/14/2024, 11/21/2024, 11/27/2024, 12/5/2024, 12/12/2024, 12/18/2024, 1/6/2025, and 1/9/2025, revealed the following: 105707 Page 11 of 12 105707 01/16/2025 Fouraker Hills Rehab and Nursing Center 1650 Fouraker Rd Jacksonville, FL 32221

F 0925 Level of Harm - Minimal harm or potential for actual harm Each report included comments from the service technician regarding the service provided and recommendations. 11/7/2024 - Inspected and serviced guest rooms no activity found today also customer needs to fix gaps around AC units. Residents Affected - Some 11/14/2024 - Inspected and serviced 100, 300, 500 hallways and common areas no activity found today also customer needs to fix gaps around AC units. 11/21/2024 - Inspected and serviced 200 hallway and common areas no activity found today also customer needs to fix gaps around AC units. 12/5/2024 - Inspected and serviced common areas and 100, 200 hallways no activity found today also customer needs to fix gaps around AC units. 12/12/2024 - Inspected and serviced 400, 500 hallways and common areas also customer needs to work on sanitation in guest rooms and fix gaps around AC units also customer needs to talk to customer about excessive clutter in rooms. 12/18/2024 - During today's service, we did observe conducive conditions (excessive clutter, gaps in baseboards, leaking a/c unit, food left out). 1/6/2025 - Treated kitchen area customer had roaches around dishwashing area. . 105707 Page 12 of 12