Inspection·September 23, 2021

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 interviews and record review, the facility failed to provide care and treatment in accordance with professional standards of practice, by delaying hospitalization for one (Resident #51) of two residents reviewed for hospitalizations from a total sample of 40 residents. Residents Affected - Few The findings include: A review of Resident #51's medical record revealed an admission date of 4/14/21 and a readmission date of 7/21/21. Her primary medical diagnosis was nondisplaced intertrochanteric fracture of right femur. Secondary medical diagnoses included osteoarthritis, dementia with behavioral disturbances, osteoporosis, and fracture of sacrum. A significant change assessment dated [DATE] revealed resident's cognition was moderately impaired, and she required limited to extensive assistance with activities of daily living. A nursing progress note dated 7/18/21 at 2:24 AM indicated Resident #51 was observed lying on her back next to her bed. An abrasion was noted above the right eye. The resident stated she slipped and fell. She denied pain at the time of the assessment. A post fall review dated 7/18/21 indicated the fall occurred at 2:10 AM. The resident was ambulating unassisted. A review of Resident #51's physician order dated 7/18/21 at 1:26 PM indicated a STAT x-ray of the right femur and right knee for pain. A nursing progress note dated 7/18/21 at 1:27 PM indicated Resident #51 was to have a stat x-ray of the right knee and right femur due to pain. An x-ray result dated 7/18/21 at 9:03 PM indicated a minimally displaced obliquely oriented acute intertrochanteric fracture. The examination date for Resident #51 was on 7/18/21 at 8:15 PM. A physician order dated 7/18/2021 at 10:06 PM read, Transfer the resident to the emergency room for a right femur fracture. A nursing progress note dated 7/18/21 at 11:52 PM indicated Resident #51 was diagnosed with a right femur fracture. The physician was notified, and order was obtained for transfer to the emergency room for evaluation. A nursing progress note dated 7/19/21 at 2:00 AM indicated ambulance service arrived and resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 105710 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 105710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Nursing and Rehab Center 4134 Dunn Avenue Jacksonville, FL 32218 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)