Inspection·December 9, 2021

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bell positioning and accessibility. She stated call light monitoring was done by both the nurses and CNAs. She further stated call lights must be put where residents can get to them. On December 9th, 2021, at 11:32 AM, a Social Services note dated 12/05/21, indicated Resident #62 would continue with long-term care placement. He was alert and oriented to self and surroundings. His speech was impaired. He required reminders. He was pleasant and cooperative. He interacted with his peers. A review of the nurses' notes dated December 3rd, 2021, revealed that staff assisted Resident #62 with activities of daily living (ADLs). He remained continent of bowel, but was occasionally incontinent of bladder. He transferred from bed to chair with one assist, and he ambulated using a four-wheeled walker. A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated November 3rd, 2021, revealed that Resident #62 had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points, indicating moderately impaired cognition. (Total possible BIMS score ranges are as follows: 13-15: cognitively intact, 08-12: moderately impaired, and 00-07: severe impairment) He required a one-person assist with transfers/walking in his room and the corridor, locomotion on and off the unit, and for toilet use. His balance was not steady, but he was able to stabilize without staff assistance. His range of motion (ROM) was limited for both lower extremities (BLEs). A walker was used as a mobility device. A review of Resident #62's care plan (CP), dated August 8th, 2020, documented: Focus: Resident has occasional to frequent incontinence at times. Toileting/incontinence management per facility protocol C. Goal: Resident will have reduced episodes of incontinence through next review date (NRD). Interventions included: Functional call light within easy reach and prompt staff response. Do frequent rounds when resident is in his room, as he may not use the call light due to cognitive deficit and physical limitation. Focus: Resident has diagnosis (Dx) of convulsions with reduced safety awareness due to mild cognitive impairment. He requires limited assistance from staff while ambulating. Ambulates with a walker. Goal: Resident will have minimized risk of fall-related injuries through NRD, related to visual deficit through NRD, will have no injuries due to falls and/or seizures through NRD. Interventions include: Functional call light and frequently used items within easy reach and visual field of resident. Prompt staff response. SR (side rails) up x 2 as an enabler for bed mobility PRN (as needed). Keep pathway clear of clutter, environmental hazards and items placed below resident field of vision. Provide environment with adequate lighting, free of glare. On December 9th, 2021, at 6:12 PM, the Administrator was asked for the facility's policy and procedure (P&P) for call lights. The P&P provided at 6:28 PM, stated each resident had a functioning call light at bedside, which relayed an audible tone at the nurses' desk when the resident needed to summons or communicate with a staff member. All new residents would be oriented to the function and proper use of call lights. It was expected that the call light would be answered within a reasonable amount of time. All staff were responsible for answering the call lights and checking on the residents for safety needs. If the responding staff member was not qualified to meet medical needs, they would relay the resident's needs to the nurse or appropriate staff member and respond to the resident accordingly. When residents were in bed, call lights would be secured near the resident for easy access. When residents were out of bed, the call light would be secured to a location near the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 2 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0558 Level of Harm - Minimal harm or potential for actual harm for easy access. If the call light had an identified functional problem, a work order would be written, and maintenance would be notified to inspect and promptly repair the device. In such an event, staff would manually monitor the residents and meet their safety needs. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 3 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, interviews, and record reviews, the facility failed to fully develop and/or implement a comprehensive person-centered care plan for one (Resident #71) of a total sample of twenty-nine residents. Specifically, Resident #71's care plans did not address medication administration on dialysis days, and the facility was not implementing her care plan for the provision of oxygen as per her physician's orders. The findings include: During an interview with Resident #71 on 12/06/21 at 12:00 p.m., she stated she received dialysis away from the facility on Tuesdays, Thursdays, and Saturdays. Resident #71 reported she was not on oxygen, however, an oxygen tank was observed sitting in the corner of her room, not in use. A review of Resident #71's medical record revealed an admission date of 7/26/21, and a diagnosis of End Stage Renal Disease (ESRD) requiring hemodialysis three times per week on Tuesdays, Thursdays, and Saturdays at the dialysis facility. She had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition, and she required extensive assistance with Activities of Daily Living (ADLs). A review of Resident #71's physician's orders revealed a 7/31/21 order for oxygen at 2 liters per minute (LPM) continuously via nasal cannula with a start date of 7/31/21. This order was discontinued on 12/09/21and a new order was written for supplemental oxygen at 2 liters per minute as needed. (Copies obtained) A review of Resident #71's Medication Administration Record (MAR) for November 2021 and December 2021, revealed that the nursing staff were signing for having administered oxygen to Resident #71. The MAR also revealed no oxygen therapy was provided and medications scheduled at 9:00 a.m. were missed on the resident's dialysis days. A review of Resident #71's Care Plans revealed no care plans addressing Resident #71's oxygen therapy or medication administration on dialysis days. An interview was conducted with Certified Nursing Assistant (CNA) F on 12/08/21 at 2:15 p.m. When asked what type of dialysis care/services training she had received, CNA F stated, No dialysis training. I get her dressed, make sure she eats, and have her ready for dialysis on time. When asked what type of training she'd received related to respiratory interventions, CNA F stated, The nurse handles all that. I just moisture her nose if it is sore. She is on oxygen. Lately, she hasn't been on it. An interview was conducted with Registered Nurse (RN) E on 12/09/21 at 12:53 p.m. When asked what type of dialysis care/services training he had received, RN E stated, no dialysis training. He confirmed that the resident was receiving hemodialysis three times per week. When asked about the resident's medication administration, RN E stated, [Resident #71] accepts her medications with no problem. If it's at a time she is gone, we can't give her medication. Yesterday, she left at 6:00 a.m., so we could not give her the 8:00 a.m. medication; we just left them here. If the time is past, we just don't give it. By the time she is back something else is due. When asked whether Resident #71 was currently receiving oxygen, RN E stated, Yes, the dialysis center has the orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 4 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Another interview was conducted on 12/09/21 at 4:35 p.m. with Resident #71. She reported she was not receiving oxygen at the dialysis center. She stated, They give it to me if I need it. When asked whether she was receiving oxygen here at the facility, Resident #71 responded, no. During the interview, an oxygen tank was observed sitting in corner, not in use. (Photographic evidence obtained) An interview was conducted with the Director of Nursing (DON) on 12/09/21 at 5:47 p.m. When asked whether she was familiar with Resident #71 and if the resident was on oxygen, the DON replied, Yes, sometimes when she goes to dialysis. The DON stated, Most of the time she is not using it, her saturation goes to 96-97% on room air. When asked why Resident #71 had an order for continuous oxygen, the DON responded, When she started with us, she said she couldn't breathe. Tomorrow the physician comes and will review her chart. When asked why the nurses were signing the MAR for administration of oxygen if they were not administering oxygen to Resident #71, the DON replied, I'll check. When asked how she ensured the physician's orders were accurate, the DON replied, That is a med (medication) error. I will in-service staff to call the physician to change it if she is not using the oxygen. The facility's policy and procedure entitled Care of a Resident with End-Stage Renal Disease (ESRD) read, The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. (Photographic evidence obtained) The facility's policy and procedure for Oxygen Administration instructed staff to verify that there was a physician's order for this procedure. Staff were to review the physician's orders for facility protocol for oxygen administration and review the resident's care plan to assess for any special needs of the resident. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 5 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure that residents who required dialysis services received such services, consistent with professional standards of practice, by failing to ensure ongoing communication with the dialysis facility regarding dialysis care and services for one (Resident #71) of two residents receiving hemodialysis from a total sample of twenty-nine residents. Residents Affected - Few The findings include: During an interview with Resident #71 on 12/06/21 at 12:00 p.m., she stated she received dialysis away from facility on Tuesdays, Thursdays, and Saturdays. A review of Resident #71's medical record revealed an admission date of 7/26/21 with a diagnosis of End Stage Renal Disease (ESRD) requiring hemodialysis three times per week on Tuesdays, Thursdays, and Saturdays at the dialysis facility. She had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition, and she required extensive assistance with Activities of Daily Living (ADLs). A review of Resident #71's physician's orders revealed an order for dialysis on Tuesdays, Thursdays, and Saturdays, dated 8/3/21. An interview was conducted with Registered Nurse (RN) E on 12/09/21 at 12:53 p.m. When asked what type of training he'd received related to dialysis care and services, RN E stated, no dialysis training. RN E confirmed that Resident #71 was receiving hemodialysis three times per week and had an AV fistula (arteriovenous fistula - an abnormal connection between an artery and a vein in which blood flows directly from an artery into a vein) at her left chest. When asked at what point nursing monitored vital signs and weights, RN E stated, Every morning and anytime she receives hypertension medicines. The weight team track and monitor weights and weights are completed at the dialysis clinic. When asked how care was coordinated and communicated between the dialysis staff and the facility nurses, RN E stated, Vital signs are completed before she (Resident #71) leaves. If she has an issue, the dialysis center will notify us. An interview was conducted with the Director of Nursing (DON) on 12/09/21 at 5:47 p.m. When asked about Resident #71's weights and post-dialysis care, the DON stated, The fistula is checked for bruising and bleeding. When asked whether the Dialysis Communication forms were created at the facility or the dialysis center, the DON replied, The facility completes the top portion of the form, and the dialysis center completes the bottom of the page. On 12/09/21 at 4:48 p.m., a review of nine Dialysis Communication Forms revealed missing information as follows: 10/14/2021 - top portion of form weight and cycles per minute missing, nurse's signature missing (This was the only form available for review for October 2021.) 11/16/2021 - top portion of form weight missing, nurse's signature missing 11/18/2o21 - top portion of form weight missing, nurse's signature missing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 6 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0698 11/20/2021 - top portion of form weight missing, room number missing, nurse's signature missing Level of Harm - Minimal harm or potential for actual harm 11/23/2021 - top portion of form weight missing, nurse's signature missing 11/26/2021 - top portion of form weight missing, nurse's signature missing Residents Affected - Few 11/30/2021 - top portion of form weight missing, nurse's signature missing 12/02/2021 - top portion of form weight missing, nurse's signature missing 12/04/2021 - top portion of form weight missing, nurse's signature missing 12/09/2021 - top portion of form weight missing, nurse's signature missing During an interview with the DON on 12/09/21 at 7:20 p.m., only the October 14, 2021 form was available for the month of October. No other October forms were available for review. When asked what the purpose of the dialysis communication forms was, the DON replied, The forms are very important. They have the blood pressures on them. She further stated, If blood pressures are low, Resident #71 can have a code. The facility uses the forms to communicate with the dialysis center on how the resident is doing. The DON reported that the facility initiated the form. The facility's policy and procedure for Care of a Resident with End-Stage Renal Disease (revised 8/3/2011), stated, Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: how information will be exchanged between the facilities. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 7 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0758 Level of Harm - Minimal harm or potential for actual harm Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on record review and interview, the facility failed to monitor behaviors for one (Resident #31) of ten residents investigated for unnecessary medications, from a total of 29 residents in the sample. The findings include: A review of Resident #31's medical record revealed he was admitted to facility on 11/24/20 and was readmitted on [DATE]. His diagnoses included occlusion and stenosis of left carotid artery, cerebral infarction, hemipelgia, cirrhosis of liver, dementia with behaviors, unspecified dementia without behaviors, adult failure to thrive, repeated falls, cerebrovascular disease, and hypertension. Resident #31 was care planned for combative behaviors with interventions that included psychology evaluations and medications as needed. He also was care planned for potential for discomfort and side effects related to the use of psychotropic medications for Alzheimer's disease with interventions that included evaluate behaviors, administer medications and observe for adverse effects of medications. A review of the resident's Physician's Order Sheets for December 2021 revealed they included current orders for Seroquel two times a day for behavior and psychological symptoms of dementia, and Buspirone three times a day for anxiety. A review of the Medication Administration Record (MAR) for December 2021 revealed that no behaviors were being monitored in relation to the administration of Seroquel. An interview was conducted with Licensed Practical Nurse (LPN) H on 12/09/21 at 3:16 PM. She was asked if a resident was receiving Ativan or Seroquel whether they should be monitored for behaviors. LPN H replied, Yes. She was asked whether behaviors were being monitored for Resident #31's Seroquel medication, and she replied, No, Seroquel was started on 11/22/21. I'm not sure why they didn't put behavior monitoring on for that medication. The facility's policy and procedure for psychotropic medication administration was requested but was not received during the course of the survey. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 8 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significant medication errors by failing to administer as-needed antihypertensive medications to residents for blood pressures at or above the parameters established by the physician for two (Resident #52 and Resident #22) of two residents reviewed, from a total of 29 residents in the sample. Residents Affected - Few The findings include: 1. A review of the medical record for Resident #52 revealed an initial admission date of 3/2/2017. Her admitting diagnosis was partial intestinal obstruction. Secondary diagnoses included protein-calorie malnutrition and hypertension. A review of a Significant Change Minimum Data Set (MDS) assessment, dated 10/28/2021, revealed a Brief Interview for Mental Status (BIMS) score of 06 out of a possible 15 points, indicating severely impaired cognition. The assessment did not identify any behaviors or rejection of care and no history of falls. Resident #52 required extensive to total assistance with activities of daily living. A review of Resident #52's physician's orders revealed an order dated 11/10/2021 for clonidine 0.1 milligram (mg) tablet to be given every 6 hours as needed for a systolic blood pressure greater that 150 mmHg (millimeters of mercury). (Photographic Evidence Obtained) A review of Resident #52's blood pressure flow records for November and December 2021 revealed the following entries: 12/6/2021 7:35 a.m. 162/77 12/5/2021 9:21 a.m. 162/70 12/5/2021 1:56 a.m. 164/83 12/4/2021 11:26 p.m. 172/81 12/4/2021 3:52 a.m. 166/84 12/4/2021 12:18 a.m. 164/70 11/30/2021 9:47 p.m. 173/82 11/29/2021 5:57 p.m. 172/78 11/29/2021 10:07 a.m. 161/69 11/28/2021 10:47 p.m. 165/87 11/27/2021 8:34 p.m. 170/70 11/27/2021 3:55 p.m. 174/76 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 9 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0760 11/22/2021 10:28 p.m. 188/73 Level of Harm - Minimal harm or potential for actual harm (Photographic Evidence Obtained) Residents Affected - Few A review of the Medication Administration Records (MARs) for November and December 2021 revealed no documented administration of clonidine. (Photographic Evidence Obtained) On 12/09/2021 at 2:55 p.m., an interview was conducted with Registered Nurse (RN) A. She confirmed that she was assigned to care for Resident #52. She was asked to review Resident #52's blood pressure flow records and medication administration records. She stated she was not aware the resident had an order for as-needed clonidine. After reviewing the physician's order, the nurse stated, If those parameters are met, the medication should be given. A review of the pharmacy consults for October and November 2021 revealed no recommendations identified by the consultant pharmacist for the as-needed clonidine. 2. A review of the medical record for Resident #22 revealed an initial admission date of 1/17/2018. Her primary medical diagnosis was cerebral infarction. Secondary diagnoses included cerebrovascular disease and hypertension. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09 out of a possible 15 points, indicating moderately impaired cognition. Resident #22 required extensive to total assistance with activities of daily living. A review of Resident #22's physician's orders revealed an order dated 9/29/2021 for clonidine 0.1 milligram (mg) tablet to be given every 8 hours as needed for a systolic blood pressure greater that 150 mmHg. (Photographic Evidence Obtained) A review of the medical record revealed the resident was transferred to the hospital and returned on 11/6/2021. Resident #22's blood pressure was documented as 181/70 on the admission nursing data collection upon returning from the hospital. A review of the medication administration record for November 2021 revealed no documented administration of clonidine. (Photographic Evidence Obtained) A review of Resident #22's blood pressure flow records for December 2021 revealed an entry dated 12/7/2021 at 7:36 p.m. with a blood pressure of 165/69. An entry dated 12/7/2021 at 11:32 p.m. revealed a blood pressure of 174/85. A review of the medication administration records for December 2021 revealed no documented administration of the as-needed clonidine. (Photographic Evidence Obtained) A provider progress note dated 11/10/2021 directed staff to notify the physician or nurse practitioner for chest pain, shortness of breath, or a systolic blood pressure greater than 160 mmHg or lower than 100 mmHg. A review of the nursing progress notes revealed no documentation to indicate the physician had been notified of the elevated blood pressures on 12/7/2021. (Photographic Evidence Obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 10 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/09/2021 at 2:55 p.m. RN A, she was asked to review the physician's orders and blood pressure records for Resident #22. She reviewed the orders and again acknowledged that if the blood pressure parameters established by the physician had been met, the as-needed clonidine should have been administered. A review of the pharmacy consults for October and November 2021 revealed no recommendations identified by the consultant pharmacist for the as-needed clonidine. A review of the facility's medication administration policy titled Administering Medications revealed a directive for staff to administer medications in accordance with the orders. (Photographic Evidence Obtained) According to the American Heart Association (accessed 12/9/2021) at https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure, high blood pressure (also referred to as HBP, or hypertension) is when your blood pressure, the force of blood flowing through your blood vessels, is consistently too high. When left untreated, the damage that high blood pressure does to your circulatory system is a significant contributing factor to heart attack, stroke and other health threats. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 11 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observations, record reviews and interviews, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This had the potential to negatively impact all residents who received meals from the kitchen. The findings include: On 12/06/21 at 2:15 PM, observations were made of the low temperature dishwasher while being used by a dietary staff member. The dishwasher was observed at a temperature of 115 °F. Two more wash cycles were observed and the temperature never rose above 118 °F. Dietary Staff Member (DSM) I reported the dishwasher temperature should be 120 to 125° F. She was asked what temperature the dishwasher was at now, and she replied, I don't know, I have to get my glasses. DSM I was asked what the facility's process was at the beginning of washing dishes in the dishwasher. She stated, I let it run one time before I start doing dishes. I check it at the beginning, but I don't log until the end of washing dishes. DSM I retrieved her glasses and looked at the dishwashing machine while it ran. She reported that it reached 118 °F. She was asked what she did if the temperature was low, and she replied that she would log it and then get the supervisor. DSM I was asked to notify the Food Service Director (FSD) about the low dishwasher temperature she just read. The FSD was informed and he ran the machine again himself. It was still under 120°F. At this time the FSD did not give the kitchen staff any instructions or ask them to wait. Before leaving the kitchen, the FSD was asked if he told staff what to do in the dish room regarding cleaning the dishes and he replied, not yet. The December 2021 temperature log for the dishwasher was reviewed on 12/06/21 at 2:30 PM and revealed there was a dishwasher temperature and PPM (parts per million) already filled in for the night shift today, 12/6/21. The FSD was asked about the entries already filled in for today's night shift and he stated, The employee was getting a head of himself. The FSD was asked to check the sanitizer for the three-compartment sink, but he could not find a color key to compare the strip from the sink with it. After several minutes, he went to the office and retrieved a new bottle. On 12/06/21 at 5:00 PM, another visit to kitchen was made. The staff at the three-compartment sink were asked to check the sanitation level, but they could not find test strips or a strip bottle with a color key to test the PPM. They were hand washing dishes at of time of this observation. An interview was conducted with the FSD on 12/7/21 at 5:00 PM. He stated this morning, a representative from the facility's contracted water treatment/purification/cleaning/hygiene company was here and checked the dish machine. He stated the representative told him if the dishwasher temperature was higher then 120 °F, it would neutralize the sanitizer. He reported at the time of the visit, the representative did a couple of things to the dishwasher and it was working properly now. The representative's report was requested for review. It was received the following day, 12/8/21, at 3:00 PM. The report indicated the dishwashing maching should be at 120 to 140 °F during use and it was at 139°F the day of the representative's visit. (Copy obtained) On 12/8/21 at 11:15 AM, the FSD was asked if he had conducted an in-service with kitchen employees regarding the dishwasher. He replied, nothing official. I just had a talk with them. On 12/09/21 at 4:30 PM, the FSD was asked if he had conducted any formal training with the kitchen staff regarding the dishwasher. He replied no. He was asked to clarify the appropriate temperature (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 12 of 13 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 105834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the dishwasher should reach when running. He stated the dishwasher should be between 120 to 140°F. He said he was going with the representative's recommendations. He stated, Yes, I know I said the temperature should be no more than 120° F, but I am just going to go with our [contractor's] report. It was pointed out that the log's temperature ranges for a high temperature machine did not match the machine recommendations or the poster on the wall, and the FSD agreed it was confusing. (Copy of logs obtained) The FSD demonstrated the dishwasher again on this day. He had to run it four (4) times to get the temperature up over 120 °F for the wash cycle. 2. [NAME] K was observed obtaining food temperatures on 12/08/21 at 11:34 AM. She said the facility fortified a portion of the mash potatoes with a concentrated whey protein powder (Beneprotein). She was asked how much she added to the food and she replied, I put 15 scoops in mash potatoes, 1 scoop for every person that is on fortified potatoes. An interview was conducted with the Certified Dietary Manager (CDM) on 12/09/21 at 2:15 PM. She reported that the facility did fortify foods with packets of Benecalorie. She reported she believed only 4 to 5 residents were on fortified foods. She stated the recipe was 1 packet of Benecalorie added to a 1/2 cup of mashed potatoes. At 2:39 PM on 12/09/21, the FSD stated he was acting as the cook today and at lunch service he put six scoops of Beneprotein in the mashed potatoes. He stated, It was because it is what he saw the cook do. During this interaction between the CDM and FSD, the CDM told the FSD that it should be 1 packet of Benecalorie for 1/2 cup of mashed potatoes, and that he should be using Benecalorie not Beneprotein. The FSD was asked what training the kitchen staff had recevied related to dishwashing duties, and he replied, none. When asked about new employee training he stated, New employees learn from shadowing other staff members. A review of the facility's policy titled Sanitization revealed, Dishwashing machines must be operated using the following specifications: Low temperature dishwasher wash temperature 120° F and final rinse with 50 parts per million (PPM) hypochlorite for at least 10 seconds. (copy obtained) A review of the facility's policy titled Dishwashing Machine Use revealed, Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 13 of 13