Inspection·June 19, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a second interview with the Administrator on 06/19/2023 at 2:50 p.m., she was asked if there were any other investigations conducted other than the grievance investigation from 05/19/2023 for Resident #1. She stated no. She was asked when this grievance investigation was concluded. She stated, We notified the daughter on 5/25/23 of the resolution. She was asked to clarify who was caring for Resident #1 when the bruising occurred. She stated, I don't know who was caring for her. The grievance form was based on the daughter's feedback and the resident's feedback. She was asked if staff were attempting to transfer the resident to the toilet without a sit-to-stand device or were they using a transfer device. She stated, I'm not sure. I believe they were using the sit-to-stand device. She stated she did not know when this incident occurred. She did not know which staff were involved. When asked how the bruising was discovered, she stated, She did not have the discoloration a day prior to. The daughter comes in and provides hands-on care and there was no discoloration the day prior. The daughter discovered the bruising. She came in a couple of days after Mother's Day and she brought it to our attention. The daughter notified me personally. She came down to the office and told me and I started the grievance. The staff were already addressing it. The daughter said it supposedly occurred on the 14th. I don't know how or where she got that date from. The Administrator stated she observed the bruising the day it was reported. When asked to describe what she observed, she stated, It was discoloration below her right breast and on her side. There was nothing on the left side. When asked whether the source of the injury was observed by anyone, she stated no. She was asked if the injuries were discovered by another person. She stated, Yes, it was discovered a couple days after using the lift. It took a couple days for the discoloration to show up. She was asked if the source of the injury could be explained by the resident. She stated, No, the resident was not able to really give us what happened. In an interview with Employee A on 06/19/2023 at 3:05 p.m., she was asked when she was first notified about the bruising discovered on Resident #1. She stated May 19, 2023. When asked whether the event was reported to her by staff or family, she replied, By staff. By the floor nurse. She no longer works here. When asked whether she observed the bruises, she replied, At that time, no. When asked when she observed the resident's bruises, she stated, It was either that evening or the next morning. When asked to describe what she observed, she stated, Her breast was bruised from the bottom of her right breast and across the right breast to her side, and a long lateral bruise on the lower part of her right lateral leg. When she was asked what she did when the event was reported to her, she stated, I informed [Administrator] and [Regional Nurse]. I was also the Interim Director of Nursing (IDON) at that time and I wasn't really sure what to do, so I called them. She was asked what their response was. She stated, I think we had to report it to Agency for Health Care Administration (AHCA). I'm not sure if we reported it. As the Risk Manager, I had to do the investigation to interview the staff. Because it was such an odd location, we had to rule out that anything happened. Just to find out how the bruising happened. My thought process was how would she get bruising like that outside of a physical assault. She was asked if the source of the injury was observed by any person. She stated no. She was asked if the injury was discovered by another person. She stated, Yes, by the nurse. She was asked if the source of the injury could be explained by the resident. She stated, No, she wasn't able to say what happened. She was asked if the injury was suspicious because of the extent of the injury or the location of the injury. She stated yes to both. A review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation (undated) revealed: Policy: It is the policy of this facility to take appropriate steps to prevent abuse, neglect, exploitation, misappropriation and the occurrence of an injury of unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 2 of 3 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 06/19/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator, the Risk Manager, The Social Service Director, and the Director of Nursing. The Abuse Coordinator/Designee shall report any alleged violations of abuse or serious bodily injury immediately but not later than two hours to the Agency for Health Care Administration, the Adult Protective Services, and the local law enforcement if they feel a crime has occurred. If the alleged violation involves neglect, misappropriation of resident property, exploitation, or injuries of an unknown source and involves no serious bodily injury, it must be reported no later than 24 hours. 6. Reporting: Upon initial investigation, where suspicion that Abuse/Neglect/Exploitation may have occurred, the Abuse Coordinator/designee shall immediately report the alleged violation to AHCA (for Federal report), Adult Protective Services, and local law enforcement when appropriate. The Risk Manager/Designee will file the Immediate Federal Report with AHCA and then submit the summary and findings of the investigation with the 5-day Federal Report. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 3 of 3