Inspection·October 12, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm On 10/12/23 at 12:50 pm, in an interview with CNA G, she was asked who provided fingernail care for residents. She stated, Whenever I see them long, I'll do it. The Activities staff will do the manicure and polish. She was asked if she was caring for Residents #29 and #30 today. She stated yes. She was asked if she had cleaned and trimmed their fingernails recently. She stated, I try to do the best I can with their nails. Residents Affected - Few A medical record review for Resident #29 revealed diagnoses including type 2 diabetes and legal blindness. A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 7/21/23, revealed that Resident #29 required extensive assistance of one person for personal hygiene. No behaviors, including refusal/rejection of care were indicated. A review of the person-centered Care Plan revealed: Focus: (6/5/23) Resident has an (ADL) Activities of Daily Living Self-Care Performance Deficit; Goal: Resident will have ADL needs met through the review date; Interventions: Check nail length and trim and clean on bath day and as necessary. Resident requires assistance by staff with personal hygiene. Focus: (6/5/23) Resident has Potential/Actual Impairment to Skin Integrity; Goal: Resident will maintain or develop clean and intact skin by the review date; Intervention: Avoid scratching and keep hands from excessive moisture; keep fingernails short. 2. On 10/09/23 at 11:30 am, Resident #30 was observed lying in bed awake. Her fingernails on both hands were observed to be elongated with brown debris under each nail. The resident was asked at what length she preferred her nails. She stated, I want them trimmed and cleaned. I don't want them polished but I want them trimmed and clean. On 10/10/23 at 11:20 am, Resident #30 was observed lying in bed awake. Her fingernails were elongated with brown debris observed under each nail. She was asked for permission to photograph her hands. She agreed and photographs were taken. (Photographic evidence obtained) On 10/10/23 at 11:30 am, Licensed Practical Nurse (LPN)/Unit Manager D entered the room. Resident #30 asked LPN D to apply her arm splints. LPN D placed a splint on the resident's left hand/arm. The resident asked, What about my hand? LPN D stated, I can put a washcloth in your hand to keep it from closing. While placing the washcloth in the resident's hand, dead skin was observed to flake off of the resident's palm. The resident stated, No one washes my hands, that's why I've got all that dead skin. LPN D stated, They should be washing your hands twice a day. Resident #30 stated, Well they don't. That's dirt. I need soap and water. On 10/11/23 at 8:45 am, Resident #30 was observed lying in bed awake, watching TV. Her fingernails remained elongated with brown debris underneath. A medical record review for Resident #30 revealed diagnoses including unspecified dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 2 of 12 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 10/12/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm A review of her quarterly Minimum Data Set (MDS) assessment, dated 8/2/23, revealed that Resident #30 required extensive assistance of one person for personal hygiene. No behaviors, including refusal/rejection of care were indicated. A review of the person-centered Care Plan for Resident #30 revealed: Residents Affected - Few Focus (7/14/23) Resident has an ADL Self-Care Performance Deficit; Goal: (revised 9/16/23) Resident will demonstrate the appropriate use of adaptive device to increase ability through review date; Interventions: (revised 7/28/23) bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report changes to the nurse. Focus: (7/14/23) Resident has Potential/Actual Impairment to Skin Integrity; Goal: Resident will maintain or develop clean and intact skin by the review date; Intervention: Avoid scratching and keep hands from excessive moisture; keep fingernails short. 3. On 10/9/23 at 11:53 am, Resident #70 was observed lying in bed awake. He was nonverbal but smiled and nodded his head. His fingernails were elongated on each finger. He was scratching at his upper arms. On 10/10/23 at 10:55 am, Resident #70 was observed lying in bed awake. His fingernails on both hands remained elongated. On 10/10/23 at 11:35 am, a telephone interview was conducted with Resident #70's spouse. The spouse was asked about the resident's care at the facility. She stated, I've asked them to take care of his fingernails, it has been quite a while, and I haven't been able to check up on it again. I trim them sometimes when I come, but I can't get up there as much as I'd like to. On 10/11/23 at 9:08 am, Resident #70 was observed in bed. His fingernails remained elongated. On 10/12/23 at 11:15 am, LPN D was asked who was responsible for residents' fingernail cleaning and trimming. She stated, Everyone is responsible for nail care, the nurses, the CNAs, and myself. LPN D was asked when fingernail care was provided. She stated, Nail care is done on shower days and as needed. A review of the medical record for Resident #70 revealed diagnoses including encephalopathy and unspecified dementia. A review of the resident's Care Plan, dated 9/13/23, revealed a focus area, goal, and interventions which indicated that Resident #70 had an ADL Self-Care Deficit related to dementia, impaired balance, and limited mobility. Interventions included checking nail length, trimming and cleaning the nails on shower days and as necessary. Staff were to report any changes to the nurse. A review of the annual Minimum Data Set (MDS) assessment, with a reference date of 8/11/23, revealed that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 00 of 15 possible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 3 of 12 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 10/12/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few points, indicating severe cognitive impairment. Resident #70 was also documented as requiring extensive one-person physical assistance for personal hygiene. Rejection of care behaviors were not documented as having been exhibited. 4. On 10/9/23 at 11:57 am, Resident #54 was observed in bed with overgrown facial hair. His mustache was grown past his upper lip and was in his mouth, and his beard was covering both of his cheeks as well as his neck. When he was asked how he preferred to keep his facial hair, he stated he did not like it this long, but I don't have any money for the barber shop. On 10/10/23 at 11:00 am, Resident #54 was observed in bed talking on the phone. His facial hair was in the same condition was was previously observed on 10/9/23 at 11:57 am. On 10/11/23 at 9:00 am, Resident #54 was observed in bed. His facial hair was in the same condition was was previously observed on 10/9/23 at 11:57 am and on 10/10/23 at 11:00 am. He stated he was going to request a shave today. On 10/12/23 at 1:00 pm, Resident #54 was observed sitting up in bed awake. His facial hair was in the same condition as was observed on 10/9, 10/10 and 10/11. He was asked if anyone had been in to shave him. He stated, I've asked and they are too busy. I asked last night on the evening shift but she never came back. He stated he preferred to be clean shaven, but I don't have any money for the barber. A review of the medical record for Resident #54, revealed a person centered Care Pplan dated 9/26/23 with a focus area for Activities of Daily Living (ADL) Self-Care Performance Deficit related to decreased mobility with interventions to include, but not limited to: Personal Hygiene: The resident requires (extensive assistance) by (1) staff member with personal hygiene, and has contractures of both hands. A review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/16/23, revealed that Resident #54 had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. Resident #54 was also documented as requiring extensive one-person physical assistance with personal hygiene. Rejection of care behaviors were not documented as having been exhibited. A review of the facility's policy titled Restorative Nursing - ADLs Assistance (Bathing, Dressing, Grooming Undated) revealed: The facility will provide restorative programming to assist residents in attaining and maintaining the highest practicable level of function . A resident will be eligible for restorative ADL programming if he/she demonstrates interest in improving or participating in self-performance of activities of daily living and requires skill practice and/or training in dressing, bathing, or grooming. Procedure: 1. c) Grooming: May include maintaining personal hygiene, planning the task, gathering supplies, combing hair, washing face and hands, brushing teeth, shaving, applying deodorant, applying make up, trimming nails, or use of adaptive equipment. In an interview with the Administrator on 10/11/23 at 8:10 am, she was asked if the facility had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 4 of 12 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 10/12/2023 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 0677 any other policies pertaining to ADLs and/or grooming. She stated no, this was their only policy. 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: 105834 If continuation sheet Page 5 of 12 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 10/12/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less based on four errors out of 27 opportunities for error, resulting in an error rate of 14.81% and involving three (Residents #66, #61, and #53) of seven residents observed during medication administration. Failure to administer medications correctly as ordered could result to side effects with serious harm to the residents. Residents Affected - Some The findings include: During medication administration observation on 10/10/23 at 11:33 am, Licensed Practical Nurse (LPN) A was observed conducting point-of-care blood glucose testing for Resident #66. She obtained the resident's blood glucose level of 182 milligrams/deciliter (mg/dl). She reviewed the medication administration record (MAR) and stated the resident required four units of Novolog insulin per sliding scale. She obtained the multi-dose vial of Novolog and withdrew five units. As she was about to administer the medication, she was asked to clarify the dosage again and she confirmed she had drawn up five units in error. She pushed one unit off the syringe, then administered the remaining four units of insulin in the resident's right upper arm. A review of Resident #66's October 2023 MAR, revealed that the resident had orders for Novolog 100 units/milliliter administered per sliding scaled before meals. A review of the sliding scale revealed that 182 mg/dl required four units. (Copy obtained) On 10/10/23 at 11:56 am, LPN B was observed conducting point-of-care blood glucose testing for Resident #61. She obtained the resident's blood glucose level of 279 mg/dl. She then reviewed the October 2023 MAR and stated the resident needed four units of Lispro insulin. She obtained the Lispro Kwik Pen and dialed insulin to six units. After performing hand hygiene and donning gloves, she asked the resident where he would like the insulin administered. Resident #61 said, abdomen and lifted his shirt. LPN B then asked the resident, What section of the abdomen? As she was about to administer the medication, she was asked to clarify the dosage again. She said, Six units. She was asked to review the physician's order. She walked to the cart that was parked outside the door and said, Oh, it was supposed to be four units. She dialed the pen back to four units. She was asked how to prime the insulin pen to remove bubbles. She said, Add two more units. She could not appropriately explain how to prime the insulin pen. (Copy of the October MAR obtained) In an interview on 10/10/23 at 12:23 pm, the Director of Nursing (DON) was asked to explain the protocol for priming an insulin pen. She said, The nurse should push out two units of insulin then dial the pen to the appropriate setting per sliding scale. When asked if the nurses were trained to do that, she replied yes. She added that the facility conducted nursing competencies upon hire and annually thereafter, and they reviewed insulin administration at that time. Another medication administration observation was made on 10/11/23 at 9:50 am. LPN C was observed preparing medications for Resident #53. She obtained two tablets of Gabapentin 300 mg (milligrams), Gemeda 75 mg, and Potassium Chloride Extended Release (ER) 20 milliequivalents (meq). LPN C opened the Gabapentin capsules in a separate cup. She then obtained the remaining two medications and poured them in a pill crusher pouch and crushed them. She mixed the powered mixture in apple sauce and administered it to the resident who was seated in the dining room area. The nurse checked off the MAR as having administered the resident's medication. When she was asked to review the MAR, she confirmed that she had not administered either the Cholecalciferol (Vitamin D3) 125 micrograms (mcg) or the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 6 of 12 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 10/12/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Cyanocobalamin (B12) 1000 mcg, but had checked them off as having been administered. (Copy obtained) She checked her medication cart and stated she did not have the right dosage of Vitamin D3 the cart. According to Mayo Clinic.org (https://www.mayoclinic.org/drugs-supplements/potassium-citrate-oral-route/proper-use/drg-20074773, accessed on 10/12/23 at 10:00 am), extended-release tablets should not be broken, crushed, chewed, or sucked because in doing so, they may cause irritation to the mouth or throat. A review of the facility's guideline titled Insulin Administration using an insulin Pen (undated), revealed how to use steps which included, but not limited to: 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it into the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the dose window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. This will prime the needle and remove air from the needle. Repeat this step if needed unit a drop appears. 12. Dial the number of units ordered. A review of the facility's policy and procedure titled Administering Medication (revised April 2019), revealed: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation indicated: 4. Medications are administered in accordance with presciber orders, including any required time frame. 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of medication before giving the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 7 of 12 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 10/12/2023 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist one (Resident #28) of one resident reviewed for dental care, from a total sample of 31 residents, in obtaining routine and/or 24-hour emergency dental care. Failure to provide dental care could result in pain/discomfort, tooth loss, and infection. Residents Affected - Few The findings include: On 10/09/23 at 12:11 pm, Resident #28 stated her teeth were falling off. She was observed trying to hold her tooth on the lower jaw and feeling it with her tongue. She stated she had problems chewing food because her teeth are all falling off. She stated she recently had one tooth fall off and was not sure of whether or not there were pieces of the tooth left in her mouth. She said she was not receiving dental care at the facility. She denied pain and stated she had learned to deal with it. I will make it. In an interview on 10/10/23 at 11:45 am, the resident's power of attorney (POA)/Daughter stated she visited the resident often and at unexpected times. Most of the time she was not notified about the resident's care. She added, I was not notified of Mom's broken glasses until I came in today. She revealed the broken glasses arm. When she was asked about Resident #28's dental services, she stated the resident had partial dentures, but they had been lost at the previous nursing home. She added that she tried to schedule an appointment for new ones, but the resident's dentist stated the resident had very tender gums and it would be painful trying to fit new ones. When she was asked if the resident was receiving additional services at the facility she said no. She was not aware of whether or not her mother had any dental issues or if anyone was checking her for that. She also mentioned that her mother stated she was having a hard time chewing her meals, but she the daughter not know if the facility had changed the resident's diet texture to make chewing easier. A review of the medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease - stage three; vascular dementia, polyneuropathy, and acute angle-closure glaucoma. A review of the diet order dated 4/26/23, revealed a regular textured diet and thin consistency liquids. A review of the quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 8/20/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 possible points, indicating severe cognitive impairment. She required limited assistance for bed mobility, transfers, and toilet use, and supervision for eating. There were no swallowing or dental concerns identified. There was no care plan addressing the resident's dental status. In an interview with the Social Services Director (SSD) on 10/12/23 at 12:04 pm, she stated she placed Resident #28 on the list for a dental consultation upon admission. Upon initial evaluation, the dental company would then decide whether to continue with services or not. When she was asked about Resident #28's dental status, she confirmed the resident was not receiving dental services at the facility. She stated Resident #28 had not been accepted by the dental company affiliated with the facility due to her insurance (Medicaid pending upon admission). The SSD added that the facility changed dental providers around June 2023. She said the new company sent consent forms to the resident's representative and had not heard back yet. She was unable to produce confirmation of the consent form having been sent to the resident's representative. She was then asked about Resident #28's health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 8 of 12 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 10/12/2023 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 0791 coverage. She provided paperwork which indicated that Resident #28's Medicaid was approved on 8/18/23. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled Dental Services (undated), revealed: The facility will assist residents in obtaining both routine and 24-hour emergency dental care. For Medicaid residents, the facility will provide all emergency dental services and those routine dental services to the extent covered under the Medicaid state plan. The facility will inform the resident of the deduction for the incurred medical expenses available under the Medicaid state plan and assist the resident in applying for the deduction. If any resident is unable to pay for the dental services, the facility should attempt to find alternative funding sources or delivery systems so that the resident may receive the services needed to meet their dental needs to maintain his/her highest practicable level of well being. Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 9 of 12 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 10/12/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and a review of the facility's policies and procedures, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections during point-of-care testing for two (Residents #66 and #61) of two residents observed during point-of-care testing, out of seven residents observed during medication administration. Failure to adhere to infection control standards during point-of-care testing poses a risk to residents of acquiring communicable diseases. Residents Affected - Some The findings include: On 10/10/23 at 11:33 am, Licensed Practical Nurse (LPN) A was observed conducting blood glucose testing for Resident# 66. She obtained a glucometer from a bag and placed it on the nurses' cart without a barrier. She obtained a lancet, alcohol wipes and a test trip, and placed them in a medication cup. She took the supplies to the resident's room and placed the glucometer on the resident's sink without a barrier as she performed hand hygiene. She went to the bedside and placed all of the supplies on a paper towel as she donned clean gloves. She cleaned the resident's right thumb and released the thumb after cleaning it to place the test trip in the glucometer. The resident's hand was contracted and was against his chest. The cleaned finger was touching the resident's gown. After placing the test trip in the glucometer, LPN A pricked the resident's finger and obtained a blood glucose reading of 182 milligrams per deciliter (mg/dl). She picked up all of the supplies and discarded them appropriately. She placed the used/soiled glucometer on the nurses' cart, doffed the gloves and performed hand hygiene, then she donned clean gloves and cleaned the glucometer with a Sani Wipe for two minutes. She did not allow it to air dry before placing it back in the bag. She stated each resident had their own glucometer. She also stated the facility had two glucometers in each medication cart that were shared between multiple residents. When asked if she cleaned the glucometer before use, she replied, We always put it back in the bag when its cleaned, so I assumed it was clean. I did not see any dirt on it either. LPN A confirmed that she did not use the barrier for the glucometer, and did not ensure that the blood collection site remained clean after cleaning it and before obtaining the blood sample. When asked how long the glucometer should be cleaned, she reviewed the Sani Wipe container and said three minutes. Another observation was made on 10/10/23 at 11:56 am. LPN B was observed conducting blood glucose testing for Resident #61. She obtained a glucometer from a bag in the medication cart. She got two lancets and three alcohol wipes and placed them in a medication cup. She took the glucometer bag with test strips, the glucometer and the other supplies that were in the medication cup to the resident's room and placed them on the resident's bedside table without a barrier. She performed hand hygiene and donned clean gloves. She pricked the resident's right middle finger and obtained a blood glucose reading of 279 mg/dl. She picked up the remaining alcohol wipes, the lancet, and the used/soiled glucometer and placed them on the medication cart. She discarded the used lancet and test trips, doffed the gloves, and performed hand hygiene. She then picked up the used/soiled glucometer with her bare hands, obtained Sani Wipes, cleaned the glucometer, and placed it on a medication cup to air dry. She then reviewed the October 2023 Medication Administration Record (MAR) and began preparing the insulin to administer without first performing hand hygiene. After administering the insulin, LPN A stated the glucometer was ready to be stored. She stated she forgot the glucometer bag in the resident's room and went to get it. When she was asked about the leftover supplies that were brought back from the resident's room and placed on the nurse's cart in a medication cup, she said, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 10 of 12 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 10/12/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm These are still clean. I did not use them. I will use them on my next resident. When she was asked if she had taken those items into Resident #61's room, she confirmed that she had, stating, Yes, but they are still clean. She was then asked about the glucometer bag that was left in the resident's room. She said she had always taken the bag to the resident's room because it held the test strips. She confirmed that the the glucometer was a shared glucometer used for more than one resident. Residents Affected - Some A review of the facility's policy and procedure titled Blood Sampling - Capillary (Finger Sticks) (Revised September 2014), revealed: The purpose of this procedure is to guide the safe handling of capillary - blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. The General Guideline included te following: Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between residents' uses. Lancets and platforms must always be changed after use on each resident. Steps in the procedure were outlined as follows: 1. Wash hands. 2. [NAME] gloves. 3. Place blood glucose monitoring device on clean field. 4. Place a new lancet and disposable platform on the spring-loaded finger-stick device. 5. Wipe the area to be lanced with an alcohol pledget. 6. Obtain the blood sample following the manufacturer's instructions for the device. 7. Discard lancet and platform into the sharps container. 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts and/or devices after each use. 9. Wash hands. 11. Replace blood glucose monitoring device in storage area after cleaning. A review of the facility's policy and procedure titled Infection Prevention and Control Program (Revised October 2018), revealed: An infection control program 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 Policy interpretation and implementation, Section 11 - Prevention of Infection - indicated that the important facets of infection prevention included: 1. Identifying possible infection or potential complication of existing infection. 2. Instituting measures to avoid complication or dissemination. 3. Educating staff and ensuring that they adhere to proper techniques and procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 11 of 12 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 10/12/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm The policy further indicated that those with potential direct exposure to blood and body fluids are trained in and required to use appropriate precautions and personal protective equipment. . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105834 If continuation sheet Page 12 of 12