Health inspection·October 14, 2021

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents who required dialysis received such services and associated care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #49) of one resident receiving dialysis services, from a total of 34 residents in the sample. Specifically, the facility failed to ensure ongoing communication was monitored and maintained with the dialysis center, and physician's orders were followed for catheter site monitoring. Residents Affected - Few The findings include: The facility's policy on Charting and Documentation, implemented on 1/1/2021 without revision, stated in pertinent part: It is the standard of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. A review of Resident #49's medical record, revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her primary diagnosis was diabetes mellitus type 2 with diabetic chronic kidney disease. Additional diagnoses included sepsis, pneumonia, dependence on renal dialysis, end-stage renal disease, and acute respiratory failure with hypoxia. The 9/6/2021 minimum data set (MDS) assessment documented a brief interview for mental status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. She was documented to not reject care. A resident care plan, initiated on 9/13/2021, documented that the resident needed dialysis due to renal failure. Interventions included: -administer/monitor effectiveness of medications as ordered; -check access site for signs and symptoms of infection, pain, or bleeding daily and PRN (as needed); check and change dressing daily at access site. Document. To left chest cath site; and, -communicate and collaborate with dialysis center regarding weights, medication, diet, and lab results. Resident record review revealed a 10/12/2021 physician's order to obtain vital signs for blood pressure, pulse, respiration, temperature, and oxygen saturation every shift. A review of the October 2021 medication administration record (MAR), revealed the first documentation was on 10/14/2021. Resident record review revealed a 9/6/2021 physician's order to check the dialysis left chest catheter site every shift for signs and symptoms of bleeding/infection/dislodged dressing. If signs or symptoms were present, notify the physician. A review of the September 2021 treatment administration record (TAR), revealed the catheter site was not monitored on 12 of 75 potential observations. A review of the October 2021 TAR, revealed the catheter site was not monitored on 9 of 40 potential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 2 of 9 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 106065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003 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 observations. Level of Harm - Minimal harm or potential for actual harm Resident record review of Dialysis Communication Forms revealed: Residents Affected - Few -9/24/2021: Facility did not document follow-up blood pressure, respiration. and oxygen saturation directly upon return to the facility. -9/29/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. -10/1/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. -10/8/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. The catheter site was not monitored. -10/11/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. -10/13/2021: Facility did not document follow-up blood pressure, temperature, pulse, and respiration directly upon return to the facility. Resident #49 was interviewed on 10/12/2021 at 11:27 a.m. She stated she went to dialysis three times a week. She took a communication book with her each time. The last time she went to dialysis, the staff there did not send a weight back to the facility. She said she was supposed to remind them. Upon return to the facility, her catheter was not regularly checked by the nurse but was kept covered. An interview was conducted with Registered Nurse (RN) J at 10:50 a.m. on 10/14/2021. She stated she would fill out the top portion of the resident's Dialysis Communication Form, and the resident would then take the notebook (with the form) with her to the dialysis center. When the resident returned, the nurse would see that the dialysis center had completed their section of the form. The nurse would then assess the resident and document their status upon return. An interview was conducted with Medical Records (MR), at 11:08 a.m. on 10/14/2021. The Medical Records Clerk stated that until about two months ago, the dialysis communication forms would be filled out by the nurse before the resident left for dialysis. When the resident returned, the dialysis center staff would have filled out their portion of the form. If that portion had not been filled out, the nurse would call the dialysis center for missing information, and fill out the return portion of the form. She stated she used to receive the Dialysis Communication Forms, made sure they were completely filled out, and then put them in the resident's record. She said the nurses were now responsible for ensuring the communication forms were completed and put in the system. An interview was conducted with Licensed Practical Nurse (LPN) G at 11:27 a.m. on 10/14/2021. She stated the facility staff filled out their portion of the Dialysis Communication Form before the resident left for dialysis. She further stated the dialysis staff would fill out their portion of the form while the resident was away. When the resident returned, they would chart the resident's vitals and put the information directly into the vitals section of the resident's electronic record. She stated the nurse would also make a progress note if they noticed a concern with the resident. She did not contact the dialysis center when the communication forms come back with the resident and were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 3 of 9 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 106065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incomplete. She also would not directly chart on the communication form after the resident returned to the facility, but would put that information directly into the resident's record. She had not been made aware that she needed to follow-up with dialysis if the information was missing. She said she did not check the resident's catheter upon return from dialysis, but would ask the resident if they had any concerns. Resident #49 was interviewed on 10/14/2021 at 11:35 a.m. She stated the dialysis staff seldom completed their portion of the communication forms. When she returned to the facility, she was tired. She'd give the facility staff her notebook upon return, but the facility staff seldom checked her vital signs upon her return from dialysis. An interview was conducted with the Director of Nursing (DON), at 12:00 p.m. on 10/14/2021. He stated he expected the facility nurse to complete the Dialysis Communication Forms. The dialysis center did not always complete the information that they were supposed to. If the resident returned to the facility and the nurse noted that the communication information was not complete, the nurse would contact the dialysis center and have the information sent over, which could sometimes take a few days. The nurse would also chart vital signs in the resident's record directly. Sometimes there were communication failures due to the fact that the nurse on duty could change from the time the resident left for dialysis and returned to the facility. He stated he would ensure there was better communication between staff shifts. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 4 of 9 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 106065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003 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 record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (Resident #390) of six residents whose medications were reviewed, from a total of 34 residents in the sample. Specifically, the facility failed to ensure antibiotics were administered for a new resident admitted with sepsis. Residents Affected - Few The findings include: The facility policy on Antibiotic Orders, implemented on 1/15/2021 without revision, stated in pertinent part: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antimicrobial Stewardship Program. If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all of the above drug and dosing elements. The facility's consultant pharmacist will review: a. antibiotic orders; b. changes in duration, including unplanned discontinuation of antibiotic orders. A review of Resident #390's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnosis was sepsis. Additional diagnoses included urinary tract infection, bacteremia, and acute kidney failure. She was documented on the Nursing admission Assessment as alert and oriented to person, place, time, and situation. The resident's baseline care plan, initiated 10/2/2021, documented that the resident had an infection and needed an antibiotic to treat it. Interventions included the administration of the antibiotic as ordered by the physician. The Nursing admission Assessment, dated 10/1/2021, documented that the resident was admitted with an active infection requiring antibiotic therapy. Resident record review revealed a physician's order for Cefdinir (antibiotic used for bacterial infections) Capsule 300 mg (milligrams), give 1 capsule by mouth every 12 hours related to urinary tract infection, at 9:00 a.m. and 9:00 p.m. starting on 10/1/2021 at 9:00 p.m. The order was discontinued on 10/6/2021 at 11:41 a.m. Resident record review revealed a second physician's order for Cefdinir Capsule 300 mg, give 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 5 of 9 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 106065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003 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 capsule by mouth every 12 hours related to urinary tract infection, at 9:00 a.m. and 9:00 p.m., starting on 10/6/2021 at 9:00 p.m. The order was discontinued on 10/7/2021 at 8:59 p.m. Resident record review of the medication administration record (MAR) for October 2021, revealed that the resident was not administered Cefdinir Capsule 300 mg on 10/1/2021 at 9:00 p.m., 10/2/2021 at 9:00 a.m., 10/3/2021 at 9:00 p.m., or 10/6/2021 at 9:00 p.m. There was no indication why the resident did not receive the medication on 10/1/2021, 10/3/2021, or 10/6/2021. The nurse documented on the MAR for 10/2/2021 at 9:00 a.m., to see the nurses' notes. Resident record review revealed a progress note on 10/2/2021 at 8:40 a.m. indicating that Cefdinir Capsule 300 mg medication not available. Resident record review revealed a physician's progress note on 10/4/2021 that documented for the resident to continue Cefdinir as ordered for the urinary tract infection. The progress note did not indicate that they were aware the resident had missed three doses prior to this visit. An additional physician's visit progess note on 10/11/2021 again documented to continue antibiotics, but did not identify that the resident had missed numerous doses. An interview was conducted with Registered Nurse (RN) I at 8:30 a.m. on 10/14/2021. She stated when a resident was admitted , the nurses would use an audit form to ensure they had gone through all important information upon admission. The medication reconciliation form was provided upon admission. She said upon admission, the nurse would contact the pharmacy and put the medical information into the admitting resident's chart. The RN said the facility usually received the resident's medications the same night. Antibiotics and pain medications were medications that she would expect to see administered as soon as possible. An interview was conducted with Licensed Practical Nurse (LPN) G at 8:48 a.m. on 10/14/2021. She stated she contacted the physician and the pharmacy once a resident was admitted to the facility and she was able to review the medication reconciliation form. She would then document everything in the resident's record. She did not have many concerns with medications taking too long to arrive, but if the medication had not arrived timely, she would document in the resident's chart that she had contacted the pharmacy again. She would communicate with the physician to see whether the he/she wanted to modify the order. The physician would often extend the antibiotics so that the resident continued to get the dosage that was needed even if the days were extended. She stated this information would be documented in the chart. Upon review of Resident #390's record, LPN G stated she did not know why the resident did not receive all of her antibiotics. If the medication was not administered, there should be documentation in the resident's chart. An interview was conducted with the Director of Nursing (DON), at 9:20 a.m. on 10/14/2021. He stated the admitting nurse would use the facility's audit sheet to make sure a new resident's medications and assessments were in place upon admission. The IDT (interdisciplinary team) would look to see that everything was put in place in the resident records, Monday through Friday. The admitting nurse would electronically send over the medication list to the pharmacy. If a new resident was admitted prior to 4:30 p.m., and the medications were put in the electronic system, they would usually get the medications back from the pharmacy by 11:00 - 11:30 p.m. If the resident came later, the medications would usually arrive by 3:00 - 6:00 a.m. If the medications did not arrive, there would usually be a note in the resident record that indicated the physician or pharmacy was notified. The DON stated antibiotics would be crucial. There should not be missing documentation related to medication administration. There should be a note indicating why the medication was not given. Usually the physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 6 of 9 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 106065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003 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 would extend the dosing to the quantity needed, so the resident would get the correct number of doses. He stated they would contact the physician to see whether they would extend Resident #390's antibiotics or not. He stated the failure to document administration of antibiotics should have been identified. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 7 of 9 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 106065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility failed to store and serve food in accordance with professional standards for food service safety. This failure could lead to the spread of foodborne illness, and potentially impacted every resident who consumed food from the facility's kitchen. The findings include: On 10/11/21 at 1:30 p.m., an observation of the dry storage closet was made. A scoop was discovered inside a plastic container of sugar. A flour container had plastic wrap over it, but it was not securely covered. A plastic bin labeled bread crumbs was open as well. In the area of the dry storage closet where loaves of bread and bread products were kept, bags were observed without dates on them, not securely closed, and a bag of muffins that was wide open, was also observed. Observations were made of two air vents in the kitchen that had matter hanging from them appearing to be rust and dust debris. At the time of the observations, the traveling Dietary Manager stated a work order had been placed to clean and replace the vents. (Photographic evidence obtained) On 10/11/21 at 1:45 p.m., a resident wearing socks but no shoes walked into the kitchen. He was observed standing next to a rack of plastic dome covers in a location were he would have had to have passed the beverage preparation area, refrigerator, sink, and other kitchen equipment in order to get to. On 10/13/21 at 11:30 a.m., the Culinary Director was interviewed about non-kitchen staff and residents walking into the kitchen. He stated there was a line of tape at the door jamb that residents were not supposed to cross. The Culinary Director pointed out the tape line that non-kitchen staff and residents were not supposed to cross. The tape was faded. The doorway he pointed out was centrally located inside of the kitchen, and from this doorway, the entire trayline service area and stove could be observed. Nursing staff and residents without hairnets were able to walk through the beverage preparation area that included the coffee maker, an ice machine, and the refrigerator. There was no supply of hairnets at this door. On 10/14/21 at 2:00 p.m., an interview was conducted with the Maintenance Director. He reported that no work orders had been received from the kitchen for cleaning the vents, but there was an order to replace the vents. (Photographic evidence obtained) On 10/13/21 at 10:58 a.m., observations were made of dietary staff prepping for the trayline lunch service. At this time, Dietary Staff Member Y was wearing gloves. She was observed touching the top of the garbage can to open it further before disposing of an item. She proceeded to continue with lunch service without changing her gloves. She was observed washing a trayline item serving spoon in the sink and picking up a hand full of plates and set them down on the trayline counter with the same gloves. She was observed holding dishes while putting food on the plate again with same gloves. She did not replace her gloves or wash her hands during these events. [NAME] Z was also observed in the kitchen at this time. He was seen discarding his gloves and replacing them with new gloves, but he did not wash his hands between glove changes. An Interview was conducted with the Culinary Director on 10/13/21 at 11:30 a.m. He stated the kitchen staff were expected to wash their hands between glove changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 8 of 9 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 106065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003 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 0812 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106065 If continuation sheet Page 9 of 9