Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0553
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Allow resident to participate in the development and implementation of his or her person-centered plan of
care.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to ensure that each resident had the right to participate in the
development and implementation of his or her person-centered plan of care for one (Resident #23) of 42
residents sampled.
The findings include:
A review of Resident #23's record revealed he was initially admitted on [DATE]. After being transferred to
the hospital on 4/6/2022, he was last readmitted on [DATE]. His diagnoses included atherosclerosis of
native arteries of extremities with gangrene, acquired absence of left leg above knee, acquired absence of
right leg above knee, polyneuropathy, congestive heart failure, malignant neoplasm of the colon, and
memory deficit following cerebral infarction.
A review of the Progress Notes in the electronic medical record (EMR) revealed that Resident #23 was alert
and oriented with some confusion but was able to make his needs known.
A review of the Minimum Data Set (MDS) assessment completed on 1/26/2022, Resident #23 scored 9 out
of a possible 15 points on the Brief Interview for Mental Status (BIMS), indicating moderately impaired
congition. His activities of daily living (ADL) functional status was listed as: total dependence with transfers,
extensive assistance with toilet use and bed mobility, and limited assistance with dressing, eating, and
personal hygiene.
A review of the resident's active care plan revealed it was initiated on 12/3/2021.
During an interview with Resident #23 on 4/10/2022 at 12:18 p.m., he stated he was kept in the dark about
his care. He denied having been notified of or attending any care plan meetings.
During an interview on 4/12/2022 at 2:25 p.m., Resident #23 stated things had gotten a little better in the
facility. He again addressed concerns about not knowing what was going on with his care. He stated his
niece was his next of kin, was involved in his care and could provide additional information. He requested
that she be contacted for additional information.
During a telephone interview with Resident #23's niece on 4/12/2022 at 3:11 p.m., she confirmed that she
was the resident's next of kin and she was heavily involved in his care. She stated she received a letter
regarding a care plan meeting last year but had not received anything since that time. She stated she could
call the nurses' station for information, but that no one had called her to schedule a meeting or to discuss
the resident's plan of care.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0553
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 4/13/2022 at 3:13 p.m. with the Social Services Director (SSD), she stated care plan
meetings were held quarterly. Families were contacted by phone and a notice was also mailed out to advise
them of care plan meetings. She stated the meetings could be held in person or via telephone or Zoom if
the families were unable to come to the facility. When asked about Resident #23, the SSD stated she was
familiar with the resident. She confirmed that his niece was involved in his care. When asked about care
plan meetings for Resident #23, she provided written correspondence for a care plan meeting for Resident
#23 dated 2/25/2021. She confirmed that this was the last meeting held for the resident. She stated she
had made several unsuccessful attempts to contact the resident's niece regarding his care, but when asked
could not provide evidence of this.
During an interview with the Director of Nursing (DON) on 4/13/2022 at 4:02 p.m., she stated the SSD was
solely responsible for scheduling the residents' care plan meetings. She stated the Administrator would be
responsible for identifying whether or not this was being done.
During an interview with the Administrator on 4/13/2022 at 4:20 p.m., she confirmed that she had identified
concerns with residents not having scheduled care plan meetings. She stated the concerns had been
discussed during Quality Assessment and Assurance (QAA) meetings, however, no performance
improvement plan had been put in place to date. She stated the SSD was solely responsible for care plan
meetings (scheduling, reviewing , and ensuring they were done).
On 4/14/2022 at 11:31 a.m., the Administrator advised the survey team that a facility-wide audit was done
to identify residents who had missed care plan meetings. She stated Resident #23 was identified in the
audit and again confirmed that the resident had not had a care plan meeting since 2/25/2021.
A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered (Revised
December 2016), revealed that the Interdisciplinary Team (IDT), in conjuction with the resident and his/her
family or legal representative, develop and implement a comprehensive, person-centered care plan for
each resident. Each resident's comprehensive person-centered care plan will be consistent with the
resident's rights to partciapiate in the development and implementation of his or her plan of care, including
the right to partcipate in the planning process.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff and resident interviews, medical record review, and facility policy review, the facility
failed to ensure the resident environment remained as free of accident hazards as was possible for one
(Resident #86) of a sample of 42 residents.
The findings include:
On 04/10/22 at 12:56 p.m., two bottles of Systane eye drops were observed on Resident #86's bedside
table. The resident was asked if she administered the eye drops herself. She stated yes. She stated, I have
my family buy them for me because it's a larger bottle and I am able to use it, even with my arthritis. She
was asked when she used the eye drops. She stated, I use them when my eyes are itchy and scratchy, and
then I don't have to wait for the nurse. She was asked if staff were aware that she had the eye drops on her
bedside table. She stated yes. She was asked how long she had kept the eye drops at her bedside. She
stated, As long as I've been here. She was asked again whether she kept the eye drops on her bedside
table and she stated yes.
On 04/11/22 at 9:20 a.m., two bottles of Systane eye drops were on Resident #86's bedside table. The
resident was asked how often she used the eye drops. She stated, My ophthalmologist said I could use
them whenever my eyes feel dry or scratchy. I'd say three or four times a day.
On 04/12/22 at 8:45 a.m., two bottles of Systane eye drops were observed on Resident #86's bedside
table.
On 04/12/22 at 9:25 a.m., during an interview with Licensed Practical Nurse (LPN) B, she was asked if any
of the residents on her assignment today had an order to keep medications at the bedside. She replied, No,
I don't think so; not that I know of. She was asked if any of her residents had eye drops kept in their rooms.
She replied, I think she (referring to the room behind her) did, but I don't think she has them in her room
anymore. She was asked what the protocol was for residents who wanted to self-administer medications.
She stated, The provider can give permission for that. If a resident wanted to self-administer medications or
keep them in their room, the provider would need to give permission first, to make sure the resident is
appropriate to self administer. She was asked if she was caring for Resident #86 today. She replied yes.
She was asked if the resident kept any medications in her room. LPN B replied, I'm not sure. I don't think
so. She was asked if this resident kept any eye drops in her room. She replied, I'm not sure. She was asked
if this resident had a physician's order to keep eye drops in her room. She stated, No, I don't think so.
During a medical record review for Resident #86 on 04/12/22 at 10:15 am, the following order was viewed:
3/21/22: Systane Hydration PF solution 0.4-0.3%: instill one drop in both eyes two times a day for dry eyes.
A review of the Electronic Medication Administration Record (eMAR) for Resident #86 showed this
medication was being signed off as having been administered each day in April 2022 (up to April 11, 2022)
at 9:00 a.m., at 9:00 p.m., and at 9:00 a.m. on April 12, 2022.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 04/12/22 at 11:30 a.m., the Assistant Director of Nursing (ADON) and the St. [NAME] Unit Nurse
Manager were observed performing wound care for Resident #86. While setting up an area on resident's
bedside table, the ADON was asked if Resident #86 required a physician's order to keep the Systane eye
drops at her bedside, as two bottles were observed on the bedside table. The ADON stated, Yes, she
should have an order to keep them in the room. She was asked if the resident had an order to keep them at
bedside. She stated, I don't know, I'll have to look.
On 04/12/22 at 1:15 p.m., the ADON stated [Resident #86's] eye drops are care planned and the order to
self-administer was clarified. She was asked when the resident was care planned and when the order was
clarified. She stated, We just called the doctor and he's okay with the resident self-administering the eye
drops. We care planned that and the resident demonstrated she was able to self-administer the eye drops.
The ADON was asked for a copy of the facility's policy for Self-Administration of Medications. She was also
asked if any other residents had eye drops or other medications at the bedside. She replied No.
Further review of Resident #86's medical record revealed an evaluation titled Self Medication Evaluation
form dated 4/12/22 and locked at 12:38 p.m. The record review did not reveal any other Self Medication
Evaluations performed for Resident #86.
A review of the resident's active care plan on 04/12/22 at 1:02 p.m., revealed no focus
areas/goals/interventions for self-administration of medications.
On 04/13/22 at 9:15 a.m. during a wound care treatment observation with Resident #86 and the wound
care nurse, a bottle of Systane eye drops was observed on the resident's bedside table inside of a red
plastic cup.
On 04/14/22 at 12:00 p.m. during a wound care treatment observation with Resident #86 and the wound
care nurse, a bottle of Systane eye drops was observed on the resident's bedside table inside of a red
plastic cup.
Information from www.Systane.Myalcon.com (accessed on 04/14/22 at 12:20 p.m.) revealed the following
warnings:
Safety: for external use only. Stop use and ask a doctor if you experience any of the following:
eye pain
changes in vision
continued redness or irritation of the eye
conditions worsens or persists longer than 72 hours
Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review, the facility failed to ensure that one (Resident #251) of three
residents with an indwelling catheter, from a total of 42 sampled residents, received appropriate care and
services to prevent urinary tract infections (UTI).
The findings include:
On 4/10/22 at 2:35 PM, cloudy urine in a urinary catheter bag dated 1/18/22 was observed. Resident #251
could not recall when it was last changed.
During another observation of Resident #251 on 4/12/22 at 12:30 PM, cloudy urine was observed in his
urinary catheter bag dated 1/18/22.
A review of the clinical record revealed that Resident #251 was admitted to the facility on [DATE] with a
primary diagnosis of hydrocephalus. Other diagnoses included presence of urogenital implants.
A review of the active physician's orders revealed an order for Suprapubic catheter - change as needed as
a whole system with drainage bag French (Fr) 20 balloon 10 ml (milliliters). Suprapubic catheter care:
Cleanse stoma with soap and water, dry, and apply clean dressing every night shift.
A review of a skin/wound note, dated 3/15/22, revealed: Suprapubic site with brown drainage - cleansed
with normal saline (NS) and drainage sponge applied with paper tape.
A review of the active care plan revealed the resident had a suprapubic urinary catheter with interventions
to change per physician's order, monitor, record and report to the physician any signs and symptoms of UTI
(urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of the urine
color, increased pulse, increased temp, foul smelling urine, altered mental status, and/or change in
behavior.
A review of the Social Services Progress Note dated 1/4/22, revealed the resident was admitted on [DATE]
with a urinary tract infection.
A review of the admission Minimum Data Set (MDS) assessment, dated 1/3/22, revealed the resident had a
Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points, indicating moderately
impaired cognitive. The resident required extensive assistance for bed mobility, transfers, toilet use, and
limited assistance for eating. He had an indwelling urinary catheter, and had a urinary tract infection within
the last 30 days from the assessment reference date.
On 4/14/22 ay 9:44 AM, Registered Nurse (RN) F confirmed that the resident's suprapubic dressing was
not dated. When asked how often the urine bag needed to be changed, she looked at the bag and said, Oh
wow, it's way past due. She added that it should be changed every 30 days and as needed. She confirmed
that the tubing contained sediment and discolored urine. She also confirmed that the catheter insertion
gauze was not dated, therefore, one was unable to tell whether it had been cleaned as ordered.
In an interview on 4/14/22 at 12:40 PM, the Director of Nursing (DON) stated the facility did not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
have a timeline for urinary catheter bag changes. She stated if there were any signs of occlusion or
infection, then the whole system should be changed. She confirmed that Resident #251's bag contained
sediment and the urine had an unusual appearance. She stated the whole system will be changed and the
physician will be notified for orders of urinalysis to rule out infection.
A review of the facility's policy and procedure titled Catheter Care, Urinary (Revised September 2014),
revealed that the purpose of the procedure was to prevent catheter - associated urinary tract infection.
Changing indwelling catheters or the drainage bags at routine, fixed intervals is not recommended. Rather,
it suggested to change catheters and drainage bags based on clinical indication such as infection,
obstruction, or when the closed system is compromised. Observe the resident for complications associated
with urinary catheters by checking the urine for unusual appearance (i.e., color, blood, etc). The policy also
revealed that catheter care documentation should include:
3. All assessment data obtained when giving the catheter care.
4. Character of the urine such as color (straw- colored, dark, or red) clarity (cloudy, solid particles or blood)
and odor.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/10/22
at 3:16 p.m., Resident #43 was observed lying in bed with the head of the bed elevated. Her oxygen
concentrator's flow rate was set at 3 L min and she was receiving oxygen through a nasal cannula. She was
asked if she was aware of what her oxygen flow rate was set at. She stated, I'm not sure, I think maybe 3
L/min? She was asked if she ever changed the oxygen flow rate on her concentrator. She stated, No, I don't
that. I can't even reach it, see? The nurses take care of that.
Residents Affected - Few
A review of her medical record revealed and active order for oxygen with a flow rate to be set at 2 L/min via
nasal cannula continuously.
On 4/11/22 at 9:10 a.m., Resident #43 was observed lying in bed with the head of her bed elevated. Her
oxygen concentrator flow rate was set at 3 L/min. (Photographic evidence obtained)
On 4/11/22 at 12:25 p.m., Resident #43 was observed lying in bed with her eyes closed. Her respirations
were observed at 18 per minute. Her oxygen concentrator flow rate was set at 3 L/min.
On 4/12/22 at 9:20 a.m., Resident #43 was observed lying in bed, watching TV with the head of her bed
elevated. Her oxygen concentrator flow rate was set at 3 L/min. (Photographic evidence obtained)
On 4/12/22 at 4:20 p.m., Resident #43 was observed lying in bed with the head of her bed elevated. Her
daughter was visiting and her oxygen concentrator flow rate was set at 3 L/min. LPN A was observed in the
hallway by the resident's room at this time. She was asked if she was caring for Resident #43 today. She
stated yes. She was asked what the resident's oxygen flow rate was ordered to be set at, and she stated,
She's 3 L/min, I think. I just checked her O2 sat a few minutes ago, and she's 99%.
On 4/13/22 at 8:35 a.m., Resident #43 was observed lying in bed with the head of her bed elevated and a
nasal cannula in place. Her oxygen concentrator flow rate was set at 2.5 L/min. (Photographic evidence
obtained)
On 4/13/22 at 12:10 p.m., Resident #43 was observed lying in bed eating lunch, with the head of her bed
elevated and a nasal cannula in place. Her oxygen concentrator flow rate was set at 2.5 L/min.
On 4/14/22 at 8:20 a.m., Resident #43 was observed lying in bed with the head of her bed elevated and a
nasal cannula in place. Her oxygen concentrator flow rate was set at 2.5 L/min. (Photographic evidence
obtained)
During a medical record review for Resident #43, it was revealed that her diagnoses includes congestive
heart failure (CHF), chronic obstructive pulmonary disease (COPD), cerebral vascular accident (CVA),
morbid obesity, sleep apnea, and generalized anxiety disorder.
A review of her current/active physician's orders revealed an order for oxygen at 2 L/min via nasal cannula
continuously.
A review of the person-centered care plan, dated 8/3/21 (revised 2/25/22), revealed the following focus
areas, goals and interventions:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Focus: I may use oxygen therapy and require suctioning r/t hx (related to a history of) CVA (cerebrovascular
accident - stroke), CHF (congestive heart failure), COPD, and increased secretions.
Goal: I will have no s/sx (signs or symptoms) of poor oxygen absorption through the next review date.
Interventions: Change the resident's position every 2 hours to facilitate lung secretion movement and
drainage as tolerated. Give medications as ordered by MD (physician), monitor/document side effects and
effectiveness. Monitor for s/sx of respiratory distress and report to MD PRN (as needed): respirations, pulse
oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis,
hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. Oxygen Settings: I may use O2 via
nasal cannula/mask per MD orders. Suction as needed.
A review of the facility's policy for Oxygen Administration (1/21, revised 1/22) revealed:
Policy Explanation and Compliance Guidelines:
1. Oxygen is administered under orders of a physician, except in the event of an emergency.
4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's
evaluation and orders, such as but not limited to:
c. equipment setting for the prescribed flow rates.
Based on observations, interviews, and record reviews, the facility failed to ensure that two (Resident #72
and Resident #43) of 16 residents receiving respiratory care, for a total sample of 42 residents, received
oxygen as ordered.
The findings include:
1. On 4/10/22 at 1:20 PM, Resident #72's oxygen flow rate was set at 3 Liters per minute (L/min).
(Photographic evidence obtained)
On 4/12/22 at 9:26 AM, an observation of Resident #72 revealed her oxygen canula was dated 4/11/22 and
her oxygen flow rate was set at 3 Liters per minute (L/min). (Photographic evidence obtained)
On 4/13/22 at 9:03 AM, Resident #72's oxygen flow rate was set at 3 Liters per minute (L/min).
(Photographic evidence obtained)
A review of the medical record revealed that Resident #72 was admitted on [DATE]. Her diagnoses included
Chronic Obstructive Pulmonary Disease (COPD), unspecified; bilateral; generalized anxiety disorder; and
polyneuropathy, unspecified. Active physician's orders included: Oxygen via nasal cannula continuous at 2
L/min to keep saturation greater than 92%, Oxygen tubing change every shift every Sunday, [NAME] Cap
([NAME] ([NAME] methysticum) 1 mg (milligram) every morning and bedtime for generalized anxiety
disorder, take 1 capsule every morning and at bedtime for shortness of breath, and Chloroxygen
Concentrate 50mg/18 drops orally every morning and at bedtime for shortness of breath.
A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 3/4/2022, revealed the
resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
indicating intact cognition. She required extensive assistance for bed mobility and toilet use, supervision
with setup help only with eating, and she was on oxygen therapy.
A review of the active care plan indicated the resident had a focus area of Emphysema/COPD with a risk
for respiratory distress and may use oxygen. Interventions included oxygen therapy as ordered by the
physician. Monitor difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond
endurance, and monitor for signs or symptoms of acute respiratory insufficiency: anxiety, confusion,
restlessness, shortness of breath at rest, cyanosis, and somnolence.
A medication administration note dated 3/20/2022 at 8:07 AM read, Oxygen via nasal cannula continuous
at 2 liters to keep saturation greater than 92% every shift.
An Encounter Note dated 3/16/2022 at 11:00 PM read, No rales, rhonchi, or wheezing; oxygen saturation
within normal levels .496/j44.9: COPD (chronic obstructive pulmonary disease) Continue with supplemental
oxygen and monitor symptoms.
A medication administration note dated 3/12/2022 at 5:00 PM read, Oxygen via nasal cannula continuous
at 2 liters to keep saturation greater than 92% every shift.
A medication administration note dated 3/6/2022 at 8:26 AM read, Oxygen via nasal cannula continuous at
2 liters to keep saturation greater than 92% every shift.
A medication administration note dated 2/28/2022 at 5:17 AM read, Oxygen tubing change every night shift
every Sunday. Patient refused to let me change tubing. Educated her it is supposed to be changed every
week to keep clean but she refused.
A medication administration note dated 2/7/2022 at 3:12 AM read, Oxygen via nasal cannula continuous at
2 liters to keep saturation greater than 92% every shift.
On 4/14/22 at 11:40 AM, Licensed Practical Nurse (LPN) E confirmed that Resident #72's current oxygen
setting was at 3 L/min. She walked to the nurses' station and verified that the April 2022 TAR (Treatment
Administration Record) contained an order for oxygen to be set at 2 L/min. She also verified the resident's
physician's order indicated oxygen to be set at 2 L/min. She continued to state Resident #72 was
complaining that when lying flat, she does not feel it. When asked who monitored the resident's oxygen flow
rate, LPN E confirmed that nursing and the unit managers did a level check. When asked how often
Resident #72's flow rate was monitored, LPN E confirmed it was monitored daily by reviewing the TAR &
MAR (Medication Administration Record). She stated she reviewed Resident #72's medications during
morning medication administration and would complete a second review during her afternoon medication
administration pass.
In an interview with the Director of Nursing (DON) on 4/14/22 at 12:35 PM, she confirmed that nursing
reviewed oxygen flow rates every shift, based on orders. She continued to state that for residents receiving
oxygen, nursing must follow physicians' orders every shift or depending on what the order read.
A review of the facility policy and procedure titled, Oxygen Administration (Revised 01/2022), revealed:
Oxygen is administered to residents who need it, consistent with professional standards of practice, the
comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanation
and compliance guidelines included:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
1) Oxygen is administered under orders of a physician, except in the case of an emergency. In such case,
oxygen is administered and orders for oxygen are obtained as soon as practical when the situation is under
control.
2) Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory
therapists.
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff interview, and facility policy review, the facility failed to ensure safe and secure storage
(including limited access and mechanisms to minimize loss or diversion) of all medications, with the
potential of affecting all residents, related to staff not ensuring one (St. [NAME] nursing unit (rooms
300/400) of two treatment carts containing medications was locked when not in use and unattended.
The findings include:
On 4/10/22 at 12:10 p.m., an observation was made of an unlocked and unattended treatment cart on the
St. [NAME] nursing unit (rooms 300/400). The same cart was observed unlocked and unattended at 1:53
p.m. The second drawer was opened, and multiple bags of medications with resident labels were observed.
There was no staff observed in the area. (Photographic evidence obtained)
On 4/11/22 at 11:15 a.m. and at 4:38 p.m., this same treatment cart on the St. [NAME] nursing unit (rooms
300/400) was observed unlocked and unattended. (Photographic evidence obtained at 4:38 p.m.)
On 04/12/22 at 8:45 a.m., this same treatment cart on the St. [NAME] nursing unit (rooms 300/400) was
observed unattended and unlocked. The drawers were opened and accessed. (Photographic evidence
obtained)
In an interview on 4/13/22 at 9:15 a.m., Licensed Practical Nurse (LPN) C was asked how many treatment
carts were in the facility. She stated, There are two, one for the 100/200 hallway and one for the 300/400
hallway. She was asked where the treatment carts were stored. She stated, One is on each unit by the
nurses' station. She was asked if the carts were secured behind a locked door. She stated, No, they are out
by the nurses' station. She was asked if the carts were expected to be locked when they were not in use
and were unattended. She stated, Yes, we don't want residents with memory issues to open the carts and
get into them. She was asked if there were medications on the treatment carts that could be harmful to a
resident if they removed it and ingested it. She replied, Yes, there's creams and ointments that we wouldn't
want any resident to ingest. She was asked who held the keys for the treatment carts. She stated, I have
one key for each cart, and then the 100 hall nurse has a key for that hall, and the 400 nurse has a key for
that hall, so there are two keys for each cart.
On 4/14/22 at 8:50 a.m., the treatment cart on the St. [NAME] nursing unit (300/400 hallway) was observed
to be unlocked and unattended. (Photographic evidence of lock and items in second drawer was obtained)
A review of the facility policy titled Storage of Medications revealed:
Policy statement:
The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes)
containing drugs and biologicals shall be locked when not in use, and trays or carts used to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
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
106142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River City Nursing and Rehab Center
15480 Max Leggett Parkway
Jacksonville, FL 32218
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
transport such items shall not be left unattended if open or otherwise potentially available to others.
Level of Harm - Minimal harm
or potential for actual harm
.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106142
If continuation sheet
Page 12 of 12
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the April 14, 2022 survey of RIVER CITY NURSING AND REHAB CENTER?
This was a inspection survey of RIVER CITY NURSING AND REHAB CENTER on April 14, 2022. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at RIVER CITY NURSING AND REHAB CENTER on April 14, 2022?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow resident to participate in the development and implementation of his or her person-centered plan of care."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.