Health inspection·April 25, 2024

F 0550 mechanically altered diet. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled Assistance with Meals (revised July 2017), revealed the following: Residents Affected - Few Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example, not standing over residents while assisting them with meals. The staff will prepare residents for eating. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106142 If continuation sheet Page 2 of 7 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 04/25/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as body weight, by failing to provide nutritional interventions in a timely manner for two (Residents #54 and #94) of two residents reviewed for nutritional status, resulting in significant weight loss. Residents Affected - Few The findings include: 1. During a tour of the facility on 04/23/24 at 8:59 AM, Resident #54 was observed eating her breakfast while lying in bed. She had difficulty holding her spoon while eating her pureed food. A moderate amount of food was present on the cloth clothing protector which was worn over her shirt. She also had a Mighty Shake nutritional supplement on her tray which was untouched. Resident #54 consumed approximately 15% of her meal tray. A review of Resident #54's medical record revealed an admission on [DATE] and a medical history significant for stroke, right-sided paralysis, Parkinson's disease, difficulty swallowing, and weakness. An admission Minimum Data Set (MDS) assessment, completed on 01/24/24, documented that Resident #54 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. This MDS also documented that Resident #54 held food in her mouth and had coughing/choking during meals. Her weight was documented as 188 pounds. This MDS also noted that Resident #54 was ordered to receive a mechanically altered diet when she was admitted to the facility. This MDS noted that Resident #54 was at risk for but had no skin breakdown or pressure ulcers upon admission. A review of Resident #54's recorded weights revealed that on 04/19/24, she weighed 160.6 pounds, indicating that she lost 14.76 percent of her weight since her initial weight taken at the facility on 01/23/24, approximately three months earlier. A review of Resident #54's progress notes revealed there were no Nutrition Progress Notes written since her admission. There was a Comprehensive Nutritional Evaluation documented by a dietitian on 01/23/24, which indicated that Resident #54 was at nutritional risk due to her difficulty swallowing. This evaluation recommended adding Boost nutritional supplement and for staff to assist her with eating. Further review of Resident #54's progress notes revealed there was a Skin and Wound Evaluation written on 04/14/24, which documented a stage 2 pressure ulcer located on Resident #54's medial sacral area. This note documented the wound as in-house acquired with the following measurements: 1.1 centimeter (cm) x 2.1 cm x 0.6 cm. A second Skin and Wound Evaluation written on 04/21/24 documented the following measurements of the same wound: 1.6 cm x 3.2 cm x 0.7 cm, indicating that the wound worsened during this review period. A review of Resident #54's physician's orders revealed an order written on 01/18/24 for: Liberalize diet, pureed texture, nectar consistency. An order was written on 03/19/24 for: Magic Cup nutritional supplement to be given two times a day (with lunch and dinner) for weight management. An order was written on 04/11/24 for: Mighty Shake nutritional supplement to be given three times a day, and an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106142 If continuation sheet Page 3 of 7 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 04/25/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order was written on 04/14/24 for: ProHeal Critical Care nutritional supplement to be given two times a day for 30 days for the new sacral pressure ulcer. An observation was made on 04/24/24 at 8:20 AM of Resident #54 during the breakfast meal. She was observed lying in bed wearing a cloth clothing protector. Her tray was uncovered, and she was attempting to eat her pureed food. The Mighty Shake nutritional supplement had been poured into a cup and Resident #54 was observed drinking the shake from the cup with minimal difficulty. When her tray was removed at 8:56 AM, she had consumed approximately 50% of the mighty shake and 5% of the meal tray. Certified Nursing Assistant (CNA) D was overheard telling CNA E that Resident #54 hardly ate her food and drank about half of her shake. An observation was made on 04/24/24 at 12:10 PM of Resident #54 during the lunch meal. She was sitting in her wheelchair wearing a cloth clothing protector. Her tray was uncovered and she was attempting to eat her pureed food. There was a Magic Cup nutritional supplement observed on her tray that she was attempting to eat. Resident #54 consumed about 50% of her meal tray and 100% of her Magic Cup. On 04/24/24 at 12:10 PM, an interview was conducted with Resident #54's husband. He stated he had concerns about the weight his wife had lost and the new wound that had formed on her sacrum. He stated he was concerned about her ability to properly feed herself and that he tried to come to the facility each day to assist her with her lunch. When asked if he had spoken to a dietitian at the facility about his concerns, he stated he had spoken to a dietitian shortly after Resident #54 was admitted , but that he had not seen the dietitian since then. On 04/25/24 at 8:44 AM, an observation was made of Resident #54 during the breakfast meal. She was lying in bed wearing a cloth clothing protector. Her tray was uncovered and she was attempting to eat her pureed food. The Mighty Shake nutritional supplement was present on the tray but was unopened. Resident #54 struggled with her Mighty Shake carton. When her tray was removed at 9:01 AM, she had consumed approximately 5% of her meal. A telephone interview was conducted with Registered Dietitian (RD) C on 04/25/24 at 10:01 AM. RD C stated she started working at the facility in May 2023 and came to the facility every other Tuesday to see residents. She further stated she was a part-time dietitian for this facility and worked at numerous facilities. There was a dietary manager at the facility with whom she communicated. She said the dietary manager watched the residents' weights and would tell her about changes and which residents she should see each time she came to the facility. When asked when she had last seen or assessed Resident #54, she stated she had not seen Resident #54 since her initial evaluation in January. She said she was not aware that Resident #54 had suffered weight loss. She was also not aware that Resident #54 had a new wound and stated she was upset by this information. She said she was scheduled to come to the facility on [DATE], would assess Resident #54, and planned to order Boost nutritional supplement related to the weight loss that was suffered, because it was more concentrated in calories and protein which gives it more bang for the buck. An interview was conducted with the facility's Dietary Manager on 04/25/24 at 10:33 AM. The Dietary Manager stated she started working full-time at the facility in September 2023. She said she often did not see RD C when she came to the facility, because she was in Care Plan Meetings on Tuesdays. She further stated she would leave notes containing resident information and weights for RD C to review when conducting her resident rounds. The Dietary Manager stated she was aware that Resident #54 had lost weight and that she had spoken with the resident's husband about starting nutritional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106142 If continuation sheet Page 4 of 7 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 04/25/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supplements with her meal trays. When asked what other interventions could be implemented, she stated they could try double protein with meals or another supplement such as Boost, but that she could not write orders, only the dietitian could write orders. 2. During a tour of the facility on 04/22/24 at 11:40 AM, Resident #94's family stated they had concerns about the resident's weight loss. The family member stated they came to the facility almost every day to assist Resident #94 with her lunch meal, and that the facility staff assisted her with her other meals. A review of Resident #94's medical record revealed and admission date of 07/10/23 and a medical history significant for stroke, right-sided paralysis, difficulty swallowing, and weakness. A Quarterly MDS assessment, completed on 01/16/24, revealed that Resident #94 had a BIMS score of 1 out of 15 possible points, indicating severe cognitive impairment. This MDS documented that Resident #94 was ordered to receive a mechanically altered diet. It also documented that she had suffered weight loss. A review of the last six months of recorded weights revealed that on 10/02/23, Resident #94 weighed 172.6 pounds, and on 04/08/24 she weighed 149.8 pounds. This indicated that Resident #94 lost 13.21 percent of her weight within six months. A review of Resident #94's progress notes revealed a Nutritional Progress Note written on 08/29/23 at 2:22 PM by a dietitian. It noted that Resident #94 had been receiving tube feedings but that it had been stopped and she was having fair to good oral intake of meals. A review of the resident's nutrition evaluations revealed a Quarterly Nutritional Evaluation, documented by the facility's Dietary Manager on 10/11/23, revealing that Resident #94's weight was stable. Further review revealed the next Quarterly Nutritional Evaluation documented by the facility's Dietary Manager on 01/11/24 indicated that Resident #94 had suffered a 6.52 percent weight loss in one month. Weight Change Notes were written by the facility's Dietary Manager on 01/15/24, 01/29/24, 02/05/24, and 03/07/24, which all documented weight loss being suffered by Resident #94. Additionally, a Quarterly Nutritional Evaluation was done on 04/11/24 by the facility's Dietary Manager, which documented the 13.21 percent weight loss in six months: however, there were no notes written by the dietitian addressing this weight loss. A review of Resident #94's physician's orders revealed an order dated 07/11/23: Liberalize diet, pureed texture, nectar consistency. An order was written on 01/18/24 for: Magic Cup nutritional supplement to be given two times a day for weight maintenance, and an order was written from 01/31/24 to 03/29/24 for Mighty Shake to be given three times a day. An observation was made on 04/23/24 at 8:57 AM of Resident #94 during the breakfast meal. She was lying in bed with a staff member assisting her with her meal. She had consumed about 15% of her meal with the staff member's assistance. An observation was made on 04/23/24 at 12:23 PM of Resident #94 during the lunch meal. She was lying in bed with a family member assisting her with her meal. She had consumed about 25% of her meal with the family member's assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106142 If continuation sheet Page 5 of 7 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 04/25/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation was made on 04/24/24 at 8:18 AM of Resident #94 during the breakfast meal. She was lying in bed with her plate uncovered and the cloche cover lying on her bed. No staff member was assisting her with her meal. Further observation revealed Certified Nursing Assistant D entering Resident #94's room at 8:43 AM to assist the resident with eating. CNA D stood over Resident #94 while assisting her with the meal. When her tray was removed at 8:54 AM, she had consumed about 15% of her meal with CNA D's assistance. An observation was made on 04/24/24 at 12:09 PM of Resident #94 during the lunch meal. She was lying in bed with a staff member assisting her with her meal. She consumed approximately 25% of her meal tray and 100% of her Magic Cup nutritional supplement with the staff member's assistance. An observation was made on 04/25/24 at 8:45 AM of Resident #94 during the breakfast meal. She was lying in bed and CNA E was assisting her with her meal. CNA E stood over Resident #94 while assisting her with her meal. When her tray was removed at 8:51 AM, she had consumed approximately 15% of her meal with CNA E's assistance. A telephone interview was conducted with Registered Dietitian C on 04/25/24 at 9:49 AM. When asked when she had last seen or assessed Resident #94, she stated she had last assessed Resident #94 in October 2023. She said she was not aware that Resident #94 had suffered weight loss. When asked why the Mighty Shake supplement was stopped in March despite the weight loss, The dietitian stated she did not know. She said she was scheduled to come to the facility on [DATE] and would assess Resident #94 at that time. She planned to order Boost nutritional supplement related to the weight loss that was suffered. An interview was conducted with the facility's Dietary Manager on 04/25/24 at 10:25 AM. She stated she was aware that Resident #94 had suffered weight loss, but that she had not talked to the dietitian about the weight loss. When asked why the Mighty Shake supplement was stopped in March, she stated a staff member told her the family wanted it stopped. She further stated she did not remember who the staff member was that told her and she had not followed up with the family or the dietitian regarding that change. When asked what other interventions could be implemented, she stated they could try double protein with meals or another supplement such as Boost, but that she could not write orders, only the dietitian could write orders. A review of the facility's policy titled Medical Nutrition Therapy Documentation (dated 2019) revealed the following: The Certified Dietary Manager's role is to collect the factual data for documentation, communicate pertinent information to the Registered Dietitian and the interdisciplinary team, and implement the physician's diet and supplement orders as applicable. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106142 If continuation sheet Page 6 of 7 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 04/25/2024 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 - Few 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. Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments with access granted only to authorized personnel for one (Resident #45) of one resident reviewed for medication storage. The findings include: During a tour of the facility on 04/22/24 at 1:00 PM, Resident #45's room was entered and a medication cup containing seven (7) medication tablets was observed sitting unattended on the bedside table. (Photographic evidence obtained) Further observation revealed an individual entering Resident #45's room. An interview was conducted with this individual on 04/22/24 at 1:37 PM. She stated she was Resident #45's private duty aide. She further stated the nurse brought the observed medications into Resident #45's room around breakfast time, and that this was not the first time the nursing staff had left medications for her to administer to Resident #45. When asked, the private duty aide stated she was not a certified medication technician, she was a certified nursing assistant. When asked to clarify whether she worked at the facility or was hired by Resident #45's family, she stated she was hired by Resident #45's family. A review of Resident #45's record revealed that Licensed Practical Nurse (LPN) A documented that she administered the following medications to Resident #45 on 04/22/24 at 9:36 AM: Acetaminophen (a medication used for pain) 650 milligrams (mg) (2 tablets), Cetirizine (an allergy medication) 10 mg, Clopidogrel (a blood thinning medication) 75 mg, Rosuvastatin (a cholesterol lowering medication) 10 mg, Sertraline (an antidepressant medication) 25 mg (1/2 tablet), and Vitamin D (an oral supplement medication) 2000 units. A review of Resident #45's Minimum Data Set (MDS) assessments revealed she had a Brief Interview for Mental Status score of one out of 15 possible points, indicating severe cognitive impairment. Further review of the medical record revealed there was no documentation verifying that Resident #45 was safe to self-administer medications or that her private duty aide was safe to administer her medications to her. An interview was conducted with LPN A on 04/25/24 at 8:20 AM. She stated she had no recollection of leaving the above medications at Resident #45's bedside. A review of the facility's policy titled Medication Administration (revised 01/01/23), revealed: Medications are administered by licensed nurses or other staff who are legally authorized to do so as ordered by the physician and in accordance with professional standards of practice. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106142 If continuation sheet Page 7 of 7