Federal inspectors found that Fernandina Beach Rehabilitation and Nursing Center failed to maintain proper nutrition for two residents who suffered dramatic weight loss between December 2023 and June 2024. One resident dropped from 108 pounds to 84.7 pounds, losing 21.57% of her body weight. The other fell from 157 pounds to 115.8 pounds, a 26.24% loss.
The first resident, identified as Resident #57, appeared thin when inspectors observed her lying in bed during their June 25 facility tour. Medical records revealed she had dementia, anxiety, depression, and severe cognitive impairment with a score of 6 out of 15 on mental status testing.
Staff had been aware of her declining condition for months. An interdisciplinary team meeting in January noted "overall decline and generalized weakness" with "significant weight loss recently" and "poor" oral intake. The team decided to try bringing her to the dining room to see if the environment would encourage eating.
By February, another meeting acknowledged her weight "continues to trend down" despite receiving nutritional supplements three times daily. Staff noted she was "eating in the dining room infrequently" and needed to be brought there "more frequently/consistently."
A March quality review revealed the resident was "trending down overall" with "poor PO intake." The physician had declined to prescribe an appetite stimulant, but staff changed her supplement from Ensure Clear, which she disliked, to chocolate Ensure three times daily.
Yet when inspectors observed her meals, the supplements were consistently missing. During lunch on June 25, she consumed only 25% of her meal with no Ensure present on her tray. Records showed she had consumed zero percent of her Ensure supplement 41 times between June 1 and June 26. Over 30 days, she consumed 50% or less of 48 documented meals.
The breakdown in care became clear during staff interviews. Licensed Practical Nurse C told inspectors she had not been providing the resident's supplements "because Resident #57 did not like Ensure Clear." When told the order had been changed to chocolate in March, the nurse said she was unaware of the change. This meant the resident went months without receiving her physician-ordered supplement.
The facility's dietitian told inspectors he felt established interventions were having a "positive effect" and didn't see a need for additional measures, despite the continued weight loss.
A certified nursing assistant working through a staffing agency said she had worked with the resident before but "had never helped her with Ensure." Another CNA employed by the facility said she didn't provide Ensure to residents, noting "the Ensures do not come from the kitchen on the trays."
The second resident, #34, lost 41.2 pounds over six months. She had dementia and moderate cognitive impairment. Quality notes documented her "unplanned weight loss" and "variable" oral intake, with her diet downgraded from regular texture to mechanical soft in April.
When inspectors observed her meals, she consumed nothing at breakfast on June 26 and told them "no" when asked if she would eat her lunch. The next day, she managed 25% of breakfast but again consumed nothing at lunch, again telling inspectors "no" when asked about eating.
Staff acknowledged knowing about her weight loss since March, when she "triggered in the computer system for significant weight loss." The dietitian recalled she "used to be sprightly, but now not so much." Interventions included encouraging her to eat in the restorative dining room and having the kitchen follow up on food preferences.
The facility also failed to properly coordinate dialysis care. One dialysis patient told inspectors she was supposed to receive lunch to take with her to appointments but "this happens all the time" that none was provided. She had eaten nothing since breakfast and would have to wait until dinner.
The resident's sister, present daily, confirmed the facility had not provided lunch since admission. "I usually buy her snacks to have when she gets back from dialysis. I have had to buy her lunch and take it to her at the dialysis center at times."
Even when staff prepared a bagged lunch, coordination failures continued. Inspectors watched the dietary manager standing in the lobby holding a bagged lunch for the dialysis patient, but the resident left without receiving it. When asked if the resident got her lunch, the dietary manager replied, "No, she didn't get it."
The facility's dialysis policy required providing snacks or meals "per request, prior to or after dialysis appointments," but staff consistently failed to follow through.
Communication breakdowns extended to required forms for dialysis patients. The facility failed to complete communication forms for three of four dialysis residents, with missing information about lab work, vital signs, and treatment status that should have been shared with the dialysis center.
Medication storage violations compounded the care failures. Inspectors found prescription medications left unattended at residents' bedsides, including vitamin C tablets, asthma inhalers, and eye drops. Some residents had outdated self-administration assessments from years earlier that didn't match their current medications.
At one nurses' station, medication cards for a resident were left unattended on the desk for 38 minutes where they could be accessed by anyone. In a medication room, inspectors found personal drinks and fried chicken stored alongside medications. One medication cart contained expired acetaminophen suppositories.
Record-keeping problems affected pain medication tracking. For one resident prescribed oxycodone every four hours as needed, electronic medication records didn't match narcotic sign-out sheets. The resident told inspectors she sometimes waited hours for pain medication, keeping her own written log of requests because staff responses were so unreliable.
"Sometimes it takes hours to get it," she said. "Yesterday, I requested my pain medication at 4:00 PM and the nurse brought it to me at 4:10 PM... I asked for it again at 8:00 PM and the nurse said she would bring it, but she never did... I finally got my pain pill at 11:10 PM."
Basic infection control failed during medication administration. Inspectors observed a licensed practical nurse administering medications to two residents without performing hand hygiene before or after either encounter, violating the facility's own policies requiring established infection control procedures.
The facility also failed to assess pneumococcal vaccination status within required timeframes for two residents, with assessments overdue by weeks. The Director of Nursing, serving as acting infection preventionist, acknowledged she was new to the role and hadn't begun reviewing newly admitted residents' vaccination records.
Administrative failures included not providing required transfer notifications when a resident was hospitalized for cellulitis, foot pain, fever, and nausea. The facility failed to notify the resident's representative or the state ombudsman in writing, and couldn't provide documentation of bed hold notices for the hospital transfer.
The resident with severe weight loss remained at 84.7 pounds when inspectors completed their review, having lost nearly a quarter of her body weight while staff failed to provide basic nutritional interventions ordered by her physician.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fernandina Beach Rehabilitation and Nursing Center from 2024-06-27 including all violations, facility responses, and corrective action plans.
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