Fernandina Beach Rehabilitation And Nursing Center

F-F609.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,

before transfer or discharge, including appeal rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47306

Residents Affected - Few Based on record review and staff interview, the facility failed to 1) Provide the appropriate transfer/discharge notice to the resident and their responsible party, and 2) Notify the Office of the State Long-Term Care Ombudsman in writing of a resident transfer to the hospital for one (Resident #70) of two residents reviewed for transfer/discharge and hospitalization , from a total sample of 42 residents.

The findings include:

A review of Resident #70's medical record revealed that she was transported to the hospital on 4/30/24 for right foot pain, fever, and nausea. A progress note dated 5/3/24 revealed that she was transferred back/readmitted to the facility on [DATE REDACTED] from the hospital with a diagnosis of cellulitis to the right lower extremity.

On 6/26/24 at 3:30 PM, an interview was conducted with the Administrator, who was informed that Resident #70's medical record contained no notification in writing to the resident's representative or the local Ombudsman of the resident's transfer to the hospital on 4/30/24.

On 6/27/24, emails provided by the Administrator and addressed to the local Ombudsman notifying the Ombudsman of resident transfers and discharges were reviewed. The emails were dated 2/5/24, 3/6/24, and 4/10/24. There were no emails dated for the month of May 2024. Resident #70's name did not appear in any of the emails.

On 6/27/24 at 10:07 AM, a follow-up interview was conducted with the Administrator regarding the emails to

the local Ombudsman. The Administrator was asked if she had additional emails for the month of May 2024 that would verify notification of Resident #70's transfer to the hospital on 4/30/24. The Administrator replied no, the emails she provided were all she had. The Administrator was asked if she had documentation verifying notification of Resident #70's representative in writing of the transfer to the hospital on 4/30/24. The Administrator stated she did not. The Administrator stated she was not aware of a facility policy regarding notification of the local Ombudsman.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Level of Harm - Minimal harm or potential for actual harm 47306

Residents Affected - Few Based on record review, interview, and facility policy review, the facility failed to provide a Bed Hold notice to one (Resident #70) of two residents reviewed for transfer/discharge to acute care settings, from a total sample of 42 residents.

The findings include:

A review of Resident #70's medical record revealed a progress note dated 4/30/24 indicating that the resident was transported to an acute care hospital on 4/30/24. The record did not contain a Bed Hold notice for the transfer.

On 6/27/24 at 10:07AM, an interview was conducted with the Administrator. The Administrator stated no Bed Hold notice was issued for the resident regarding her transfer to the hospital on 4/30/24.

A review of the facility's policy titled Attachment A, Bed Hold Policy and Notification (Undated), revealed that

it was facility policy to inform residents/legal representatives upon admission and after leaving the facility for hospitalization , observation, or therapeutic leave, of the facility's Bed Hold Policy and Notification. The policy indicated each resident/legal representative would be informed by staff of the facility's Bed Hold Policy and Notification upon admission to the facility and/or when a resident left for hospitalization , observation, or therapeutic leave.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45951 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the maintenance of Residents Affected - Some acceptable parameters of nutritional status, by failing to provide nutritional interventions in a timely manner to prevent significant weight loss for two (Residents #57 and #34) of five residents reviewed for nutrition, from a total sample of 42 residents.

The findings include:

1. During a tour of the facility on 06/25/24 at 9:38 AM, Resident #57 was observed lying in her bed. She appeared thin.

A review of the resident's medical record revealed she had suffered weight loss. On 12/23/23, Resident #57 weighed 108 pounds, and on 06/18/24, she weighed 84.7 pounds. This indicated the resident lost 21.57% of her body weight within six months. She was admitted to the facility on [DATE REDACTED] with a medical history significant for dementia, anxiety, depression, weakness, transient ischemic attack (TIA), and osteoarthritis.

A review of the Quarterly Minimum Data Set (MDS) assessment, completed on 04/12/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severe cognitive impairment. She required staff assistance to set up her meal trays, and it was documented that she had suffered unintentional weight loss.

A Care Plan was revised during the survey week regarding Resident #57's weight loss.

Review of the resident's active physician's orders revealed she was ordered to receive a regular diet with regular textured foods and thin consistency liquids. An order was written on 03/15/24 for Ensure chocolate nutritional supplement to be given three times a day.

An observation was made on 06/25/24 at 12:45 AM of Resident #57 in her bed with her lunch meal tray. A staff member set her tray up for her. Continued observation revealed that she consumed approximately 25% of her meal. There was no Ensure supplement present on her tray.

A review of her nutritional intake records revealed she had consumed zero percent of her Ensure supplement 41 times between 06/01/24 and 06/26/24. A 30-day look back of meal consumption revealed she consumed 50% or less of 48 of her documented meals.

A review of progress notes regarding Resident #57's weight status, revealed that on 01/18/24, an Interdisciplinary Team (IDT) meeting discussed the weight loss, stating Overall decline and generalized weakness. Has had a significant weight loss recently. PO [oral] intake is poor. Doesn't go to the dining room anymore. Will try and bring her to the dining room to see if the environment during meals helps cue her to eat.

Further review of progress notes revealed that on 01/31/24, an IDT meeting discussed the weight loss again, stating Can add Ensure Clear [supplement] TID [three times per day].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 An additional IDT meeting note was written on 02/15/24, stating, Eating in the dining room infrequently. Getting Ensure TID. Weight continues to trend down. Need to bring her to the dining room more Level of Harm - Minimal harm or frequently/consistently. potential for actual harm

A Quality of Care note written on 03/14/24, revealed, Reviewed for weight loss. Trending down overall. Poor Residents Affected - Some PO intake. Getting Ensure Clear, dislikes. MD declined appetite stimulant. Can change to Ensure Chocolate TID.

An observation was made on 06/26/24 at 1:18 PM of Resident #57 in her bed with her lunch meal tray. She consumed 0% of her meal. There was no Ensure supplement present on her tray.

An interview was conducted with the facility's Dietitian on 06/26/24 at 3:58 PM. He stated he had been following Resident #57 for the last few months and that the IDT met weekly to discuss any residents with weight loss. He stated Resident #57 had been receiving Ensure supplements since February. He further stated they had started with Ensure Clear, but she did not like that supplement, so they changed to Ensure chocolate. He recalled speaking to Resident #57's physician about ordering an appetite stimulant, but the physician did not agree with that course of action. When asked what other interventions were considered to assist in stopping Resident #57's weight loss, the Dietitian stated the staff were instructed to encourage Resident #57 to go to the restorative dining room for her meals. When asked which meals she should be eating in the dining room, he stated the staff should be encouraging her at all meals to go to the dining room. When asked who was responsible for providing the Ensure supplements to the residents, he stated it was Nursing's responsibility to make sure the Ensure supplements were distributed to the residents at mealtimes.

He further stated the kitchen was responsible for ordering the Ensure. When asked if any other interventions were considered for Resident #57's weight loss, he stated he felt the established interventions were having a positive effect, so he did not feel there was a need for additional interventions.

An observation was made on 06/26/24 at 6:08 PM of Resident #57 in her bed with her dinner tray. There was no Ensure supplement present on her tray. Certified Nursing Assistant (CNA) A was observed assisting her with her meal. An interview was conducted with CNA A at this time. She stated she did not work for the facility but rather worked for a nurse staffing agency. She stated she was familiar with Resident #57 and had worked with her before. When asked if the resident required assistance with dining, CNA A stated she ate well with assistance. When asked what she had consumed at her other meals that day, CNA A stated the resident had not eaten her breakfast and that she had slept through her lunch. When asked if she had assisted Resident #57 with Ensure supplements that day or before, the CNA stated she had never helped her with Ensure.

An interview was conducted with CNA B on 06/26/24 at 6:12 PM. She stated she worked for the facility, and

she was familiar with Resident #57. When asked how residents received Ensure supplements, she stated

the CNAs did not provide Ensure to the residents but maybe the nurses do. She stated, All I know is that the Ensures do not come from the kitchen on the trays. When asked if she recalled assisting Resident #57 with Ensure supplements, she stated she did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 An interview was conducted with Licensed Practical Nurse (LPN) C on 06/26/24 at 6:18 PM. She confirmed that the nurses kept the Ensure supplement bottles in their medication carts, and that they were responsible Level of Harm - Minimal harm or for providing them to the residents. When asked if she had been providing Resident #57 with her Ensure potential for actual harm supplements, she stated she had not because Resident #57 did not like Ensure Clear. She said she had spoken to the Dietitian about changing her to chocolate, but that they had not. When told that the Ensure Residents Affected - Some order had been changed in March to the chocolate, she stated she was not aware of that change. This indicated that Resident #57 was not receiving her physician-ordered supplement.

An observation was attempted on 06/27/24 at 9:16 AM of Resident #57's breakfast tray. Resident #57 was in bed at the time of this observation, but the tray had been removed from the bedside. A staff member stated Resident #57 had consumed approximately 10% of her meal. A strawberry flavored Ensure was present on her bedside table and was approximately half consumed.

An observation was made on 06/27/24 at 12:44 PM of Resident #57 in her bed with her lunch meal tray. Resident #57 had consumed 0% of her meal. There were two Ensure cartons present on her tray - one was

the leftover strawberry flavor from her breakfast tray and was approximately 70% consumed. The other was chocolate and was unopened.

2. During a tour of the facility on 06/25/24 at 10:10 AM, Resident #34 was observed sitting up in her wheelchair. She appeared thin.

A record review revealed that Resident #34 had suffered weight loss. On 12/03/23, she weighed 157 pounds, and on 06/17/24 she weighed 115.8 pounds. This indicated that Resident #34 lost 26.24% of her body weight in six months.

Resident #34 was last admitted to the facility on [DATE REDACTED] with a medical history significant for dementia, agitation, anxiety, schizoaffective disorder, depressive type, and malnutrition.

A review of the resident's Quarterly MDS assessment, completed on 04/25/24, revealed she had a BIMS score of 8 out of 15 possible points, indicating a moderate cognitive impairment. Weight loss was documented as unknown.

A Care Plan was revised during the survey week regarding Resident #34's weight loss.

A review of the resident's active physician's orders revealed she was ordered to receive a regular diet with mechanical soft textured foods and thin consistency liquids.

An observation was made on 06/26/24 at 9:13 AM of Resident #34 in her room with her breakfast tray. She had consumed 0% of her meal.

A review of a 30-day look back of meal consumption revealed she had consumed 50% or less of 34 of her documented meals.

A review of the Quality of Care notes written in March, April, and June 2024 revealed the staff were aware of unplanned weight loss. It was also documented that her oral intake was variable, and her diet had required a downgrade in April 2024 from regular texture to mechanical soft. No notes were found regarding weight loss interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 An observation was made on 06/26/24 at 1:19 PM of Resident #34 in her room with her lunch meal tray. She consumed 0% of her meal. When she was asked if she was going to eat her food, she said no. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the facility's Dietitian on 06/26/24 at 4:13 PM. He stated he had been following Resident #34. He said she had triggered in the computer system for significant weight loss in Residents Affected - Some March. He recalled, She used to be sprightly, but now not so much. He stated as a result of the weight loss,

they initiated encouraging Resident #34 to go to the restorative dining room for her meals. He said the kitchen followed up with her regarding her food preferences and the Psychiatry team saw her due to her change in mood. When asked if any other interventions were considered for Resident #34's weight loss, he stated he felt the established interventions were having a positive effect, so he did not feel there was a need for additional interventions.

An interview was conducted with CNA B on 06/26/24 at 6:13 PM. She stated she worked for the facility, and

she was familiar with Resident #34. She stated Resident #34 was in the dining room for her dinner, but that

she often ate in her room. She said depending on the day, Resident #34 decided where to eat her meals. Resident #34 had not eaten any of her breakfast or lunch that day, so she was hopeful that she would eat a good dinner.

An observation was made on 06/27/24 at 9:15 AM of Resident #34 in her room with her breakfast tray. She had consumed 25% of her meal.

An observation was made on 06/27/24 at 12:46 PM of Resident #34 in her room with her lunch meal tray.

She had consumed 0% of her meal. When she was asked if she was going to eat her food, she said no.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50783 potential for actual harm Based on observations, record reviews, and interviews, the facility failed to 1) Provide meals for one Residents Affected - Some (Resident #23) of four residents receiving hemodialysis, and 2) Complete communication information forms for three (Residents #55, #413, and #13) of four residents receiving hemodialysis.

The findings include:

1. On 6/25/24 at 10:30 AM, Resident #23 left for her dialysis appointment and did not receive a lunch or snack to take with her. Upon her return at 4:00 PM, she stated she was supposed to take a lunch with her; however, none was provided to her. This happens all the time. She said she had not had anything to eat since breakfast and was now having to wait until dinner time to eat. She confirmed that the facility was supposed to provide a snack or a lunch to take with her, but they never do. The resident's sister, present

during this interview, stated, I am here every day, and they have not provided a lunch for her since her admission that I know of. (admitted on [DATE REDACTED]) 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.

During an observation of Resident #23's room on 6/25/24, her lunch was served in her room at 12:45 PM while she was out of the facility at dialysis. At 2:30 PM on 6/25/24, the lunch tray was no longer observed in

the resident's room.

An interview was conducted with Certified Nursing Assistant (CNA) S on 06/26/24 at 2:14 PM. She stated lunch trays were usually served around 1:00 PM on the units, but if staff knew that a resident had an appointment prior to that, they could request an early lunch tray or have a sack lunch provided for the resident to take with them.

An interview was conducted on 6/26/24 at 2:06 PM with Registered Dietician (RD) Q. He stated the kitchen prepared and provided a lunch for all dialysis residents to take with them during their appointments. A communication form was filled out by the facility with any concerns or pertinent information. The residents took those with them to their dialysis appointments and the dialysis nurse used the forms to communicate any lab work, medications, resident vital signs, and/or weights prior to treatment and again post treatment. Upon the residents' return to the facility, the communication forms were kept in a binder at the nurses' station for the staff and the RD to review for information that may be needed to complete resident assessments.

On 6/26/24 at 2:47 PM, an interview was conducted with Dietary Manager J who stated lunch trays were served on the units around 12:50 PM. For residents with an appointment before then, staff could request an early tray to be delivered to them before their appointment or take a sack lunch with them while they were out of the facility. She also stated for residents going to dialysis centers, the transportation driver would pick up the resident's lunch from the kitchen prior to them leaving for the appointment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 2. On 6/26/24 at 11:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) F, who stated all dialysis communication information was kept in a binder at the nurses' station. Further review of progress Level of Harm - Minimal harm or notes and dialysis communication forms located in a binder at the nurses' station and labeled Dialysis potential for actual harm Communication Binder, revealed there was no documentation present for three of four residents receiving dialysis. (Residents #55, #413, and #13) Residents Affected - Some

On 6/26/24 at 12:00 PM, Corporate Nurse G was asked to provide dialysis communication forms for the residents receiving dialysis.

On 6/26/24 at 4:31 PM, a second request was made to Corporate Nurse G for the dialysis communication forms for the residents receiving dialysis.

A review of the dialysis communication forms provided by the facility, revealed that either section one was not completed by nursing facility staff prior to dialysis appointments, and/or section three was not completed by nursing facility staff upon the residents' return from dialysis. A review of the four dialysis residents' medical records revealed that the dialysis communication forms for all four were incomplete.

Resident #55's dialysis communication forms were incomplete on 4/6/24, 6/20/24, 6/22/24, and 6/25/24. (Photographic evidence obtained)

Resident #413's dialysis communication forms were incomplete on 6/20/24, 6/22/24, and 6/25/24. (Photographic evidence obtained)

Resident #13's dialysis communication forms were incomplete on 6/6/24, 6/11/24, 6/13/24, and 6/18/24. (Photographic evidence obtained)

On 6/26/24 at 6:06 PM, an interview was conducted with the Director of Nursing (DON). She stated communication between the facility and the dialysis center was conducted via a communication form that listed pertinent information about the resident such as lab work, nutritional status, vital signs, and the residents' status. The form was sent with the resident to the dialysis center on the days of their appointments. Upon their return, the form was checked to see if any concerns were addressed at the center

during treatment, or if there were any recommendations that the facility should follow up on prior to the next treatment. The DON denied having any knowledge of a binder to keep the communication sheets in and further stated, Those sheets should go to medical records and then be uploaded in the computer.

On 6/26/24 at 6:30 PM, an interview was conducted with LPN H at the nurses' station on Unit Two. She was asked to provide the dialysis binder used for communication with the dialysis center. She picked up the binder that was sitting directly in front of her and opened it, revealing only one communication form, dated 6/15/24. The nurse then stated, with Corporate Nurse G present, Oh no, the communication sheets are sent to medical records when the resident returns. We don't keep them in here anymore.

On 6/26/24 at 7:10 PM, Corporate Nurse G stated the medical records office was locked, no one had access to the room, and the communication forms could not be obtained until the following morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 On 6/27/24 at 10:32 AM, Resident #23 was observed preparing to leave for her dialysis appointment. She was being assisted by staff into the transport van and was leaving the facility for her appointment. Further Level of Harm - Minimal harm or observation revealed that Dietary Manager J was standing at the front lobby desk holding a bagged lunch for potential for actual harm Resident #23. When she was asked whether Resident #23 got her lunch, Dietary Manager J stated, No, she didn't get it. Residents Affected - Some

On 6/27/24 at 11:00 AM, an interview was conducted with Transportation Driver T. He stated it was his responsibility to ensure the resident's lunch was picked up from the kitchen to take with her, and to communicate with any outside transportation any care needs the resident may have during transport; however, the dialysis center did not allow them to eat while they were there.

On 6/27/24 at 11:30 AM, the Regional Director of Clinical Practice stated she spoke with a nurse at the dialysis center and was told that the facility did not allow the residents to eat while being administered their treatment; however, they were more than welcome to eat prior to their treatment or after their treatment was completed while waiting for transportation back to the facility. She further stated the dialysis center encouraged the facility to supply their lunch to bring with the resident to the center.

A review of the facility's policy titled Standards and Guidelines for Dialysis Care (Issued: 10/2014, Revised: 1/2024) revealed: The facility staff will provide information that is useful or necessary for the care of residents to the dialysis center. The facility will communicate with the dialysis center related to the resident's tolerance of treatment. The facility will provide a snack/meal to the resident per request, prior to or after dialysis appointments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44730 Residents Affected - Few Based on observations, interviews, and record review, the facility failed to maintain proper storage of medications for three (Residents # 51, #65, and #6) of 112 residents observed during the initial tour of the facility, one resident (#41) during an observation at one nurses' station (Station 2), and in one medication cart (Station 2 - C Hall) during a medication storage observation.

The findings include:

1. On [DATE REDACTED] at 9:29 AM, an observation was made of Resident #51's over-the-bed table, which revealed a clear medication cup sitting there with two orange-colored pills in the cup. Resident #51 stated the medication was her Vitamin C chewable tablets, and she liked to suck on them after she took her other medications because she did not have any teeth. (Photographic evidence obtained)

On [DATE REDACTED] at 10:29 AM, an interview was conducted with Licensed Practical Nurse (LPN) H. When shown a photograph of the medication observed on Resident #51's over-the-bed table the previous day, LPN H stated

the medication was indeed Resident #51's Vitamin C, and she confirmed that she should not have left the medication at the resident's bedside. She stated she should have stayed with the resident until she took the medication.

On [DATE REDACTED] at 5:33 PM, an interview was conducted with the Director of Nursing (DON), who stated it was her expectation that all nurses remain with the residents until their medications had been taken.

45951

2. On [DATE REDACTED] at 9:42 AM, an observation was made of Resident #65's room. A Budesonide inhaler (asthma medication) was on his bedside table. (Photographic evidence obtained) When asked if the staff always left

this inhaler in his room for him, Resident #65 replied, sometimes.

A review of the resident's medical record revealed he had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating that he was cognitively intact.

Further review of the medical record revealed he did not have an assessment present for safe self-administration of medication. An interview was conducted with the Director of Nursing on [DATE REDACTED] at 4:28 PM. She confirmed she knew the inhaler had been left at Resident #65's bedside and that it had since been removed and properly stored in the medication cart.

3. On [DATE REDACTED] at 10:07 AM, an observation was made of Resident #6's room. A box of Artificial Tears (eye drops), a Budesonide inhaler, and an Incruse Ellipta inhaler (treats chronic obstructive pulmonary disease including emphysema) were observed on her bedside table. (Photographic evidence obtained) When asked if the staff always left these medications in her room, Resident #6 replied, yes, always.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 A review of the resident's medical record revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating she was cognitively intact. Level of Harm - Minimal harm or potential for actual harm Further review of the medical record revealed there were two assessments completed regarding safe self-administration of medication. The first was completed on [DATE REDACTED] for eye drops and oral inhaler-Albuterol Residents Affected - Few 0.83%, and the second was completed on [DATE REDACTED] for Fluticasone nasal spray. Both assessments noted that

the resident was safe to self-administer these medications.

An interview was conducted with the Director of Nursing on [DATE REDACTED] at 4:30 PM. She stated she was unaware of the medications found at Resident #6's bedside. She was pleased to hear that the assessments had been done but agreed that since they were more than three years old and did not match the current medications, new assessments should be completed. When she was asked if there was a policy regarding medication self-administration assessments, she replied that there was not.

4. On [DATE REDACTED] at 12:40 PM, an observation was made at the Station 2 nurses' station of a stack of medication cards containing medications that was left unattended. (Photographic evidence obtained) Closer observation revealed the medication cards were labeled with Resident #41's information. Continued observation revealed that LPN C returned to the nurses' station at 1:18 PM. When she saw the medication cards, she asked, Did you take a picture of those? She was asked why the medication cards had been left unattended at the nurses' station for so long. She stated Resident #41 had been transferred from another hall to her hall just

before lunch, and the person who brought him over had handed her the medication cards. She said she placed them at the nurses' station because she wanted to check and organize them before placing them in her medication cart. She stated she knew she shouldn't have left them out of the cart and loose on the desk where they could be seen and accessed by others. Corporate Nurse G was present during this interview.

An interview was conducted with the Director of Nursing on [DATE REDACTED] at 4:34 PM. She stated she was unaware of the medications/cards that had been found at the nurses' station.

A medication room observation was made on [DATE REDACTED] at 5:53 PM with LPN D at the Station 1 nurses' station medication room. Upon entering the room, LPN D asked if she could leave to continue her charting. She was made aware that she needed to stay in the room during the observation. Three personal drinks and a to-go container of fried chicken were observed in an upper cabinet of the medication room. (Photographic evidence obtained) When LPN D was asked if she knew who the drinks and food belonged to, she threw her hands up and said, I swear I was doing my work down the hall! I just came to the nurses' station to do my charting. She then called Nurse Manager F and LPN E for assistance. When they arrived at the medication room, LPN D promptly left. Nurse Manager F and LPN E removed the drinks and food from the medication room immediately.

A medication cart observation was made on [DATE REDACTED] at 6:09 PM with LPN C and Corporate Nurse G on the Station 2 C Hall. While reviewing the medication cart, one box containing five Acetaminophen Suppositories with an expiration date of ,d+[DATE REDACTED] was found. (Photographic evidence obtained) LPN C and Corporate Nurse G stated they would dispose of the expired medication immediately.

A review of the facility's policy titled Medication Administration (Revised ,d+[DATE REDACTED]) revealed: Only persons licensed or permitted by this state to administer medications may do so.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 A review of the facility's policy titled Medication Storage and Labeling (Revised ,d+[DATE REDACTED]) revealed:

Level of Harm - Minimal harm or Drugs used in the facility are stored in locked compartments. Only persons authorized to prepare and potential for actual harm administer medications have access to locked medications;

Residents Affected - Few Drugs are stored in the packaging in which they are received;

The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;

Outdated drugs are returned to the dispensing pharmacy or destroyed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 50783

Residents Affected - Few Based on observations, record review, and interviews, the facility failed to maintain and document accurately

on medication administration records for one (Resident #406) of 42 residents in the total sample.

The findings include:

A review of Resident #406's physician's orders revealed that the resident had an order for oxycodone HCI (narcotic pain medication) 10 mg (milligrams) every 4 hours as needed, ordered 6/18/24.

A review of the June 2024 electronic Medication Administration Record (eMAR) revealed that Resident #406's Oxycodone 10 mg was documented as having been administered on 6/24/24 at 4:27 AM, 8:48 AM, and 1:53 PM. On the resident's narcotic sign-out sheet for Oxycodone 10 mg, the medication was signed out as having been administered on 6/24/24 at 4:27 AM and 1:53 PM. On the narcotic sign-out sheet, this medication was also signed out as having been administered on 6/24/24 at 8:26 PM, but it was not documented on the eMAR for this date and time.

On 6/25/24, Oxycodone 10 mg was documented on the eMAR as having been administered at 9:39 PM, but

the narcotic sign-out sheet showed the medication was administered at 7:40 AM, 11:17 AM, 3:22 PM, and at 10:00 PM.

On 6/26/24, Oxycodone 10 mg was documented in the eMAR as having been administered at 11:20 AM and at 4:12 PM. The narcotic medication sign-out sheet for the same date indicated that this medication was administered at 11:20 AM, 4:12 PM, and at 11:00 PM.

(Photographic evidence obtained)

An interview with the Director of Nursing (DON) was conducted on 6/27/24 at 12:21 PM. The above-mentioned concern was discussed. The DON stated the medication, once administered, would be and should be documented in the eMAR. Once the medication was documented as having been administered,

the eMAR would automatically flag for thirty minutes to an hour for the nurse to document the effectiveness or ineffectiveness of the medication that was administered.

On 6/27/24 at 2:06 PM, Resident #406 was interviewed. She stated nursing staff did not administer her pain medication as she requested, stating, Sometimes it takes hours to get it. I started to write it down when I asked for pain medication. Yesterday, I requested my pain medication at 4:00 PM and the nurse brought it to me at 4:10 PM. I can get it every 4 hours as needed. I asked for it again at 8:00 PM and the nurse said she would bring it, but she never did. I asked for it again at approximately 9:00 PM and I never got it. I asked for it again at approximately 10:00 PM and still I did not get it. I finally got my pain pill at 11:10 PM.

A review of the facility's policy titled Standards and Guidelines of Medication Administration (Issued: 10/2020, Revised: 1/2024) revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 0842 As required, or indicated for a medication, the individual administering the medication records in the resident's medical record: The date and time the medication was administered; the dosage; the route of Level of Harm - Minimal harm or administration; the injection site (if applicable); any complaints or symptoms for which the drug was potential for actual harm administered (if applicable); any results achieved and when those results were observed; and the signature and title of the person administering the drug. Medication administration times are determined by resident Residents Affected - Few need, preference, and benefit, not staff convenience.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50783 potential for actual harm Based on a review of medical records and facility policy, and observations made during medication Residents Affected - Few administration, the facility failed to implement infection control measures to prevent the spread of infection. Standard of practice hand hygiene procedures were not implemented during provision of care for two (Residents #406 and #72) of four residents observed during medication administration.

The findings include:

On 6/27/24 at 8:28 AM during a medication administration observation with LPN R, she was observed walking up to the medication cart, unlocking the cart, removing a medicine cup from the top drawer, locking

the medication cart, and taking the medicine cup to Resident #406's room to administer the medication in the cup. LPN R did not perform hand hygiene before or after administering medications to the resident. When LPN R returned to the medication cart, she unlocked the cart, pulled medication cards from the drawer, reviewed orders for each medication, placed medication that was to be administered in a medicine cup, locked the cart and entered Resident #72's room to administer the medications. She did not perform hand hygiene before removing medications from the medication cards, before administering the medications to Resident #72, or after medication administration was complete. LPN R returned to her medication cart and proceeded to review the Medication Administration Record for the next medication administration.

A review of the facility's policy titled Standards and Guidelines of Medication Administration (Issued: 10/2020, Revised: 1/2024), revealed that staff were to follow established facility infection control procedures, including handwashing, antiseptic technique, gloves, isolation precautions, etc., for the administration of medications, as applicable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 105470 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105470 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fernandina Beach Rehabilitation and Nursing Center 1625 Lime Street Fernandina Beach, FL 32034

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45951 potential for actual harm Based on record review and interview, the facility failed to assess residents' pneumococcal vaccination Residents Affected - Few status in a timely manner for two (Residents #454 and #406) of five residents reviewed for vaccination status, from a total sample of 42 residents.

The findings include:

A record review for Resident #454, revealed that she was admitted to the facility on [DATE REDACTED], and her assessment for pneumococcal vaccination status was due by 6/10/24.

A record review for Resident #406, revealed that she was admitted to the facility on [DATE REDACTED] and her assessment for pneumococcal vaccination status was due by 6/21/24.

A review of residents' pneumococcal vaccination status was conducted on 6/27/24 at 2:30 PM with the Director of Nursing (DON), who confirmed that she was the acting Infection Preventionist for the facility. Five residents were selected for review regarding their pneumococcal vaccination status. The DON stated she was new to the role of Infection Preventionist and she was not in this role when Residents #454 and 406 were admitted to the facility. She reviewed Residents #454 and 406's records and confirmed that she could not find pneumococcal vaccination status records for either resident. She stated in her new role, she planned to conduct a whole-house audit beginning on 7/1/24 to review the pneumococcal vaccination status of each resident, but that she had not begun reviewing the records of the facility's newly admitted residents, which included Residents #454 and 406.

A review of the facility's policy titled Immunizations-Pneumonia (Issued: 7/2020, Revised 2/2024), revealed that residents with no medical contraindications would be offered the pneumococcal vaccine to encourage and promote benefits associated with vaccinations. Assessments of pneumococcal vaccination status would be conducted within five (5) working days of the resident's admission if not conducted prior to admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 105470