First Coast Health And Rehabilitation Center

Based on record review, interviews and a review of facility policies and procedures, the facility failed to 1) Complete the notice of transfer or discharge (Discharge/Transfer Notice AHCA 3120-002 form), and 2) Send a copy of the notice of transfer/Discharge to the representative of the Office of the State Long-Term Care Ombudsman's office for three (Residents #90, #92 and #23) of three residents reviewed for discharge requirements. The findings include:1.A review of Resident #90's medical record revealed an initial admission date of 11/26/25 and a re-entry date of 12/4/25. The resident was then discharged to an acute care hospital via emergency medical services for shortness of breath/respiratory distress on 12/29/25. A physician's order, dated 12/29/25, instructed nursing staff to send the resident to the hospital for respiratory distress.An SBAR (Situation, Background, Assessment, Recommendation) Summary revealed that on 12/29/25 at 20:20 (8:20 PM), Resident #90 had a change in condition (shortness of breath) with provider recommendations to Send resident to the hospital via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an effective pest control program, as evidenced by repeated observations of live roaches and fruit flies in four (#101, #103, #105, and #214) of 39 resident rooms and two (100 hall and 300 hall) of three hallways. Failure of the facility to eradicate pests can pose health risks to vulnerable residents including transmission of diseases, allergic reactions and discomfort/infection related to bug bites. Pests can potentially threaten sanitation, contaminate food and cause residents emotional distress.The findings include: On 1/20/26 at 8:34 AM, a live roach was observed crawling on the floor from room [ROOM NUMBER] into the hallway. (photographic evidence obtained)On 1/20/26 at 8:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) E, who witnessed and confirmed the live roach crawling from room [ROOM NUMBER] into the hallway. CNA E stated sightings of roaches and flies occurred daily.On 1/20/26, small flying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident shower/bathroom in the East Wing and [NAME] Wing bathroom were maintain in a safe, functional, sanitary, and comfortable environment; and failed to secure the bathroom sinks to the walls in rooms [ROOM NUMBER]. The findings include: On 11/6/2024 at 10:17 am, during a tour of the East Wing, a foul odor was present upon entering the shower room used for residents. A bucket placed under the toilet tank was observed. When the toilet was flushed water immediately began to pour into the bucket from a crack in the tank. (Photographic evidence obtained) Observation of the shower revealed there was a leak in the neck that connected the shower head to the wall. When the shower was turned on, water sprayed from the neck and the wall of the shower. (Photographic evidence obtained) On 11/6/2024 at 10:43 am, while touring the [NAME] Wing, a blanket and towel were observed on the floor outside a restroom located near the nurses'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain sufficient nursing staff at all times to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being for three (Residents #50, #71, and #289) of three resident requiring one on one supervision, from a total of 26 residents in the sample. This had the potential to negatively impact all 90 resident in the facility at the time of the survey. The findings include: 1. A review of Resident #50's clinical record revealed an admission date of 8/4/20 with diagnoses that included encephalopathy, seizures, anxiety, depression, and schizoaffective disorder. A quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident has a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition. A review of the physician's orders dated 2/9/24 revealed Resident #50 was to have one to one (1:1) supervision every shift. 2. A review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on employee record reviews and staff interviews, the facility failed to provide the required in-service training for nurse aides, to ensure the continuing competence of nurse aides, no less than 12 hours per year, which includes dementia management training and resident abuse prevention training to 3 Certified Nursing Assistants (CNAs) (CNA Staff D, E, and F) of 5 staff reviewed. This has the potential to jeopardize continued conpetence of CNAs. The finding include: A record review of training files revealed the following: CNA D was hired on 2/10/21. Further review revealed no evidence a current 12 hours of in-service education was provided. CNA E was hired on 9/25/06. Further review revealed no evidence a current 12 hours of in-service was provided. CNA F was hired on 2/9/23. Further review revealed no evidence a current 12 hours of in-service was provided. On 2/29/24 at 1:01 PM, the Administrator, Director of Nursing (DON) and Regional Nurse Consultant were requested to provide the CNA competence records for CNA D, E, and F. On 2/29/24 at 2:00 PM, the Administrator stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to update and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for two (Residents #50 and #71) of four residents reviewed for comprehensive care plans, from a total sample of 26 residents. The findings include: 1. A review of Resident #50's clinical record revealed an admission date of 8/4/20 with diagnoses that included encephalopathy, seizures, anxiety, depression, and schizoaffective disorder. A quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident has a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition. Progress note dated 2/7/24 stated Resident #50 was observed kissing Resident #71 in her room. A review of the physician's orders dated 2/9/24 revealed Resident #50 was to have one to one supervision every shift. A review of resident's current care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review for oxygen therapy, the facility failed to ensure that one (Resident #44) of three residents reviewed for respiratory care, received the correct number of liters of oxygen ordered by the physician, in a total sample of 26 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: On 2/26/24 at 10:25 AM, Resident #44 was observed lying in bed without oxygen via nasal cannula. The oxygen concentrator was located away from the bed with nasal cannula wrapped around the concentrator handle. (Photographic evidence obtained) A review of Resident #44's medical record revealed an admission date of 2/17/20 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure with hypoxia, and unspecified asthma with (acute) exacerbation. A review of the annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #3) of 3 residents sampled. Resident #3's wheelchair was observed with razors on his wheelchair and he was left unsupervised in the bathroom with them. This practice could result in injury to this resident or any other resident who had access to the razors. The findings included: On 12/4/23 as 12:20 pm, Resident #3 was observed entering the women's restroom unassisted on the East Wing of the facility. During this time there were no staff present at the nurses' station or on the wing. Employee D, Certified Nursing Assistant (CNA) was notified by the surveyor of the observation. Employee D knocked on the door of the women's restroom and advised Resident #3 that he could not be in the women's restroom and needed to leave immediately. The resident began to audibly yell that he had been shaving in that bathroom for years. She again…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure food was properly labeled; dishwashing machine was operating at required temperatures; maintain dishwashing machine daily temperature logs; maintained food at safe temperatures; and document food temperatures on temperature log. The findings include: During a tour of the kitchen on 3/14/22 at 9:55 AM, the following concerns were identified: 1. The milk cooler door was observed with a black substance on the rubber trim and the rubber trim was disconnected from the door. (Photographic evidence obtained) 2. The dishwashing machine was observed with a brown debris, crumble-like substance on top of it. (Photographic evidence obtained) 3. The walk-in refrigerator had the following items with no dates: a) peaches in serving cups b) five, small Styrofoam boxes stacked up c) plastic container with an orange liquid, covered loosely with plastic wrap.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, interviews, and facility policy and procedure review, the facility failed to provide respiratory care as needed and ordered for one (Resident #71) of eight residents receiving respiratory treatment, from a total of 39 residents in the sample. The findings include: A review of the medical record for Resident #71 revealed an admission date of 6/15/19 with diagnoses of aphasia following cerebral infarction, apraxia following unspecified cerebrovascular disease, chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia and speech deficit. A review of the current physician's orders revealed oxygen at 2 Liters per minute (LPM) continuous for shortness of breath, clean oxygen filter weekly, change oxygen tubing and set up weekly. An observation on 3/14/22 at 11:50 AM revealed Resident #71 was receiving oxygen through a nasal cannula at 2.5 LPM. On 3/15/22 at 10:00 AM, Resident #71 was observed receiving oxygen through a nasal cannula at 2.5 LPM. (Photographic evidence obtained) On 3/17/22 at 9:25 AM, Resident #71 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interview, and facility policy and procedure review, the facility failed to ensure drug regimen was reviewed at least once a month by a licensed pharmacist for two (Residents #44 and #58) of five residents reviewed for unnecessary medication, from a total of 39 residents in the sample. The findings include: 1. A review of Resident #44's medical record revealed he was admitted on [DATE] with a readmission date of 10/7/20. Resident had orders for Depakote 275 milligrams (mg) twice daily for mood stabilization; Remeron 7.5 mg at bedtime for depression; Buspirone 15 mg three times daily for anxiety; Fluvoxamine 50 mg once daily for obsessive compulsive disorder; and Sertraline 25 mg once daily for major depression. A review of the monthly pharmacy reports from October 2021 to March 2022 revealed Resident #44 was not reviewed during the months of November 2021, December 2021, January 2022, and February 2022. 2. A review of Resident #58's medical record revealed he was admitted on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy and procedure review, the facility failed to monitor resident behaviors related to the use of psychotropic medication for one (Resident #58) of five residents reviewed for unnecessary medications from a total of 39 residents in the sample. The findings include: A record review for Resident #58 revealed he was admitted on [DATE] with a readmission date of 2/8/22, with the following diagnoses: anxiety disorder, major depressive disorder, acute renal failure on dialysis, hemiplegia, and hemiparesis right side, and left below the knee amputation. A review of the physician orders on 2/8/22, revealed an order for Escitalopram Oxalate (Lexapro)10 milligrams (mg) once daily for depression and Buspirone (Buspar) 5 mg three times daily for anxiety. (Photocopy obtained) Further review of the physician's orders on 2/9/22, revealed an order for Lexapro (escitalopram) antidepressant behavior monitoring every shift for behavioral disturbances and Buspar (Buspirone) behavior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.