Jacksonville Rehabilitation and Nursing

Inspectors wroteBased on observations, interviews, record review, and a review of facility in-service training, the facility failed to follow proper dish sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents receiving food from the facility's kitchen. The facility also failed to log proper temperatures for the dish machine. Sanitation is important in health care settings serving nursing home residents.

Inspectors wroteBased on observations, interviews, record reviews, and a review of the facility's policies and procedures, the facility failed to provide transfer/discharge notification to the Long-Term Care (LTC) Ombudsman's office prior to or as soon as was practicable for eight (Residents #12, #115, #92, #64, #31, #25, #23 and #18) of 12 residents reviewed for transfer/discharge. Appropriate notification of the LTC Ombudsman's office provides added protection for residents from being inappropriately transferred or discharged , provides residents with access to an advocate who can inform them of their options and rights, and ensures that the LTC Ombudsman's office is aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on observations, interviews, record review and a review of the facility's policies and procedures, the facility failed to provide a nourishing, palatable, and well-balanced diet that met the daily nutritional and special dietary needs of its residents, taking into consideration their preferences, by failing to adhere to therapeutic diet orders for a pescatarian diet and follow standardized recipes and portion control in accordance with professional standards for food service. These practices affected nine residents/resident meal trays (Residents #86, #24, #39, #75, #88, #61, #73, #28 and #81) observed during meal service on 4/27/26 and 4/30/26 and placed all residents receiving food from the facility's kitchen at nutritional risk, potentially impairing their ability to heal and/or contributing to a decline in their overall health status. The findings Include:1. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections, by failing to 1) Ensure nursing staff properly performed hand hygiene while working with three (Residents #93, #70 and #74) of six residents observed during medication administration, and 2) Ensure urinary catheter bags did not rest on the floor for one (Resident #107) of nine residents observed with urinary catheters.

Inspectors wroteBased on observations and interview, the facility failed to ensure that ten (Residents #20, #119, #129, #8, #110, #77, #62, #72, #87 and #120) of 66 residents sampled, had adequately equipped communication systems allowing them to call for staff assistance and relaying the call directly to a staff member or to a centralized staff work area from each resident's bedside. Failing to ensure each resident has a working call light for summoning staff when assistance is needed can result in preventable falls, increased pain and anxiety.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that the resident environment for one (Resident #62) of 24 residents reviewed for safety, was as free of accident hazards as was possible, by allowing hazardous, sharp objects to remain accessible in Resident #62's room without identified safety parameters, which could negatively impact Resident #62 or any other resident who entered the resident's room and accessed these objects.

Inspectors wroteBased on observations, staff interviews, document review, and facility policy and procedure review, the facility failed to maintain the physical environment in a safe, functional, sanitary and comfortable environment in 16 resident rooms (#201, #208, #209, #210, #214, #219, #302, #304, #305, #307, #308, #309, #310, #313, #315, and #321) affecting 40 out of 117 residents in the facility, as well as an industrial size fan running in the hallway on the second floor with dirt and dust stuck to it, and a wheelchair in disrepair with food particles in the hallway on the third-floor. These concerns could negatively impact residents' enjoyment of their environment as well as their safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, by failing to employ either a certified dietary manager or a certified food service manager when a registered dietitian was not employed on a full-time basis. This had the potential to affect all of the residents in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Expired buns were used during meal service, dietary staff were unable to explain how to test the dish machine, the dish machine test log was pre-dated with test results, the temperatures in the refrigerators in the 2nd and 3rd floor nourishment rooms were greater than 41 degrees Fahrenheit (F), and an open, unlabeled, undated candy bar was discovered in the 3rd floor nourishment room refrigerator. This could potentially affect every resident residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The facility's high-temperature dish machine failed to reach the minimum final rinse temperature. This could potentially negatively affect all residents consuming meals from the facility's kitchen by exposing them to foodborne illnesses.

Inspectors wroteBased on observations, staff interviews, and facility record and policy review, the facility failed to maintain the physical environment in a safe, comfortable, and sanitary manner in eight (Rooms 215, 219, 221, 223, 302, 305, 318, and 319) of 46 rooms in the facility, as well as the 3rd floor elevator area. Door frames were not maintained structurally, a floorboard was raised near the 3rd floor elevator causing a tripping hazard, and holes in walls were identified as well as broken/missing floor tile. The facility also failed to maintain a comfortable and sanitary environment for one (Resident #87) of two residents reviewed for enteral feeding from a total survey sample of 35 residents, by leaving enteral nutrition product splattered and dried on the pump and pole throughout the survey. These concerns could affect residents' comfort and safety.

Inspectors wroteBased on record review and interviews, the facility failed to document the basis for a resident's transfer to an acute care hospital, the specific resident needs that could not be met in the facility, and the service available at the acute care hospital to meet the resident's needs for one (Resident #118) of one hospitalized resident reviewed, from a total survey sample of 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, including measurable objectives and timeframes for two (Residents #66 and #113) of 35 residents in the total survey sample. This resulted in the facility having failed to provide Resident #66 with needed toenail care and having failed to change Resident #113's midline dressing, which could lead to pain, difficulty mobility and dressing for Resident #66, and potential infection and pain for Resident #113.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that four (Residents #64, #99, #100, and #66) of 35 residents in the total survey sample, received the necessary care and services to maintain good grooming and personal hygiene.

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure physician-ordered medication was available and provided to one (Resident #18) of 35 residents in the total survey sample.

Inspectors wroteBased on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Two errors were identified from 25 opportunities for error, resulting in a medication error rate of 8%, affecting two (Residents #18 and #52) of eight residents observed during medication administration from a total survey sample of 35 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by 1) Failing to ensure the dishwashing machine reached appropriate temperatures, 2) Failing to ensure the refrigerator and freezer maintained appropriate temperatures, 3) Failing to ensure food temperatures were recorded daily, and 4) Failing to ensure the facility's nourishment rooms were maintained per requirements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents fed by enteral means received appropriate treatment and services for two (Residents #100 and #70) of two residents reviewed who were receiving enteral nutrition from a total of 20 residents in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify resident preferences consistent with residents' food allergies to meet the needs of one resident (#36) reviewed from a total sample of 20 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain resident medical records that were complete and accurately documented for one (Resident #36) of five residents reviewed for nutrition and hydration services from a total sample of 20 residents. (Residents #36).