Jacksonville Skld Nur & Rehab

Inspectors wroteBased on interview and record review, the Facility failed to ensure a resident's wheelchair was properly secured in the transport van for 1 (R2) of 4 residents reviewed for accidents in the sample of 4. The surveyor confirmed by observation, interview, and record review that the deficiency practice occurred on 8/12/2025 and the deficient practice was corrected on 9/2/2025 prior to the start of the survey. Therefore the survey is Past Noncompliance. Findings Include:During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:1. Transportation vehicle was checked to ensure all safety mechanisms were properly functioning. Completed 8/12/2025.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse for 1 (R5) of 3 residents reviewed for abuse in a sample of 3. 1)R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and had a medical diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Major Depressive Disorder, Alzheimer's Disease, and Dementia. R4's Minimum Date Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's low air loss mattress was working properly for 1 (R2) of 3 residents reviewed for safe, function, sanitary, comfortable environment in the sample of 3. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] with a medical diagnosis of Thromboangitis Obliterans Buerger's Disease, Hyperlipidemia, Arthropathy, and Morbid Obesity. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact, is dependent on staff for rolling left and right, and is always incontinent of bladder and bowel. R2's Care Plan with a focus area revision date of 12/9/2023 documents R2 is at risk for pain and R2 needs assistance with activities of daily living including bed mobility with two-person physical assistance required and pressure redistribution device. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to date an open vial of Tuberculin that is used for all staff and residents, failed to date opened insulin administration pens, failed to date an open bottle of eye drops, failed to date an open bottle of liquid acetaminophen, failed to date an open vial of multi-dose insulin, and failed to properly dispense medications to residents by leaving them at the resident's bedside. This failure has the potential to affect all 75 residents in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to identify a pressure sore for 1 of 3 residents (R41) reviewed for pressure sores in the sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative services to prevent reduction in range of motion (ROM) for 1 of 4 residents (R58) reviewed for restorative therapy/Range of Motion (ROM) in the sample of 41.

Inspectors wroteBased on interview and record review the facility failed to implement an intervention to prevent falls for 1 of 4 residents (R41) reviewed for falls in the sample of 41

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide complete incontinent care and catheter care for 2 of 5 residents (R44, R58) reviewed for incontinence and catheter care in the sample of 41.

Inspectors wroteBased on interview, observation, and record review, the facility failed to administer resident medications at the correct time as ordered for 2 of 6 residents (R44, R39), reviewed for pharmacy services in the sample of 41. The Findings Include: 1. R44's admission Record, dated 6/5/25, documents R44 was admitted to the facility on [DATE] with Diagnosis of Cerebral Infarction, Hypertension (HTN), Dementia, Major Depressive Disorder, Benign Prostatic Hyperplasia (BPH), Uropathy, Malignant Neoplasm of Bladder, Wedge fracture of lumbar vertebra, and Malnutrition. R44's Care Plan, dated 5/26/25, documents R44 has a diagnosis of hypertension. Interventions: Give antihypertensive medications as ordered, Obtain blood pressure readings per orders. It continues R44 is receiving medications with a black box warning. Medication type: antidepressant, antianxiety agent, nonopioid/opioid analgesic. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene during passing meal trays, and failed to don Personal Protective Equipment for 8 of 8 residents (R2, R7, R14, R41, R55, R56, R71, R73) reviewed for infection control in a sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to have interventions in place to prevent a fall, for 1 of 3 (R2) residents, reviewed for falls in a sample of 4. This past non-compliance occurred from 2/19/2025 to 3/10/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper inflation of the air mattress in 3 (R2, R4, and R5) of 3 residents in the sample of 8 reviewed for safety. This failure resulted in R2 being found on the floor from an unwitnessed fall and suffering a laceration on the right side of the head and several skin tears.

Inspectors wroteBased on interview and record review the facility failed to provide safety and supervision for 1 of 3 (R3) residents reviewed for falls. This failure resulted in R3 falling, obtaining a laceration to the head, sutures and experiencing pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle food in a manner that prevents potential contamination, failed to restrain hair and perform hand hygiene during food service. This failure potentially affects all 83 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide Oxygen to residents that required oxygen for 2 of 5 residents (R26, R56), reviewed for respiratory care in the sample of 40. This failure resulted in R26 becoming cyanotic with a low oxygen saturation of 51%. The Findings Include: 1. R26's Face Sheet, undated, documents R26 was originally admitted to the facility on [DATE] with diagnosis of Motor Neuron Disease, Asthma, Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, Atherosclerotic Heart Disease (ASHD), Sleep Apnea, Chronic Inflammatory Demyelinating Polyneuritis, Arthropathy, Primary Lateral Sclerosis, Major Depressive disorder, Anxiety disorder, Hypertension, Pneumonia, Malignant neoplasm of bronchus and lung, Pulmonary embolism, Venous Thrombosis and Embolism, and Dependence on Supplemental Oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication and failed to label a Tuberculin vial and Insulin vials. This has the potential to affect all 83 residents living in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide timely and complete incontinent care, including hand hygiene and glove changes for 5 of 5 (R23, R37, R48, R55, R180) reviewed for incontinence care in the sample of 40.

Inspectors wroteBased on observation, interview and record review the facility failed to properly dispose of soiled linens, and cleanse hands between glove changes for 4 of 8 residents (R23, R48, R55 and R37) reviewed for infection control in the sample of 40.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide adequate lighting for 1 of 3 residents (R63) reviewed for reasonable accommodations for residents in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with moderate cognitive deficits who was identified as a potential risk for elopement did not exit the building unattended for 1 of 3 (R2) residents reviewed for elopement in the sample of 5. This past non-compliance occurred between 12/30/2023 and 1/2/2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication, and label insulin and tuberculin vials. This has the potential to affect all 79 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to label cooked and opened food and discard expired food to prevent potential food borne illness. This has the potential to affect all 79 residents in this facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely and complete incontinent care for 5 of 6 residents (R5, R9, R17, R24, R59) reviewed for incontinent care in a sample of 45.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand-hygiene, administered subcutaneous medications via needle per standards of practice and handle linens in a manner which prevents contamination and spread of infection for 4 of 24 residents (R15, R17, R24, R59) residents reviewed for infection control in the sample of 45.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to reduce pressure and prevent the worsening of pressure ulcers for one of 3 residents(R42) reviewed for pressure ulcers in the sample of 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall interventions and safely transfer residents to prevent accidents for 2 of 5 residents (R12, R49) reviewed for supervision to prevent accidents in the sample of 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered. There were 29 opportunities with 2 errors resulting in a 6.9% medication error rate. The errors involved 2 residents ( R73 and R132) in the sample of 45 residents reviewed for medication administration.