Fernandina Beach Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Fernandina Beach Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 27, 2024

  Based on medical record review and interviews, the facility failed to protect, in a timely manner, the resident's right to be free from verbal abuse/threat to deprive the resident of services by a staff member for one (Resident #79) of a total of 42 residents in the sample. The findings include: During an interview with Resident #79 on 06/25/24 at 1:20 PM, she stated, Staff ignore me. No one will answer my call light. The staff are always outside my door laughing at me in the hallway since the other day. She stated on Sunday (06/23/24) she reported the following incident to Social Services Director (SSD) P, stating, [Certified Nursing Assistant (CNA) M] told me that I could not go back to bed after my therapy session, and I had to stay up for two hours. […]

• No harm, potential for more than minimal, widespreadF867Nov 9, 2022

  Based on interviews and record review, the facility failed to 1) Maintain an effective system to obtain and use feedback and input from direct-care staff, other staff, residents, and resident representatives, including how such information would be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement; 2) Maintain an effective system to identify, collect, and use data and information from all departments, including but not limited to the facility assessment, and include how such information would be used to develop and monitor performance indicators; 3) Develop, monitor, and evaluate performance indicators, including the methodology and frequency for such development, monitoring, and evaluation; and 4 ) Conduct distinct performance… […]

• No harm, potential for more than minimal, patternF692Jun 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure the maintenance of 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. […]

• No harm, potential for more than minimal, patternF698Jun 27, 2024

  Based on observations, record reviews, and interviews, the facility failed to 1) Provide meals for one (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. […]

• No harm, potential for more than minimal, patternF686Feb 27, 2024

  Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that four (Residents #13, #14, #11, and #3) of eight residents with pressure ulcers, from a sample of 18 residents, received care consistent with professional standards of practice, to prevent pressure ulcers and receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The findings include: 1. A review of Resident #13's medical record revealed she was admitted to the facility on [DATE] and discharged to emergency room care on 1/21/24. […]