Inspection·June 17, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shown the food splatter on the floor, the bed frame, the feeding pump pole, the wall, and the food pump. He stated the housekeeper was responsible for cleaning the food splatters in the rooms. He was informed the food splatter had not been cleaned up and was first observed on 06/14/2021 at 12;35 PM. (Photographic evidence obtained) During a second interview with Employee J on 06/17/2021 at 1:21 PM, she stated, I saw the splatter. I tried to get it off, but it was really stuck on. A review of the facility's policy and procedure entitled Environmental Services Customer Room Cleaning (effective May 1, 2003, revised October 23, 2017) revealed: All customer rooms should be cleaned as needed or on a daily basis. Purpose: To maintain a clean, safe, and hygienic environment for all customers, visitors, and team members. Process: The following equipment and supplies should be used: 2. Mop 7. Clean rags. 9. Putty knife. 13. Germicidal cleaner. 14. Multi-purpose cleaner. 17. Paper towels. Spot cleaning and surface sanitizing: 2.1 Utilize labeled germicidal spray bottle solution and cleaning cloths and/or glass cleaning solution. 2.2 Use glass cleaner to remove fingerprints and smudges from mirrors, walls, light switches, etc. 2.3 Wash all furniture, doors, ledges, etc. starting with the least soiled and starting at the top working toward the bottom. 6. Wet Floor Mopping: 6.2 Use germicidal solution, wet mop and 4 gallon bucket with wringer and a putty knife. 6.4 Start at farthest from the door using S stroke, avoiding base boards. Flip the mop over once and wipe out each corner. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 2 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to develop a baseline care plan for catheter care for one (Resident #252) of six newly admitted residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling Foley catheter and a urinary tract infection (UTI). Failure to develop a plan of care for catheter care could potentially exacerbate the urinary tract infection. The findings include: Resident #252 was observed on 06/14/2021 at 1:10 PM seated on the side of his bed. He was attempting to get out of bed by himself. Both of his feet were on the floor. His catheter bag was not contained in a dignity bag but was sitting directly on the floor. The catheter tubing was also lying on the floor. (Photographic evidence obtained) During an interview with Employee F, Licensed Practical Nurse (LPN), on 06/17/2021 at 9:26 AM, she was asked about Resident #252's catheter care. She stated she would clean the catheter if needed. She confirmed she had not provided catheter care since his admission. She stated the staff would wipe the tubing and the bag off if they became soiled. The catheter bag was hung on the bed frame when the resident was in bed. He was new to the facility, and she was not that familiar with him yet. He was a pleasantly confused man, and so far, she had not seen any problems with him. She did not look up his physician's order for catheter care or review the Treatment Administration Record (TAR) during this time. A review of Resident #252's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) and his Order Summary Report, indicated he was admitted on [DATE] with diagnoses including: Dementia without behavioral disturbance, major depressive disorder, atrial flutter, tachycardia, hypertension, muscle weakness, unspecified protein malnutrition, constipation, retention of urine and urinary tract infection. A review of the active physician's orders, revealed no order for catheter care. (Photographic evidence obtained) A review of the care plan revealed no care plan for catheter care (Copy obtained). A review of the Nursing Assessment, dated 06/10/2021, revealed Resident #252 was admitted with an indwelling Foley (urinary) catheter and hematuria (blood in his urine). His last urology consult was on 06/03/2021. He had a UTI upon admission (Copy obtained). A review of the current Medication Administration Record (MAR) and TAR revealed no place for catheter care documentation. A review of the nursing notes from 06/10/2021 through 06/17/2021 revealed no documentation regarding catheter care. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 06/17/2021 at 2:50 PM, they both looked in the electronic medical record for nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 3 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation of catheter care. They reviewed the Initial Nursing Assessment and saw that the resident was admitted on [DATE] with an indwelling urinary catheter. They both reviewed the nursing notes and could not find any notes related to catheter care. They confirmed they did not see a physician's order or care plan for catheter care. The Minimum Data Set (MDS) Coordinator joined the interview on 06/17/2021 at 3:01 PM. She did not see orders for catheter care in Resident #252's chart. She looked at the Initial Nursing Assessment to see if the nurse documented the presence of the catheter upon admission. She saw that the nurse noted it. She reviewed the physician's orders, the care plan and the nursing notes, but did not find any documentation regarding the urinary catheter. The DON stated the old electronic system transferred the information from the assessment to the initial care plan, however the new electronic system did not do that. The MDS Director concurred. They stated they needed to make sure the nurses who reconciled the medications and treatments upon admission carried over all of the care to the initial care plan. The DON confirmed that if the care was not documented, then there was no evidence that it was done. A review of the facility's policy and procedure entitled Care Plan: Customer (effective 05/01/2003, revised 02/08/2019) revealed: An individualized, interdisciplinary baseline care plan may be initiated within 48 hours of admission or readmission for each customer as part of the Service Location delivery process. It is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. Purpose: To structure and guide therapeutic interventions, services, and treatments to meet customer's needs an achieve clinical outcomes. Process: Baseline care plan must be revised as needed until the Comprehensive Care Plan has been developed. 2. Upon admission 1.1 A licensed nurse should evaluate the customer's needs and initiate person-centered care plan problems based on findings identified on the nursing admission assessment. 1.2 The assessment must include at least the following: Special treatments and procedures. 3. The initiation of the care plan is communicated to appropriate staff where indicated. (Copy obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 4 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to coordinate hospice services for one (Resident #57) of eight residents receiving hospice services, from a total sample of 54 residents. Residents Affected - Few The findings include: A record review for Resident #57 revealed a [AGE] year old female admitted on [DATE] with diagnoses including dementia, chronic kidney disease, asthma, rhabdomyolysis, and overactive bladder. She was alert with confusion, required limited assistance with activites of daily living (ADLs), and was ambulatory without assistance. She was ordered hospice services on 10/6/20 due to a decline in condition. A review of the medical record found no hospice notes or plan of care after February 2021. An interview was conducted with the Unit Clerk on 6/17/21 at 9:05 AM. She was asked where the most recent hospice notes for Resident #57 were located. She stated this particular hospice was not good about putting notes in the charts. She said she would look in medical records. After looking in the files, she said none were found. She was then asked if the resident was still receiving hospice services. She said she would check the computer. After doing so, she stated according to the entry from the business office, the resident was discharged from hospice on 2/17/21. When asked if there was a discharge summary from hospice and physician's orders to discontinue services, the Unit Clerk said she could not find those documents. She said she would ask the Unit Manager. An interview was conducted with the Director of Nursing (DON) and Employee L, Unit Manager (UM), on 6/17/21 at 9:40 AM. When asked how often the Hospice nurse visited Resident #57, the UM said weekly. She was asked if the hospice nurse communicated with her after the visits, and she replied, Not always, but they do communicate with the nurse assigned to the resident. The UM was asked if Resident #57 was still receiving hospice services, and she said she was aware that the family wanted to revoke hospice, so Resident #57 could receive physical therapy. She had not been notified that hospice had been discontinued. During the interview, the DON stated she had just spoken to the Business Office Manager (BOM) and Resident #57 was discharged from hospice in February 2021, however, nursing was never informed. She was asked if there were hospice discharge records, and she replied that none had been sent from hospice. The DON stated the hospice agency providing services never communicated with the nursing staff that services were discontinued. A review of the hospice contract, dated 11/10/05, revealed the hospice responsibilities included: Hospice Interdisciplinary Team Care Plan will develop a plan of care for the management of each hospice patient in collaboration with the facility. This plan is updated and reviewed routinely by hospice IDT (team and facility. The nursing and social components of this plan and all documentation including but not limited to progress notes, orders and discharge plans will be placed in patients medical record at hospice and facility. The MDS/Care Plan Coordinator was interviewed on 6/17/21 at 11:10 AM. She was asked if hospice attended the care plan meetings for Resident #57. She said, not this particular hospice. She also said she was made aware just today that Resident #57 was no longer receiving hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 5 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews and record reviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, by failing to ensure medications were not left at residents' bedsides for one (Resident #47) of a total of 54 residents in the sample. The findings include: On 6/15/21 at 10:30 AM during an interview with Resident #47, a bottle of Systane eye drops, without a pharmacy label, and a plastic cup with an orange gel substance and spoon in it were observed on the resident's night table. The resident was asked if she was able to self-administer the eye drops on the table. She said no. She was asked if she knew what was in the cup with the orange substance in it, and she said, probably Metamucil. I told the nurse to leave it and I would take it later. An interview was conducted with the Employee M, Agency Nurse, on 6/15/21 at 10:40 AM. She was asked if she had left medication and eye drops at Resident #47's beside. She stated she left the resident's Metamucil on the night table, as the resident didn't want it at that time, and she said she would take it later. The nurse stated she did not give the resident any eye drops, because she was to receive Visine and Visine was not available in the medication cart. She saw the Systane drops on the night table, but she did not put them there. She said she was from the Agency and was not aware she shouldn't leave medications at bedside. A review of Resident #47's active physician's orders revealed an order for Metamucil, 1 packet every day at 8:00 AM. There was no order for Systane eye drops. An interview was conducted with the Director of Nursing (DON) on 6/15/21 at 11:30 AM. She was asked what the policy was for leaving medications and eye drops at the beside. She stated medications could not be left at the resident's bedside. If a resident refused or wanted the medications at a later time, then the nurse must document refusal or why the medication was given at a later time than ordered. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 6 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews and staff interviews, the facility failed to provide urinary catheter care for one (Resident #252) of six sampled residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling urinary catheter and a urinary tract infection (UTI). Failure to provide catheter care could potentially exacerbate the urinary tract infection. The findings include: Resident #252 was observed on 06/14/2021 at 1:10 PM seated on the side of his bed. His catheter bag was was sitting directly on the floor. The catheter tubing was also lying on the floor. (Photographic evidence obtained) During an interview with Employee F, Licensed Practical Nurse (LPN), on 06/17/2021 at 9:26 AM, she was asked about Resident #252's catheter care. She stated she would clean the catheter if needed. She confirmed she had not provided catheter care since his admission. She stated the staff would wipe the tubing and the bag off if they became soiled. The catheter bag was hung on the bed frame when the resident was in bed. He was new to the facility, and she was not that familiar with him yet. He was a pleasantly confused man, and so far, she had not seen any problems with him. She did not look up his physician's order for catheter care or review the Treatment Administration Record (TAR) during this time. A review of Resident #252's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) and his Order Summary Report, indicated he was admitted on [DATE] with diagnoses including: Dementia without behavioral disturbance, major depressive disorder, atrial flutter, tachycardia, hypertension, muscle weakness, unspecified protein malnutrition, constipation, retention of urine and urinary tract infection. A review of the active physician's orders, revealed no order for catheter care. (Photographic evidence obtained) A review of the care plan revealed no care plan for catheter care (Copy obtained). A review of the Nursing Assessment, dated 06/10/2021, revealed Resident #252 was admitted with an indwelling Foley (urinary) catheter and hematuria (blood in his urine). His last urology consult was on 06/03/2021. He had a UTI upon admission (Copy obtained). A review of the current Medication Administration Record (MAR) and TAR revealed no place for catheter care documentation. A review of the nursing notes from 06/10/2021 through 06/17/2021 revealed no documentation regarding catheter care. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 06/17/2021 at 2:50 PM, they both looked in the electronic medical record for nursing documentation of catheter care. They reviewed the Initial Nursing Assessment and saw that the resident was admitted on [DATE] with an indwelling urinary catheter. They both reviewed the nursing notes and could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 7 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not find any notes related to catheter care. They confirmed they did not see a physician's order or care plan for catheter care. The Minimum Data Set (MDS) Coordinator joined the interview on 06/17/2021 at 3:01 PM. She did not see orders for catheter care in Resident #252's chart. She looked at the Initial Nursing Assessment to see if the nurse documented the presence of the catheter upon admission. She saw that the nurse noted it. She reviewed the physician's orders, the care plan and the nursing notes, but did not find any documentation regarding the urinary catheter. The DON stated the old electronic system transferred the information from the assessment to the initial care plan, however the new electronic system did not do that. The MDS Director concurred. They stated they needed to make sure the nurses who reconciled the medications and treatments upon admission carried over all of the care to the initial care plan. The DON confirmed that if the care was not documented, then there was no evidence that it was done. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 8 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff and resident interviews and observations, the facility failed to ensure that residents requiring respiratory care, received appropriate care, consistent with professional standards of practice, by failing to follow physician's orders for the administration for oxygen for two (Residents #102 and #131) of two residents sampled for oxygen administration from a total sample of 54 residents. Residents Affected - Few The findings include: 1. On 6/15/21 at 10:27 AM, Resident #131 was observed coming out of the bathroom. Oxygen tubing was observed on the bed, the oxygen concentrator was on and the oxygen flow rate was set at 3.5 liters per minute (LPM). The resident was was asked if she knew how much oxygen flow she was ordered, and she replied 2 liters. When asked who set the flow rate, she said the device was set for 2 liters, so she didn't have to do anything except put the oxygen cannula back on. An interview was conducted with Employee K, Licensed Practical Nurse (LPN), on 6/15/21 at 10:45 AM. She was asked what oxygen rate was ordered for Resident #131. She stated 2 liters via nasal cannula. She was asked if Resident #131 was able to regulate the flow rate on her own, and she replied no. On observation of the oxygen concentrator, she confirmed the oxygen flow was set at 3.5 LPM. She decreased the flow rate to 2 LPM as per the physician's order. An observation of Resident #131 on 6/16/21 at 9:05 AM, found the oxygen concentrator's flow rate was set at 3 LPM. During an interview with Resident #131 at 9:10 AM, she was asked if she had set the oxygen flow on the concentrator. She said, No, it always stays the same. Employee K was asked to observe the concentrator, and she confirmed the flow rate was set 3 LPM. A review of the active physician's orders revealed: Monitor oxygen saturation levels every shift for shortness of breath, oxygen 2 liters via nasal cannula as needed for shortness of breath. A review of the June 2021 Medication Administration Record (MAR) revealed oxygen administration was not documented. During an interview with Employee K on 6/16/21 at 11:05 AM, she was asked where the nurses documented oxygen administration, and she replied, in the nursing notes. During a review of the nursing notes with Employee K at 11:10 AM on 6/16/21, she confirmed oxygen administration was not documented. 2. On 6/14/21 at 12:17 PM, Resident #102 was observed using a portable oxygen tank that was attached to the back of her wheelchair. The oxygen tank was empty. Upon entering the resident's room, an oxygen concentrator was observed at the resident's bedside. An oxygen cannula was observed on the floor. A clinical record review for Resident #102 indicated that she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Physician's orders included an order for oxygen continuously at 3 LPM via nasal cannula to keep her oxygen saturation above 93%, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 9 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0695 the use of Spiriva (a bronchodilator), inhale 1 puff one time a day for COPD. Level of Harm - Minimal harm or potential for actual harm The resident was care planned as At Risk for Alteration in Respiratory Status related to a diagnosis of COPD with an intervention to administer oxygen as ordered. Residents Affected - Few The admission Minimum Data Set (MDS) assessment, dated 5/6/21, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating the resident had severe cognitive impairment. She also required extensive assistance from staff for bed mobility and limited assistance for transfers and toileting. In an interview with Employee C, Registered Nurse (RN)/Unit Manager on 6/16/21 at 1:41 PM, she stated oxygen tubing was changed every Thursday and was dated at that time. She also confirmed that Resident #102's cannula was not dated, nor was the tubing bagged per the facility's protocol. Another observation on 6/17/21 at 9:23 AM, revealed Resident #102 in the living area. Her oxygen flow rate was set at 2 LPM. In an interview with Employee D, RN, on 06/17/21 at 9:31 AM, she stated Resident #102's oxygen order was for 2 LPM on an as-needed basis. She then checked the June 2021 MAR and stated the order was for 3 LPM continuously. The nurse went to the resident and confirmed that the resident was receiving 2 LPM instead of 3LPM. The nurse adjusted the flow rate to 3 LPM. In an interview with the DON on 6/17/21 at 10:23 AM, she stated the nurses were supposed to follow the physicians' orders for oxygen flow rates. She added that oxygen tubing was to be changed weekly on Thursdays. A review of the facility's policy and procedure titled Specific Procedure for all Medications, revealed: Process : Medication Occurrence Examples of medication occurrence include, but not limited to: 1. Medication Omission - The failure to administer an ordered dose, unless refused by the customer or administered because of recognized contraindication. 2. Medication Occurrence Non-Significant - Medication administered without eliciting significant adverse effects. 2.3 Wrong rate. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 10 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 locked, compartments for controlled drugs. Based on observations, interviews and record reviews, the facility failed to ensure that medications were properly stored/disposed of safely for two (Residents #138 and #61) of six residents observed during medication administration. The findings include: 1. On 6/15/21 at 4:38 PM, medication administration was observed with Employee A, Registered Nurse (RN), for Resident #138. The nurse pulled two tablets of olanzapine (Zyprexa - antipsychotic), 7.5 milligrams (mg) from a blister pack. After review of Resident #138's Medication Administration Record (MAR), she noted that the order had changed from 7.5 mg to 10.0 mg. She took the two tablets of 7.5 mg olanzapine and discarded them in the trash can. In an interview with Employee A on 6/15/21 at 5:00 PM, she was asked what the facility's protocol was for medication destruction. She stated that there was a destroyer liquid in the medication room. She admitted that medication should not be discarded in the trash can and stated she forgot. 2. On 6/16/21 at 9:03 AM, Employee B, Licensed Practical Nurse (LPN), was observed prepping medication for Resident #61. Employee B dropped the resident's furosemide (Lasix - diuretic) tablet. She picked it up and discarded it in the trash can. She performed hand hygiene and obtained another dose of Lasix 20 mg. After obtaining the Lasix 20 mg, she continued to pull other medication for the resident as ordered, and popped the pills in a medication cup. She then popped Entresto 24-25 mg (blood pressure medication) in a separate medication cup. Before administering the medication to the resident, Employee B obtained the resident's vital signs and stated her blood pressure (BP) was 116/59 millimeters of mercury (mmHg) and her pulse was 82 beats per minute. Employee B held the dose of Entresto that was in a separate cup and stated she would notify the physician that the resident's BP was below the parameters. After exiting the resident's room, Employee B took the blood pressure medication and discarded it in the trash can. During medication administration, other residents were observed wandering in the hallway with access to the trach receptacle on the nurse's medication cart. This placed them at risk of obtaining and possibly ingesting the medication in the trash. On 6/16/21 at 10:00 AM, Employee B was asked what the facility's protocol was for medication destruction. She stated she was not sure and she normally threw medication that had been refused or not administered for other reasons in the trash. Employee B added that she would check with the Unit Manager for the correct protocol. A review of Employee A's and Employee B's competencies revealed that neither employee had completed Medication Administration competencies. On 6/17/21 at 3:37 PM, the Administrator stated the facility normally relied on the web-based training for employees who needed to complete required trainings. He added that the facility only required employees to complete medication administration competencies upon hire and when an issue was identified. A review of the facility's policy and procedure titled Specific Procedures for all Medications (effective March 10, 2016 and revised July 28 2017) revealed: Process: Destruction of non-controlled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 11 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 medications Level of Harm - Minimal harm or potential for actual harm Purpose: Residents Affected - Few Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to do so after they have familiarized themselves with the medication. Non - Controlled Medications: Non-controlled medication may only be destroyed by a licensed professional at the center or by a pharmacist. Non-controlled medications if dropped on the floor or refused and/or removed in error should be destroyed in a manner that would prevent consumption by other customers. Disposing of the medication in a toilet, and or in another vessel that would be difficult to access. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 12 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by 1) Failing to maintain the dishwasher at appropriate temperatures during the wash and final rinse cycles, 2) Failing to ensure kitchen employees wore face coverings and gloves appropriately, and 3) Failing to ensure three of three nourishment rooms were clean and stored/labeled food appropriately. The facility census was 154. All residents receiving food from the kitchen and/or nourishment rooms had the potential to be affected by this deficient practice. The findings include: 1. On 6/15/2021 at 10:13 AM, during an observation of the dish room, the facility's dishwasher machine was observed to be a low temperature, chemical machine. (Photographic evidence obtained) The dishwasher label read: Wash tank minimum temperature of 140°F, Pumped rinse tank minimum temperature of 120°F; Final rinse minimum temperature 120°F. The dishwasher was in use at the time of the observation; employees were cleaning dishes from the breakfast service. Temperatures at this time read: 120°F wash, 120°F rinse, 100°F final rinse. The Dietary Manager stated the last dial was not working properly and a technician was on his way. At this time, the Dietary Manager was asked if the machine was not up to temperature, what would she do to clean the dishes? She stated she would go to hand washing all dishes, and she pointed to the three-compartment sink. After observations of the dumpster were concluded at 10:25 AM, the Dietary Manager came back and directed the staff to start washing dishes by hand. At 4:35 PM on 6/15/21, the Dietary Manager and the Administrator explained that a technician had been there, and the dishwasher was now working correctly. A second observation of the dishwasher at 4:55 PM on 6/15/21, revealed the following: Wash cycle 130°F, rinse 120°F and final rinse 140°F. The Dietary Manager continued to run the dishwasher at least ten times with very little change in temperature to the wash cycle. At 5:10 PM, temperatures of 140°F/125°F/141°F were observed during the last two cycles respectively. At this time, the Dietary Manager was asked if employees knew to check temperatures and run the machine until temperatures were up. She stated, yes. She stated that the only employees who checked temperatures were the Dietary Manager, Assistant Culinary Director, and the cooks on the weekend. Observations of the June 2021 temperature logs for the dishwasher revealed the same initials and temperature every day, every shift. The Assistant Culinary Director was asked if these were all the same employee, and she stated yes, they were the Assistant Culinary Director's initials. No variations of initials or temperatures were observed over the entire month of June. A third observation of the kitchen was made on 6/16/2021 at 11:05 AM. The dishwasher temperatures were observed. The Dietary Manager ran the machine and waited for the temperature to rise. She stated this morning she ran the dishwasher with no concerns, and she re-educated staff about appropriate temperatures for the dishwasher. At this time the dishwasher was given until 11:16 AM to get to temperature before observations were recorded. During this time between 11:05 and 11:16 AM, the Dietary Manager reset the washer, drained the water from dishwasher tank, and took out a cup that had been left in the machine before turning the dishwasher back on again and letting the dishwasher cycle run for another 10 times. At this time the temperatures were recorded at 134 °F / 134 °F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 13 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many /154°F respectively. The dishwasher was again turned on and off and drained again. A final observation of the dishwasher was made at 11:35 Am on 6/16/21, and temperatures of 148°F/ 138°F/ 148°F were recorded at this time. The total time it took for the dishwasher to meet the proper temperature was half an hour. 2. At 11:00 AM on 6/15/21 during an observation of the tray line, Employee O, Kitchen Employee, was observed with their face mask down below their face, and the following day on 6/16/2021 at 11:30 am, the same employee was observed with the mask below their nose. On 6/15/21 at 5:15 PM, the Dietary Manager was interviewed about the PPE (personal protective equipment) that was required in the kitchen. She stated employees were required to wear face masks, gloves if handling dirty dishes or any ready to eat food or preparing food, and a hair net or hat. When asked if face masks were to be worn under or over the nose she stated, over the nose. On 6/16/21 at 11:35 AM, Employee P, Kitchen Employee, was observed cleaning the counter, taking out trash and putting away seasonings all with the same gloves on. The employee took off the gloves and opened the door of the walk-in refrigerator to get items out of the refrigerator for the tray line without washing their hands first. 3. Three out of three nourishment rooms were observed on 6/17/21 with sanitation concerns as follows: The nourishment room for the 200 hall was observed at 2:00 PM on 6/17/21. The refrigerator contained an open container of pudding with a date of 6/16/2021 on it. The microwave had spatters of liquid and paper towels in it. The ice machine had black specks of residue inside on the door and around the door hinge. (Photographic evidence obtained). One Styrofoam food container had food items in it dated 6/9/2021. Another Styrofoam container in the refrigerator had food items in it with no date and no name on it. The nourishment room on the 100 hall was observed at 2:30 PM on 6/17/21. The microwave had crumbs and residue in it. A resident's food tray was sitting on top of the microwave with dirty dishes and used napkins on the tray. (Photographic evidence obtained) During an observation of the nourishment room on the second floor for the 500 hall at 2:40 PM on 6/17/21, bits of paper towel were observed on the floor. An open package of cookies was lying out on the counter with no label or open date on the package. An interview was conducted with Employee L, Unit Manager at 2:15 PM on 6/17/21. When asked who oversaw stocking and cleaning of the nourishment rooms, she stated each shift checked temperatures of the refrigerator and the staff on the 11pm to 7am shift on Sunday nights checked the dates of the food in the nourishment room refrigerators. A facility policy for foods received from outside of the facility revealed that outside food should be labeled with resident's name and use by date on it. . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105135 If continuation sheet Page 14 of 14