Inspection·January 27, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm On 1/27/22 at 1:58 PM, Resident #33 was observed lying in her bed in a supine position. Her heels were not elevated, and her heel boots were at the bedside chair. (Photographic evidence obtained) On 1/27/22 at 5:00 PM, Resident #33 was observed once again lying in her bed in a supine position and heel not elevated. Heel boots were observed at the bedside chair. Residents Affected - Few During an interview on 1/27/22 at 5:00 PM with Employee M, Certified Nursing Assistant (CNA), she confirmed that Resident #33 did not have her heel boots on. Employee M, CNA who was assigned to care for Resident #33 stated, she was aware of the heel boots near the bedside, but she never put them on the resident because, she was never told to put them on. On 01/27/22 at 5:03 PM, Employee N, Registered Nurse (RN)/Unit Manager and Director of Nursing (DON) stated that the cna's have access to the resident's care plan through the link in point of care. They added that all cna's are trained on how to access the care plan. They confirmed that it was cna's and nurse's responsibility to ensure that Resident #33 had her heel boots on. They acknowledged that the resident had skin redness on her heels and per her care plan she should have the heel boots on while in bed. A review of the facility's policy and procedure titled: Care Plans - Comprehensive Person- Centered (last revised 10/2021) revealed the comprehensive person-centered care plan will: I. 14. Aid in preventing or reducing decline in the resident 's functional status /or functional level; I. 15 Enhance the optimum functioning of the resident of the resident by focusing on a rehabilitative program; and I. 16. Reflect currently recognized standards of practice for problem areas and conditions. J. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. K. Identify problem areas and their causes and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. L. Care plan interventions are chosen after data gathering, sequencing of evens, consideration of the relationship between the resident's problems areas and their causes, and relevant clinical decision making. L. 1. When possible, interventions address the underlying sources(s) of the problem area(s) not just addressing only symptoms or triggers. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 2 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to provide assistance with bathing/showers for two (Residents #85 and #117) of three residents reviewed for activities of daily living (ADLs), out of a total sample of 40 residents. Residents Affected - Few The findings include: 1. A review of Resident #85's medical record revealed an admission date of 10/4/2021. Medical diagnoses included metabolic encephalopathy, acute kidney failure, hemiplegia, unspecified affecting right dominant side and weakness. A quarterly minimum data set (MDS) assessment, dated 11/10/21, indicated a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. The resident was documented as needing extensive assistance with bed mobility and physical help with bathing. On 1/24/22 at 2:12 PM, an interview was conducted with Resident #85. She stated that the facility did not have enough staff to care for residents. She went on to say that she did not have a bed bath last week. When she was asked what day, she is scheduled to be bathed, she replied, On Monday and Thursday. A review of the resident's care plan revealed a focus area for ADL self-care peformance deficit. Interventions included extensive assistance with one person support with resident bathing/showering. A review of the Point of Care (POC) Daily Charting for January 2022, revealed Resident #85 received one of eleven scheduled showers/baths on January 15, 2022. (Photographic evidence obtained) On 1/27/22 at 3:37 PM, and interview was conducted with Employee J, Registered Nurse (RN). When she was asked to provide documentation of when Resident #85 received a shower/bath in January, she went to the computer and pulled up the POC Daily Charting documentation which revealed Resident #85 had one shower on January 15. On 1/27/22 at 3:37 PM, Employee I, Certified Nursing Assistant (CNA) stated resident #85 was scheduled to get her baths during the night shift on Monday and Thursday. Employee I, CNA went on to say that resident showers are supposed to be documented, but when assignments are changed, showers can get missed. 2. On 1/25/22 at 9:25 AM, an interview was conducted with Resident #117. He stated that some weeks the facility forgets to give him his baths and he didn't get his bath this past Saturday. He went on to say that he's supposed to get a bath on Saturday and Wednesday. A review of Resident #117's medical record revealed an admission date of 12/12/2021. Medical diagnoses included coronary artery disease, hypertension, type 2 diabetes w/o complications, unsteadiness on feet and other lack of coordination. A quarterly minimum data set (MDS) assessment, dated 12/16/21, indicated a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. The assessment documented Resident #117 required extensive assistance from staff for bed mobility, transfer, bathing/showers, and toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 3 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 0677 Level of Harm - Minimal harm or potential for actual harm On 1/27/22 at 2:34 PM, a second interview was conducted with Resident #117. He was observed sitting in his wheelchair fully dressed, watching tv. Resident #117 reported having a bath yesterday. A review of the resident's care plan revealed a focus area for ADL self-care performance deficit. Interventions included extensive assistance with bathing/showering. Residents Affected - Few A review of the POC Daily Charting for January 2022, revealed that Resident #117 received one of eight scheduled showers/baths on January 18, 2022. (Photographic evidence obtained) On 1/27/22 at 2:41 PM, Employee K, CNA reported giving resident #117 a shower on 1/26/22. She also reported that Resident #117 shower days were on Wednesday and Saturday; the other days he gets a bed bath. When asked, where she documents after a bath/shower provided, she stated on the bath sheets and then we submit the form to the nurse. Employee K, CNA stated, I don't have a login, so other staff members have to pull up the system. Then, I tell them what I did, and the staff put it in for me. On 1/27/22 at 2:58 PM, Employee L, LPN confirmed that Resident #117 shower days were on Wednesday and Saturday. Employee L, LPN stated, When baths are provided to the patient, the CNA document on the bath sheet then transfer information into Point of Care. When asked for copies/manual for January bath sheets, there was no documentation to provide. Employee L, LPN confirmed that there was no documentation showing Resident #117's received a bath/shower. During an interview on 1/27/22 at 4:18 PM, the Director of Nursing (DON) was asked what the facility requirements were for ensuring residents baths/showers. She stated that the unit manager should monitor them weekly, and staff should be turning in the shower sheets. She also mentioned that an audit should be completed to ensure showers are provided. When the DON was asked if there was any documentation showing Resident #85 or Resident #117 received any baths/showers in January, she confirmed there was no documentation available. A review of the facility's policy and procedure titled: Shower/Tub Bath (last approved 1/2022), revealed the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The following information should be recorded in the resident's ADL record and/or in resident's medical record. A. The date and time the shower/tub bath was performed. E. Signature and title of person recording the data (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 4 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 observations, interviews and record review, the facility failed to appropriately address a resident's change in condition by failing to 1) comprehensively assess a resident's behavioral change in condition, and 2) promptly notify the resident's health care provider, and 3) implement person-centered interventions to address the change in condition for one (Resident #23) of three residents reviewed for change in condition, from a total sample of 40 residents. Residents Affected - Few The findings include: A review of Resident #23's medical record revealed he was admitted to the facility on [DATE] with a primary diagnosis of chronic kidney disease. Secondary medical diagnoses included dementia with depression, hypertension, and dyslipidemia. The resident required extensive to total assistance with activities of daily living, including transfers. A quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 3 out of a possible 15 points, indicating severely impaired cognition. A review of the nursing progress notes revealed an entry dated 12/15/21 at 2:28 a.m. and authored by Registered Nurse (RN) T indicated the resident was refusing care by kicking and swinging his legs and that per the prior shift's nurse the behavior had been present all day. The nurse was notified by the resident's roommate that Resident #23 was trying to get out of the bed. The nurse and two Certified Nursing Assistants (CNAs) responded to the room. Resident #23 was observed with his legs dangling off the side of the bed and he was trying to sit himself up. He stated, he wanted to get out of bed. The staff attempted to place Resident #23 in a wheelchair, and he became combative and stated he was going to bite the staff. The staff then laid the resident back down in bed and made attempts to reposition him which were unsuccessful. The resident was placed on a mat on the floor with a pillow, sheet, and blanket. The staff then left the room. Afterward, the nurse was approached numerous times by Resident #23's roommate because Resident #23 was disrupting his roommate's sleep. The nurse advised the roommate that the situation was under control and give me some time. The nurse was then informed by another nurse that 911 had been contacted. Emergency Medical Services (EMS) arrived on the unit and did not agree with the intervention that took place. When EMS arrived, they stated the resident was behind the door. The nurse did not witness the resident's position. EMS suggested the staff should have put the bed rails up. EMS then stated they were going to call the state because they disagreed with placing Resident #23 on the floor. The nurse spoke with the charge nurse at the emergency room and was informed they would be admitting the resident due to elevated troponin levels. A change in condition form completed by the nurse indicated the resident was combative and physically aggressive toward staff. The form did not contain any vital signs or pain assessment and indicated the resident had been transferred to the hospital. The form directed staff to evaluate the resident, check vital signs, and review the medical record prior to contacting the physician. (Photographic Evidence Obtained) A hospital history and physical dated 12/15/21 at 3:26 p.m. indicated the resident was complaining of pain to his left upper and lower extremities. The assessment and plan indicated a diagnosis of acute coronary syndrome, and that the resident would be placed on the telemetry unit. Resident #23 was readmitted to the facility from the hospital on [DATE]. A history and physical by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 5 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the attending physician indicated the resident was transferred to the hospital after being found on the floor with confusion and that in the hospital he was found to have positive troponin but was not recommended for any cardiac workup after being seen by cardiology as his medical condition was deemed stable and at baseline. Review of the care flow records for December 2021 revealed no documentation of physical or verbal behavioral symptoms and no rejection of care. On 1/24/22 at 12:06 p.m., Resident #23 was observed lying in his bed watching television. He was demonstrating no physical or verbal behaviors or outbursts. On 1/26/22 at 10:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON explained that Resident #23 was placed on the floor by the assigned nurse and two CNAs due to combative behaviors. The DON acknowledged this was not an appropriate intervention. When asked whether the nurse had rendered any assessments in response to Resident #23's combative behaviors or change in condition, the DON stated, she was not sure. The DON was asked to review the communication form completed on 12/15/21. The DON confirmed there were no vital signs in the form or documented in the medical record in response to the resident's change in condition. Continued review of the nursing progress notes revealed no documentation of the behavioral change in condition on a prior shift. The last nursing note entry prior to 12/15/21 was 11/7/21. On 1/26/22 at 11:35 a.m., Resident #23 was observed lying in his bed with his eyes closed. He was not demonstrating any physical or verbal behaviors or outbursts. The facility's investigation of the incident was reviewed with the DON. A witness statement by the assigned CNA indicated that when first getting the report, she was told that Resident #23 had been combative the prior shift and was refusing to lie down or sit in his wheelchair. The CNA, the assigned nurse, and another CNA tried to reposition the resident to stay in the bed, but he was constantly swinging his legs trying to stand. Two attempts were made to interview RN T via the contact information provided by the facility but were unsuccessful. The facility explained that she was employed by a staffing agency. On 1/26/22 at 1:25 p.m., an interview was conducted with the Clinical Educator. She explained that agency nurses are trained on nursing assessments and documentation of findings prior to working on the floor. The Clinical Educator explained that she was familiar with the incident involving Resident #23 and stated that placing the resident on the floor was not an appropriate action. She stated this was not an action that was taught to staff by the facility. The Clinical Educator acknowledged that combative behaviors could present in residents who are otherwise unable to express pain or discomfort and she added that she would have expected the nurse to conduct a comprehensive assessment of the resident (to include vital signs) to determine the source of the behaviors. A review of the facility's policy for changes in condition, titled Change in a Resident's Condition or Status revealed the policy directed nurses to notify the health care provider when there had been a significant change in the resident's physical, emotional, or mental condition. The policy further directed staff to make detailed observations and gather relevant and pertinent information for the provider including information prompted by the communication form. (Photographic Evidence Obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 6 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to Mayo Clinic (accessed 1/27/22 at 6:30 p.m. https://www.mayoclinic.org/diseases-conditions/acute-coronary-syndrome/symptoms-causes/syc-20352136), acute coronary syndrome is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart. One such condition is a heart attack (myocardial infarction) - when cell death results in damaged or destroyed heart tissue. Even when acute coronary syndrome causes no cell death, the reduced blood flow changes how your heart works and is a sign of a high risk of heart attack. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 7 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide adequate assistance to prevent accidents for one (Resident #87) of three residents reviewed for accidents, and failed to appropriately monitor the neurological status for two (Residents #280 and #33) of three residents reviewed for falls, from a total sample of 40 residents. The findings include: 1. A review of Resident #87's medical record revealed a readmission date of 11/11/21 with diagnoses that included history of falls, fracture of the ulna, and laceration of the head. A minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3 out of a possible 15 points, indicating severely impaired cognition. The resident required limited to extensive assistance with activities of daily living and was occasionally incontinent of urine and frequently incontinent of bowel. Review of the nursing progress notes revealed an entry dated 11/11/21 12:31 a.m. authored by Licensed Practical Nurse (LPN) P which indicated the resident sustained a witnessed fall on 11/10/21 at 8:30 p.m. The resident was noted to be face down with feet toward the bed and head toward the closet doors by the bathroom. After medicating the resident, the resident said that he needed to use the bathroom. I watched him get up out of bed and walk to the bathroom and saw that he was losing his balance and fell face first onto the floor by the bathroom. Resident #87 was then transferred to the emergency room. An entry dated 11/11/21 2:44 a.m. indicated the resident had a x-ray of the right arm which determined a fracture of the right ulna. The resident was incontinent upon arrival but was changed by both the LPN and CNA. Resident wanted to use the bathroom and was given a urinal to use. Review of a [NAME] II fall risk screen dated 9/3/2021 indicated a fall risk score of 11. A score of 5 or greater is high risk. Review of the comprehensive care plans revealed a focus area for altered elimination due to episodes of bowel and bladder incontinence. Interventions directed staff to provide toileting assistance as needed and offer to assist the resident to the bathroom whenever observed to be awake at night. On 1/27/22 at 12:25 p.m., an interview was conducted with CNA K. She confirmed that she was assigned to Resident #87 and that she was familiar with his care. She explained that Resident #87 was able to walk but that he did require assistance of one staff member because his legs are weak sometimes. CNA K confirmed that Resident #87 preferred to use the toilet as opposed to a urinal and that he needed to be assisted to the restroom about every three hours or he will go himself. On 1/27/22 at 12:45 p.m., an interview was conducted with LPN L. She confirmed that she was assigned to Resident #87 and that she was familiar with his care. She explained that the resident is able to ambulate with a cane but that he requires assistance of one staff member when ambulating because his gait is unsteady, and he is at risk for falls. LPN L confirmed that Resident #87 should not be walking to and from the restroom alone. LPN L added that if she saw Resident #87 ambulating independently to the restroom, she would immediately intervene and assist him the rest of the way. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 8 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 On 1/27/22 at approximately 6:15 p.m., an interview was conducted with the facility Risk Manager. She confirmed that she was familiar with the incident involving Resident #87. She explained that LPN P administered medications to Resident #87 and that while LPN P was still in the room, Resident #87 mentioned he needed to use the restroom. The Risk Manager added that LPN P stood by the resident's doorway and watched him get up out of bed and attempt to ambulate to the restroom. While ambulating, the resident tripped and fell to the floor. She was unsure whether the resident was using his cane. The Risk Manager acknowledged that the resident's comprehensive care plan directed staff to assist the resident with ambulation and explained that LPN P wasn't familiar with that. 2. A review of Resident #280's clinical record revealed he was admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] and discharged on 12/25/21. His diagnoses included obstructive neuropathy, repeated falls, dementia, and hypertension. A review of fall documentation note dated 11/20/21 read resident noted to be lying on floor by certified nursing assistant (CNA) at 2120 on 11/20/21. Resident noted to be on back on the floor at the side of the bed. Hematoma noted on the left side at the time of fall. resident stated that he was trying to go to the bathroom. A review of fall documentation dated 12/11/21 at 4:25 a.m. read, this writer was notified while on break that my resident had fell, upon returning to the unit from break, resident was noted to be back in the bed and the CNA was cleaning resident up, this writer noted that resident had a skin tear to the left outer elbow, this writer cleanses the wound and applied bandage and wrapped with Kerlix also noted the foley catheter was dislodged with red colored fluid. assistant director of nursing (ADON), daughter and director of quality assurance and physician notified with orders to re-insert the foley catheter and neurological (neuro) checks. Change in condition form dated 12/11/21 at 6:07 a.m. revealed neuro checks sluggish BP 130/90, Pulse 100 temp 98.0 respirations 17, oxygen 97.0%. Orders obtained to send resident to the hospital. Diagnostic imaging dated 12/11/21 revealed acute mildly displaced left C7 transverse process fracture. 1. No signs of unstable cervical spine fracture. 2. Multilevel heavy cervical spondylosis with ongoing auto fusion of several disc spaces and ankylosis of the facets A review of Resident #280's care plan indicated, he has a potential for fall /fall related injuries due to deconditioning with functional decline, a diagnosis of dementia with short and long term memory deficit and poor safety awareness. He is still adjusting to new environment. He has fallen multiple times since admission and has sustained fall related injuries-. Interventions included room clutter-free with adequate lighting, low bed with safety mats and scoop mattress, bed at appropriate height, call light within reach, and scheduled toileting. Resident was also assessed to need assistance with his ADL care due to de conditioning with functional decline and a diagnosis of acute on chronic metabolic encephalopathy and dementia and mobility limitations. Resident s needs extensive assistance with transfer with 1-2 persons assistance. Extensive assistance with one person for mobility and toileting. A minimum data set (MDS) assessment, dated 11/20/21, indicated a brief interview for mental status (BIMS) score that was blank. The resident was documented as requiring extensive assistance with bed mobility and toilet use. Resident #280 had one fall with injury since admission. A significant change MDS assessment, dated 12/14/21, revealed resident needed extensive assistance with bed mobility, transfer and toilet use. Resident was documented as having a fall with fracture since admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 9 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 In an interview on 1/25/22 at 4:27 p.m., the Risk Manager stated that on December 11 2021 at 4:15 a.m., Resident #280 was heard yelling for help. Staff responded and found the resident on the floor with dislodged foley catheter at 4:45 a.m The physician was contacted, and new orders were obtained for reinsertion of the foley and neuro checks. When asked the facility protocol on unwitnessed fall, she stated that the Nurses should assess the level of the injury and the level of mobility and make a determination on the level of emergency. The physician and family should be notified. She added that the facility implements neurological checks every 15 minutes (min) for the first one hour, every 30 min for 2 hrs.; every 1 hr. for 4 hrs. and every shift for 72 hrs. When asked if the neuro checks were conducted, she confirmed there was no documentation. In an interview on 1/26/22 at 9:48 a.m., the Director of Nursing (DON) confirmed that only one neuro check was conducted on 12/11/21 for Resident #280 between 5:00 a.m. and 6:00 a.m When asked how often neuro checks are performed, she said, Every 15 min for the first one hour, every 30 min for 2 hrs.; every 1 hr. for 4 hrs. and every shift for 72 hrs. She mentioned that the documentation populates in the with the scheduled time once the order is added in the computer. When asked for the policy or protocol for neuro checks, she stated that the facility does not have written documentation of the protocol or policy 3. On 1/24/22 at 1:19 p.m., Resident #33 was observed lying in her bed in a supine position. The bed was in low position and fall mat at the bedside. In an interview on 1/24/22 at 1:20 p.m., Resident #33 stated that her toe was hurting. The resident's second toe on her right foot was observed to be reddened. She also mentioned that she had a fall but could not remember the timeline. A review of the clinical record revealed that Resident #33 was admitted to the facility on [DATE] with diagnoses that included gout, dementia, coronary artery disease and heart failure. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 08 out of a possible 15 points, indicating moderate cognitive impairment. She was documented as requiring extensive assistance with bed mobility, transfer, and toilet use. A review of the resident's care plan revealed that she was at risk for fall related to injury due to poor safety awareness history of falling. Interventions included fall mat and bed in low position. A fall document dated 11/15/21 at 8:10 p.m. read, resident found on the floor with the bed on low position at the left side of the bed. With the coccyx on the floor, arm and legs on the front of the body. Resident said, I want to be out of the bed. No injuries noted. Physician contacted and new orders obtained for neuro checks. Another fall documentation progress note dated 11/19/21 indicated that resident was discovered in her room on the floor on her side in front of the wheelchair. Physician in the facility conducting rounds and saw resident. Physician wanted resident put on psychiatric consult, urine for analysis collected, Neurological checks started and x-ray if the resident starts having problems or complaints of pain. Review of the neuro checks flow sheet revealed that on 11/17/21 resident had only two neuro checks: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 10 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 one at 3:01 PM and 3:20 p.m. and one neuro check on 11/16/21 at 12:53 p.m. and 11/15/21 at 11:54 p.m. (Photographic evidence obtained) During an interview on 1/27/22 at 12:24 p.m. with Employee O, Licensed Practical Nurse (LPN), he stated that if there is unwitnessed fall, there is a fall package that outlines what needs to be completed. He stated that the assessments completed at the time of fall are to include range of motion (ROM) neuro checks. He stated that the neuro checks are conducted every 15 min for the first one hour, every 30 min for 2 hrs.; every 1 hr. for 4 hrs. and every shift for 72 hrs. He mentioned that once the orders are put in the matrix care, they populate in the treatment administration record (TAR) with the frequencies. He also mentioned that nurses receive notification when they are due. A review of facility's policy and procedure titled: Falls (last revised on 01/2018), revealed if a resident sustains a fall, or found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated. Direct care staff shall evaluate the area where the fall occurred for possible contributors. A Licensed Nurse shall notify the resident's attending Physician and Resident Representative of the event. The Licensed Nurse shall document the fall in the resident's clinical record. The documentation of the identified intervention should be maintained in the resident clinical record and available to the direct care associates. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident's clinical record. The falls should be reviewed at the Daily Stand - up Meeting following the fall for identification of any additional individualized intervention to reduce the risk of falls. An incident report shall be completed for resident falls by Licensed Nurse after the fall occurs. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 11 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record reviews, the facility failed to follow physician's orders for one (Resident #2) of three residents receiving enteral feedings, from a total sample of 40 residents. The findings include: On 1/25/22 at 3:25 PM, Resident #2 was observed lying in bed with his eyes closed. He was receiving an enteral tube feeding of Glucerna 1.5, set at 50 ml (milliliters) per hour. (Photographic evidence was obtained) A review of the clinical record revealed that Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: acute kidney failure, polyneuropathy, gastrostomy status and dysphagia, oropharyngeal phase. A review of the January 2022 Physician's Order Sheets revealed an order dated 1/10/22 for Glucerna 1.5 Liquid 70 ml/hr. Enteral Tube Continuous for water flush 180-ml every 4 hr. 50 ml/hr. (Copy obtained) A review of the resident's care plan with start date of 12/27/21 revealed the resident has a feeding tube necessary for nutritional needs related to dysphagia. Interventions included but were not limited to flush tube as order/per facility policy, administer the tube feeding formula as ordered, and administer tube feed water flush as ordered. (Copy obtained) On 1/26/22 at 1:24 PM, a second observation of Resident #2 was made on. He was lying in bed dressed in a gown. His tube feeding of Glucerna 1.5 was set at 50 ml/hr. (Photographic evidence was obtained) On 1/27/22 at 7:07 PM, Employee J, Registered Nurse (RN) who was assigned to Resident #2 was asked to come into the resident's room. He observed that the Glucerna 1.5 was set to 50 ml/hr. When he was asked to confirm the tube feeding and rate, he stated, Glucerna 50 ml, 180 every 4 hours. After reviewing the physician's order for Resident #2's tube feeding, Employee J, RN confirmed that Resident #2's medication order indicated Glucerna 1.5 Liquid at 70 ml/hr, Enteral Tube Continuous for water flush 180-mlq 4 hours, 50 ml/hr. A review of the facility's policy titled: Enteral Tube Feeding Via Continuous Pump, dated 1/2022, revealed the purpose to provide nourishment to the resident who is unable to obtain nourishment orally. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 12 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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** 2. A review of Resident #92's record revealed she was admitted to the facility on [DATE] with diagnoses of rhabdomylosis, atrial flutter, acute compression fracture T1-T2, and shortness of breath. Residents Affected - Some Further record review of Resident #92's medical record failed to show a physician's order for administration of oxygen or a care plan for oxygen administration. On 1/25/22 at 9:30 AM, Resident #92 was observed in bed awake and alert wearing a nasal cannula. The oxygen concentrator setting was set at 2 L/min. The resident stated she had COPD (chronic obstructive pulmonary disease), and the oxygen made her breathing better, and that she had been using it only for the last few days. On 1/26/22 at 9:20 AM and again at 2:50 PM, Resident #92 was observed in bed awake and alert. The resident had oxygen in use, remaining on at 2L/min via nasal cannula. Resident #92 was observed again on 1/27/22 at 9:30AM in bed with oxygen on at 2 L/min via nasal cannula. An interview with Employee E, Registered Nurse (RN)/Assistant Director of Nursing (ADON) was conducted on 1/27/22 at 12:45, regarding the administration of oxygen for resident #92. She confirmed that she could not find a physician's order for the oxygen, but said she checked the flow rate every day, and the resident has not been complaining of any breathing issues. She stated the facility did not have standing orders for administration of oxygen, but the certified nurse aide (CNA) did check her oxygen saturation daily and reported it to her. During an interview with Employee F, Certified Nursing Assistant (CNA) on 1/27/22 at 1:34 PM, she said, she checked the resident's oxygen saturations every day and let the nurse know what it was. She said she never touched or adjusted the dial on the oxygen concentrator, adding that only the nurse did that. An interview with the Director of Nursing (DON) was conducted on 1/27/22 at 4:15PM, regarding the policy for administration of oxygen. She stated that a physician order was required for the use oxygen, and that the facility would then check oxygen saturations every shift. Oxygen saturation would be checked by a nurse or C.N.A. The nurse was responsible for checking the oxygen tubing and to adjust flow rate as needed. She verbalized that all nurses should be checking orders for any changes daily. She reported that oxygen settings could be found on the physician's orders and the MAR/TARS (medication administration record/treatment administration records). 3. A review of Resident #8's clinical record revealed she was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses that included renal disease, hypertension, heart failure, heart failure, type 2 diabetes mellitus, chronic kidney disease, acute kidney failure. Further review of Resident #1's clinical record revealed no physician's order for oxygen. A review of the quarterly mininum data set (MDS) assessment, dated 10/14/21 revealed Resident #8 had a brief interview for mental status (BIMS) score score of 13, indicating cognitively intact. The assessment also revealed shortness of breath (SOB) with excretion and when lying flat, her treatments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 13 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 included oxygen and dialysis. Level of Harm - Minimal harm or potential for actual harm A review of Resident #8's care plan, initiated on 1/19/22, revealed resident was oxygen dependent with chronic heart failure (CHF): has potential for shortness of breath (SOB) and/or respiratory complications related to history of CHF and pulmonary edema. Interventions included administering medications per orders and monitor for response; provide treatment per doctor orders and monitor for response; monitor O2 saturation and administer O2 per doctor orders. Residents Affected - Some On 1/24/22 at 2:00 PM, Resident #8 was observed in her room wearing a nasal cannuala. The oxygen concentrator was set to a flow rate of 1 L/min. At this time, the resident stated it should be higher. The resident was asked when was the last time the tubing was changed, she stated 2 weeks ago. The tubing had no date on it. On 1/26/22 at 10:10 AM, an additional observation was made of Resident #8 in her room. She was wearing a nasal cannula and the oxygen concentrator was set to a flow rate of 1 L/min. At this time, the resident reported that it should be at 3 Liters and that she had been on oxygen for more the 3 months. An interview was conducted with Employee O, Licensed Practical Nurse (LPN) on 1/27/22 at 3:47 PM. He reported that Resident #8 gets oxygen continuous at 2 liters and tubing should be dated After he was requested to review Resident #8's oxygen orders, he checked the computer and stated, its not in there. Employee O, LPN was requested to review the oxgen setting in Resident #8's room. After reviewing the oxygen concentrator, he said, It's set at 1 liter. While in the room, Employee O, LPN moved the oxygen dial to 2 Liters. Resident again was asked what her oxygen should be set on, she stated, 3 Liters. At this time, Employee O, LPN moved the oxygen concentrator dial to 3 Liters. The employee had no orders for oxygen at this time in system. During an interview with the DON on 1/27/22 at 4:15 PM, she confirmed that Resident #8 did not have an oxygen order. She added that if a resident is on oxygen, it should be entered as an order and the nursing staff should check the resident's oxygen saturation every shift. A review of the facility's policy and procedure titled: Oxygen Administration (last approved on 11/20) read: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: A. Verify that there is a physician's order for this procedure. Review the physician's orders or community protocol for administration. (Copy obtained) Based on observations, interviews, record reviews and policy and procedure review for oxygen administration, the facility failed to administer oxygen at the ordered flow rate for one resident (Resident #45), and administered oxygen without a physician's order for two (Residents #92 and #8) of twenty-two residents on oxygen therapy, from a total sample of 40 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 14 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. A review of Resident #'45's clinical record revealed he was to the facility on 5/9/2021 with a diagnoses that included: chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The resident was independent with most activities of daily living. A review of the quarterly mininum data set (MDS) assessment dated [DATE] revealed Resident #45 had a brief interview for mental status (BIMS) score score of 15, indicating cognitively intact. Further review of Resident #1's clinical record revealed a physican's order for oxygen with start date of 7/11/21 which read, Oxygen at 3 liters per min to keep oxygen saturation above 90% - 3 inhalation 3 times per day every shift for oxygen continuous. (Copy obtained) On 1/25/21 at 10:01 AM, Resident #45 was observed in his room. He was not wearing an oxygen nasal canal, but his oxygen concentrator was set at 1.5 L/min (Liters/minute). Resident #45 stated, he used the oxygen at night or as needed and that his level was 2 L/min. (Photographic evidence obtained) A review of Resident #45's care plan, initiated on 5/9/2021, indicated he has potential for SOB and/or respiratory complications related to COPD and chronic respiratory failure with O2 (oxygen) use. Interventions included to monitor oxygen saturation and administer oxygen per physician orders. O2 use and equipment maintenance per facility policy/MD order. On 1/25/22 at 3:33 PM, Resident #45 was observed lying in bed fully dressed wearing an oxygen nasal canal with oxygen concentrator setting at 1 L/min (Photographic evidence obtained) On 1/26/22 at 3:30 PM, Resident #45 was observed sitting on the side of bed fully dressed not wearing oxygen nasal. The oxygen concentrator was set to a flow of 1 L/min. On 1/27/22 at 2:32 PM, Resident 45 was once again observed sitting on the side of bed fully dressed not wearing oxygen nasal. The oxygen concentrator was set to a flow of 1 L/min. (Photographic evidence obtained). During an interview with the Director of Nursing (DON) on 01/27/22 at 04:18 PM, she was asked how correct oxygen settings are communicated from one staff person to another. She stated it should be on the MAR/TAR and the physician's order. When asked when do staff check for changes in a resident's oxygen order. She confirmed they should check when they come on shift. The DON confirmed oxygen components should be audited. On 01/27/22 at 5:28 PM, Employee Q, Certified Nursing Assistant (CNA) confirmed she was familiar with resident #45. She thought, he received oxygen but did not know the oxygen level Resident #45 received. When she was asked how the correct settings are communicated from one staff person to another. She stated, It's all left to the nurses, I make sure it is connected when it should be. On 01/27/22 at 5:35 PM, Employee J, RN reported Resident #45's is on oxygen as needed. We apply it and he takes it on and off by himself. When asked, when do you check his oxygen level. Employee J, RN confirmed once a shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 15 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview and record review, the facility failed to maintain a medication error rate of less than five percent. During the medication administration observations, there were two errors and a total of twenty-six opportunities, resulting in an error rate of 7.69%. Residents Affected - Few The finding include: 1. On 1/26/22 at 9:22 AM, an observation of medication administration observation was conducted for Resident #28 with Employee J, Registered Nurse (RN). Resident #28 had a physician's order for hydrochlorothiazide (used to treat high blood pressure), 25 mg (milligram) tablet, once daily by mouth. Employee J, RN reviewed the orders as he popped the medication in the medication cup. There were two tablets for hydrochlorothiazide 12.5 mg in the bag. Employee J, RN picked out one tablet of hydrochlorothiazide and placed it back in the cart and popped the other one in the medication cup. He proceeded to administered 1 tablet of hydrochlorothiazide 12.5 mg to Resident #28. On 1/26/22 at 9:30 AM, during an interview with Employee J, RN, he acknowledged only 1 tablet of hydrochlorothiazide 12.5 mg was administered to Resident #28, instead of the physician's order of 25 mg. 2. On 1/25/22, at 3:24 PM, Resident #48 was observed in bed with intravenous (IV) of 0.9% Sodium Chloride infusing at 75cc/hour via dial a flow into the left forearm. A review of the resident's medical record revealed a physician order to flush IV site with 0.9% Sodium Chloride and administration of IV fluids 500cc 0.45% Sodium Chloride at 75cc/hour. The physician order did not include a stop date/time. On 1/25/2022 at 3:35 PM, Resident #48 was observed with an IV solution of 0.9% Sodium Chloride infusing into the left forearm at 75cc/hour via dial a flow. The IV solution bag was unlabeled. A review of the resident's medical record revealed a care plan for intravenous (IV) fluids was initiated on 1/25/2022. On 1/25/22 at 4:20 PM, an interview with the Director of Nursing (DON) was conducted regarding the facility's policy/protocol for hanging IV fluids. She stated that it should be labelled with the date and time. While the DON was in Resident #48's room, she observed the IV solution (0.9% Sodium Chloride) currently infusing. She did not indicate that it required a resident's name, room number, rate of flow, or solution being infused. When she was asked a second time what needed to be included on the labelling of the IV solution, she restated that it should have the date and time on it. She added that physician orders can be transcribed by a nurse or the unit secretary, but it is the responsibility of the nurse to double check all new orders. After reviewing Resident #48's orders in Matrix Care, she confirmed that the resident currently had the wrong solution hanging, and an incomplete order written. The DON stated, It should be there. A review of the facility's policy and procedure titled, Administering Medications, last revised on 12/2021, read: C. Medications shall be administered in accordance with the orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 16 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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 0759 Level of Harm - Minimal harm or potential for actual harm D. If a dosage is believed to be in appropriate or excessive for the resident or the medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, a clinical associate shall contact the resident's Attending Physician or the community's Medical Director to discuss the concerns. (Copy obtained) Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 17 of 18 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 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 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, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were safely stored for one resident (Resident #31) in a total sample of 40 residents. The finding include: On 1/24/22 at 12:53 PM, Resident #31 was observed lying in bed. There was a compound cream equal parts 1:1 zinc/bacitracin/nystatin/cream, observed at the bedside. (Photographic evidence obtained) A review of physician orders for Resident #31 revealed active orders to: Cleanse left and right foot with normal saline pat dry apply xeroform then calcium alginate the 4x4 gauze wrap with kerlix at bedtime (Qhs). Compound cream equal parts 1:1 zinc/bacitracin/ nystatin/cream, apply to bilateral inner thighs buttocks three times a day. On 1/25/22 at 1:40 PM, a second observation of Resident #31 was made. She was observed lying in bed with a compound cream equal parts 1:1 zinc/bacitracin/nystatin/cream, observed at the bedside. (Photographic evidence obtained) On 1/27/22 1:31 PM, the Director of Nursing (DON) went to Resident #31's room and confirmed that the cream (compound cream equal parts 1:1 zinc/bacitracin/ nystatin/cream was at bedside) was at the resident's bedside. The DON stated that the cream should not have been left at the bedside and that the nurses are supposed to apply the cream and keep it in the treatment cart. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 18 of 18