Inspection·November 16, 2023

F 0610 make a report. Level of Harm - Minimal harm or potential for actual harm Another interview was conducted with Risk Manager S on 11/15/23 at 4:06 p.m She was asked about Resident #75's grievance/complaint. She said, The social worker handles that. She was again asked if she was aware of the resident's missing money. She said, Yes, I'm aware, but the social worker is handling that. She was then asked how the facility protected the residents from misappropriation of property. She said, By investigating allegations and reporting. She then stated, That should have been reported. Residents Affected - Few A review of the facility's policy and procedure titled Abuse Investigation and Reporting (last revised on 7/2022), revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the Ascension Living Abuse Prevention policy. The policy interpretation and implementation role of the investigator section (page 2) revealed that the individual conducting the investigation will at a minimum: 4. Interview any witnesses to the incident. 7. Interview associates/members (on all shifts) who have had contact with the resident during the period of the alleged incident. 8. Interview the resident's roommate, family members and visitors. 9. Interview the residents to whom the accused employee provides care or services, and 10. Review events leading up to the alleged incident. The policy's Reporting Section (page 3) indicated that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies: 1. The State Licensing/Certification Agency responsible for surveying /licensing the community. 2. Other officials in accordance with State Law, including Adult Protective Services where state law provides for jurisdiction in long-term care facilities. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 2 of 36 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 11/16/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review, and facility policy review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid, to the maximum extent practicable, to avoid duplicative testing and effort for one (Resident #17) of 41 residents sampled. The facility failed to refer residents with newly evident or possible serious mental disorders, intellectual disability, or a related condition for a level II resident review. The findings include: A record review for Resident #17 was conducted on 11/14/23 at 10:45 a.m. The PASARR could not be located. The facility was asked to provide the documentation. Two PASARRs were provided, one dated 4/24/2015 and the other dated 12/31/2015. Neither of the PASARRs reflected the resident's diagnosis of dementia or unspecified psychosis. The record revealed that Resident #17 was readmitted to the facility on [DATE] after having been hospitalized . Her diagnoses included unspecified convulsions; unspecified dementia; unspecified psychosis not due to a substance or known physiological conditions; metabolic encephalopathy; acute kidney failure; personal history of other specified conditions; dysphagia; personal history of other infectious and parasitic disease; atherosclerotic heart disease; hemiplegia affecting left non-dominant side, and type 2 diabetes mellitus. An 11/14/23 review of the current, active Physician's Orders included: Quetiapine (Seroquel) 25 mg (milligrams), two tablets every 12 hours; Escitalopram (Lexapro) 20 mg daily; Lacosamide (anticonvulsant) 250 mg twice a day; Topiramate (anticonvulsant & nerve pain) 100 mg twice a day; Levetiracetam (anticonvulsant) 1000 mg twice a day. During an interview with Social Worker P on 11/15/2023 at 2:23 p.m., he stated it was the responsibility of the Admissions Department to review the PASARRs for accuracy when residents were admitted /readmitted to the facility. He added that he had a Masters of Social Work (MSW) degree and would complete a PASARR if a resident did not have one. If there were any changes, he would also complete another PASARR. He stated the hospital completed a new PASARR each time a resident returned to the facility after being transferred for care. He was shown the PASARRs the facility provided for Resident #17, and he confirmed the dates on the PASARRs provided as 4/24/2015 and 12/31/2015. When he was asked how this was possible considering the resident's admission and readmission dates, he stated this was all that was available for the resident. They weren't scanned into her electronic chart as they should have been. He was asked if the resident had any qualifying diagnoses. He confirmed the resident did have a diagnosis of unspecified psychosis. He was asked if it was possible that another PASARR was done that could have captured this diagnosis. He stated not that he was aware of. No additional PASSAR documentation was provided during the survey. During an interview conducted on 11/15/2023 at 5:00 pm with Registered Nurse (RN) M, he stated he was familiar with Resident #17. He cited her diagnoses as dementia, unspecified psychosis, and added that she also had seizures. He listed her medications as Escitalopram 20 mg daily for depression, Lacosamide 250 mg twice a day for seizures, Topiramate 200 mg every 12 hours for seizures and Seroquel (antipsychotic) 25 mg every 12 hrs. He noted the resident's physician's orders and medication administration record listed the Seroquel was for depression. He stated the diagnosis was inaccurate, Sometimes they put the wrong diagnosis. After reviewing the eMAR, RN M confirmed the resident had received the medication as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 3 of 36 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 11/16/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Further review of Resident #17's medical record revealed that she was seen by Mental Health Services on 10/16/2023. The chief complaint was documented as: depression, anxiety, confusion, psychosis and follow-up visit. The following was included in the 10/16/23 mental health services documentation: HISTORY OF PRESENT ILLNESS: Residents Affected - Few Chief complaint has been occurring for: several months Appears to be: better For the past: weeks History of mental illness, depression, anxiety, and psychosis MENTAL STATUS EXAMINATION: Level of consciousness: Alert Thought processes: blocking Insight/judgement: poor Oriented to: place Immediate memory: partially impaired Recent memory: partially impaired Remote memory: partially impaired Thought content and perceptions: delusions Mood/Affect: depressed, anxious SIGNS AND SYMPTOMS: Patient shows apathy with poor social interaction Patient has sleep disturbances Patient is feeling depressed and sad Patient feels restless and anxious Patient is psychotic with: delusions DIAGNOSES: Vascular dementia with behavioral disturbance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 4 of 36 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 11/16/2023 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 0644 Major depressive disorder, recurrent, moderate Level of Harm - Minimal harm or potential for actual harm Generalized anxiety disorder Unspecified psychosis not due to a substance or known physiological condition Residents Affected - Few Further review of the resident's 10/16/23 Mental Health Services note, authored by her psychiatric Advanced Practice Registered Nurse (APRN), revealed that Seroquel (antipsychotic medication) 50 mg (milligrams), one by mouth twice daily for a diagnosis of psychosis was to be continued. A review of the facility's policy titled Change in Resident's Condition or Status (original date of 12/2016, last revised on 2/2022 and last approved on 3/2022) revealed: Policy Interpretation and Implementation: (G) In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified of a significant change in the mental health or physical condition of a resident with a mental disorder or intellectual disability. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 5 of 36 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 11/16/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #2) of 41 residents sampled, was appropriately screened for a mental disorder (MD), intellectual disability (ID) or other related conditions prior to admission. Failure to ensure residents are pre-screened for MD/ID or a related condition, prior to admission to the facility, could prevent the resident from attaining or maintaining his/her highest practicable level or result in decline in the resident's physical, mental or psychosocial well-being. Residents Affected - Few The findings include: A review of Resident #2's medical record revealed that a Level 1 PASARR (Pre-admission Screening and Resident Review) evaluation was documented and dated 07/28/2010, which was more than 10 years prior to her admission to this facility on 02/17/2021. Per the resident's Annual, Comprehensive Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/1/2022, there was no indication of where the resident was admitted from. A review of the [AGE] year-old 07/28/2010 PASARR revealed the following: On page 1, section I, the resident was documented as having indications of, or a diagnosis of a major mental illness as defined in the DSM-IV R, limited to schizophrenia, mood disorder, severe anxiety disorder, or a mental illness that may lead to a chronic disability. The form's instructions indicated that if there was a positive answer in section I, the writer should continue to section II. On page 1, section II, the form asked whether the resident had a primary diagnosis of dementia (including Alzheimer's disease) or a related condition, or a non-primary diagnosis of dementia with a primary diagnosis that was not a major mental illness. The answer documented was no. Form instructions indicated the writer should continue to section three of the form if the answer was no. Section III asked whether the resident was being admitted from a hospital requiring nursing facility services and whether the resident's physician had certified before admission that the resident was likely to need less than 30 days of nursing facility services. The Documented answer was no. The form indicated that the writer should proceed to section IV. Section IV was for provisional admission to the nursing facility under time-limited categories related to a need to evaluate the resident after delirium cleared, in emergecy situations requiring protective services, and/or respite care for in-home caregivers. The documentation indicated that none of that was applicable. Instructions indicated the writer should proceed to section V. Section V indicated that a level II evaluation was required for individuals with MI (mental illness) or MR (mental retardation) who met one of the following advanced group determinations of the need for nursing facility services or for those who did not meet one of the categorical or advanced group determinations in sections III, IV, or V of the form. The level II evaluation and determination must be received prior to NF (nursing facility) admission. Question #1 of section V asked whether the resident required convalescent care from an acute physicial illness that required hospitalization and did not meet all of the criteria for an exempt hospital discharge. The answer was documented as yes. No terminal illness or severe physical illness was documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 6 of 36 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 11/16/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The form's space for signature, date completed, title of the form's author, agency, date of mental health evaluation, date referred for level II, and level II agency were all blank. On page three of the form, Resident #2 was marked as having diagnoses or an indication of severe anxiety/panic disorder and bipolar disorder. Question #2 asked whether the level I screen indicated the diagnoses/disorders resulted in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the resident's developmental stage. The answer was documented as no. The answer to question #3 indicated the resident had serious difficulty with interpersonal functioning, concentration, and adaptation to change. The answer to Question #4 indicated the resident had not received in-patient psychiatric treatment within the last two years, and had not experienced an episode of significant disruption to her normal living situation. (Copy obtained) Further review of the resident's record revealed current, active diagnoses of epilepsy, unspecified, not intractable, w/o status epilepticus; bipolar disorder, unspecified; unspecified dementia without behaviors/psychosis; generalized anxiety disorder; sleep apnea; unspecified abnormalities of gait and mobility; personal history of transischemic attacks, and hypertension. A review of the most recently completed Quarterly MDS assessment with an ARD of 08/18/2023, included coding of Resident #2's diagnoses to include dementia, anxiety disorder, and bipolar disorder. She had received antipsychotic and hypnotic medications during the MDS look-back period. A review of the resident's care plan, dated 09/18/2023, revealed the following problem areas: Organic brain syndrome with cognitive deficits. She has poor impulse control and is sometimes difficult to redirect. She is oriented to person, family, and staff. Potential for psychosocial well-being concerns related to impaired cognition. She is impulsive and not socially appropriate at times. She has periods of agitation and a diagnosis/history of bipolar disorder, organic brain injury, and chronic encephalopathy. Resident is emotionally labile person whose mood fluctuates throughout the day, from pleasant to verbally abusive behaviors related to bipolar disorder. She seeks attention from people and likes to have them listen to her music or listen to her sing. She can become anxious and agitated when it is time for ADL (activities of daily living) care or time to have her hair washed. She does not like being interrupted throughout the day to toilet and can become verbally inappropriate, yelling at staff, you are killing me, you hate me and stop it. She has history of telling passers-by that staff are killing her or hurting me. She will yell loudly, lock her chair, plant her feet firmly on the ground, and will not move when she doesn't want to be bothered. She seeks immediate gratification for her needs. She can become immediately agitated and verbally inappropriate if there is a barrier to her fulfilling a need or want. She asks repetitive questions and has anxious complaints. She is prescribed psychotropic medication and is at risk for side effects. She has impaired behavior related to her impaired cognitive skills. She has the potential for drug related complications associated with use of psychotropics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 7 of 36 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 11/16/2023 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 0645 She is at risk for increased behavioral expressions, altered mood and elopement. She uses a seat belt. Level of Harm - Minimal harm or potential for actual harm The level I PASARR is negative/level II PASARR is not needed. Resident does not have a diagnosis of mental disorder, intellectual disability, and will not need specialized services. Residents Affected - Few On 11/16/23 at 3:53 p.m., the Long-Term Care Social Worker was interviewed. He stated he had been employed in his position since February of 2023. When asked to explain the PASARR process, he stated, Since I've been here, we usually get a PASARR from the hospital before admission. If the patient comes from home, the facility has asked me to do it. The Admissions Department receives the admission packet and assures all residents are admitted with the 3008 (hospital transfer form) and PASARR already completed. If there is something that needs to be reviewed with the PASARR, the Admissions Department will refer it to Social Services for further review. Admissions gives the packet to the unit managers or whoever in nursing services will be processing the admission, so the resident can be admitted . Then the packet is given to Medical Records who scans all the admission paperwork into the medical record. Apparently, when the resident was admitted in 2011 the facility accepted the PASARR that was completed and signed on 07/28/2010, and failed to reevaluate the need for a new screening. On 11/16/23 at 4:03 p.m., the Health Information Manager (HIM/Medical Records) was interviewed. She stated the PASARR dated 07/28/2010 was the only screening that she could locate and that she would continue to look for any other PASARR screening information that may have been included in the resident's medical record. On 11/16/23 at 4:05 p.m., the Interim Director of Social Services (IDSS) was interviewed. She stated she had been employed in her position since October of 2023. She stated Resident #2 was a transfer from another skilled nursing facility, and that may have been the reason the PASARR, dated 07/28/2010, was accepted by the facility at that time. She reviewed the resident's medical record and stated Resident #2's record indicated that she was admitted to this facility from an acute care hospital. She was not able to verify from the medical record exactly which long-term care facility the resident was actually transferred from. When asked how often PASARR screenings were reviewed or updated, she replied, Since I've been here, I've been trying to look into that, and that was one of the things that the long-term care social worker and I were trying to get implemented here. I don't know what was done before I came, but we became aware that an audit process was needed. She further stated, I just got off the phone with Kepro. I was trying to find out if a Level II had ever been established for Resident #2, and they told me that they don't even have any information on her in their system. They tried to look her up by her name and date of birth and could not find any information at all. When asked what would trigger another PASARR level I evaluation after a resident has been admitted to the facility, she stated, looking at the PASARR mental health part, if the PASARR indicates the resident has diagnoses of schizophrenia or something of that nature, and the facility starts to notice any behavioral issues, you want to go ahead and submit that information to Kepro for guidance on whether the resident needs to be re-evaluated for proper placement in a long term care facility, and if a level II may be indicated. We will let Kepro provide us with that guidance. Usually, the facility may get the doctor to order a psychological/psychiatric evaluation before Kepro is alerted, and then any new conditions or diagnoses can also be sent to Kepro, along with the rest of the information they need to make a determination. When asked what diagnoses would trigger a re-evaluation, she responded, the PASARR form lists the mental illness diagnoses, the intellectual disability or related conditions that need to be checked on the form. She was asked if Resident #2 had any mental illness diagnoses checked on the form dated 07/28/2010 and she answered yes. When asked if Resident #2 had an intellectual disability checked on the form dated 07/28/2010, she answered no. When asked if Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 8 of 36 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 11/16/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #2 had any related conditions checked on the form dated 07/28/2010, she answered no. She was asked what Resident #2's current active diagnoses were that might indicate that she would need to be re-evaluated. She replied, generalized anxiety disorder, bipolar disorder, epilepsy, and dementia. She also stated, The resident probably should have been re-evaluated for an updated Level I PASARR. A review of the facility's policy and procedure titled PASARR (Pre admission Screening and Resident Review) (last reviewed on 07/2018) revealed: Policy Statement: The purpose of this policy is to outline the screening of residents with a history of serious mental illness and developmental disability. The community will not admit any new resident who is suspected of having: A serious mental illness unless: The state mental authority determines that the physical and mental condition of the individual requires the level of services provided by the facility. The state mental health authority determines whether or not the individual requires specialized services for mental illness. These determinations are based on an independent physical and mental evaluation that is performed prior to admission. An independent evaluation is an evaluation performed by a person or entity other than the state mental health authority. Procedure: A.Complete Level I screen of the PASARR on new admissions. 1. Readmits do not require a PASARR to be completed. 2. Residents being transferred to another nursing home do not require another PASARR to be completed. The nursing home must send with the resident all screens. 3. Those residents whose attending physician has certified, before admission to the community that the individual is likely to require less than 30 days of nursing facility services, do not require a PASARR to be completed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 9 of 36 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 11/16/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility policy and procedure review, the facility failed to provide an ongoing activity program that met residents' interests and supported the physical, mental, and psychosocial well-being of one (Resident #73) of 41 sampled residents. Facility activities programs that incorporate residents' interests, hobbies and cultural preferences are intregal in maintaining and/or improving residents' physical, mental, and psychosocial well-being and independence. Residents Affected - Few The findings include: On 11/13/2023 at 11:03 a.m., Resident #73 was observed lying in bed with a hospital gown on. Her eyes were closed. She did not open her eyes or respond when her name was called. The room was dark. The television was not on and no music was playing from any device in her room. The room was not homelike as evidenced by no personal belongings visible anywhere in the room and the walls were bare. There was no Activities calendar in the resident's room. During the lunch meal service on the 1 North unit on 11/13/2023 from 12:10 p.m. to 1:15 p.m., Resident #73 was not observed in the dining room or in any of the common areas. During the lunch meal service on the 1 North unit on 11/14/2023 from 12:38 p.m. to 1:00 p.m., Resident #73 was not observed in the dining room or in any of the common areas. On 11/14/2023 at 12:45 p.m., Resident #73 was observed lying in bed with a hospital gown on. Her eyes were closed. She did not open her eyes when her name was called. The room was dark and the television was not on. No music was playing from any device in her room. There was no Activities calendar in the resident's room. On 11/14/2023 at 2:30 p.m., Resident #73 was observed lying in bed with a hospital gown on. Her eyes were closed. She did not open her eyes or respond when her name was called. The room was dark. The television was not on and no music was playing from any device in her room. There was no Activities calendar in the resident's room. On 11/15/2023 at 2:51 p.m., Resident #73 was observed lying in bed with the bed covers up over her chest under her chin. Her eyes were closed. She did not answer when her name was called. The room was dark and the television was not on. There was no Activities calendar in the resident's room. During an interview with Licensed Practical Nurse (LPN) F on 11/15/2023 at 2:58 p.m., she stated she was the assigned nurse for Resident #73. She stated she had not worked at this facility long, but since she had been employed, she had not seen the resident up out of bed. She confirmed that Resident #73 was not receiving hospice or palliative care services. She stated she did not know why the resident was always in bed. She had not been ill. A review of the employee roster for the facility revealed that LPB F began employment at this facility on 10/17/2023. On 11/16/2023 at 9:39 a.m., Resident #73 was observed lying in bed. Certified Nursing Assistant (CNA) G was spoon-feeding the resident thickened orange juice from a cup. The resident did not respond to her. She did not open her eyes but would open her mouth to take the juice. The CNA stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 10 of 36 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 11/16/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm sometimes the resident would not respond because her first language was not English. The CNA touched the resident on her shoulder and called her name. The resident did not respond. When asked if the resident ever got up out of bed or attended activities, she stated the resident sometimes did. She confirmed the resident had not been up today. The resident's room was dark and the television was not on. No music was playing from any device in her room. There was no Activities calendar in the resident's room. Residents Affected - Few On 11/16/2023 at 11:09 a.m., upon entering the 1 North unit, the Unit Manager stated, Guess who's up out of bed? He confirmed it was Resident #73. Resident #73 was observed seated in her wheelchair in the dining room. She was fully dressed. Her eyes were closed and she had her hand up over her face as though she was in pain. Upon approach she was greeted in Spanish, her first language, and she opened her eyes briefly and made eye contact but did not speak. She then closed her eyes and did not respond again. No group activity was being conducted. During an interview with Activities Assistant (AA) P on 11/16/23 at 11:00 a.m., she was asked to produce the Activities participation logs. She went to the Activities department office and found the logs. She brought the months of August, September, October and November of 2023 for review. A review of the logs revealed that Resident #73 received activities on the following dates: 11/10/2023 the box was initialed V indicating she had a visitor. 1 day out of 15. 10/25/2023 the box was initialed EX 10/17/2023 the box was initialed TV, indicating she watched television. 10/09/2023 the box was initialed TV 3 days out of 31 9/01/2023 the box was initialed TH indicating therapy. 9/04/2023 the box was initialed V, indicating she had a visitor. 9/06/2023 the box was initialed EX and PC 9/14/2023 the box was initialed TV 9/19/2023 the box was initialed DR, indicating she was in the dining room. 09/21/2023 the box was initialed DR and MIN 9/26/2023 the box was initialed V and T.T. 7 days out of 30 8/08/2023 the box was initialed D.R. and T. T. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 11 of 36 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 11/16/2023 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 0679 8/11/2023 the box was initialed V. and D.R. Level of Harm - Minimal harm or potential for actual harm 8/16/2023 the box was initialed POD and EX 8/17/2023 the box was initialed DR and MN. Residents Affected - Few 8/22/2023 the box was initialed MN 5 days out of 31 (Copies obtained) Per the facility's documentation, at no other time did the resident receive activities. During an interview with AA P on 11/16/2023 at 2:20 p.m., she stated she was not sure what TT, POD, EX or MN stood for. She stated Resident #73 was not assigned to the unit that she worked on and she was not familiar with the documentation for the Activities Assistant who was assigned to Resident #73. She confirmed that the Activities Assistant assigned to Resident #73 was out on leave and the Activities Director was also out on leave. She could not explain why Resident #73 was offered activities so seldom. A review of Resident #73's medical record revealed that the face sheet indicated she was admitted on [DATE]. She was readmitted on [DATE]. She was admitted with diagnoses including but not limited to fracture of left hip, metabolic encephalopathy, hyperosmolality and hypernatremia, hypertension, unspecified dementia, unspecified severity, without behaviors/psychosis/mood/anxiety, tachycardia, elevated white blood cell count, acidosis, acute kidney failure, hyperlipidemia, polyneuropathy, and sepsis. (Copy obtained) A review of the Activities Quarterly note, dated 08/31/2020, revealed: Assessment for [Resident #73]. She enjoys looking at tv in her room and talking with her roommate and staff. She loves her snacks on Fridays and sitting in the hall looking out of the window. A review of the Activities Quarterly note, dated 02/24/2021, read: Quarterly note for [Resident #73]. Is often found in her room or in the day room watching tv. [Resident #73] loves conversation with her roommate and some staff. We will continue to assist as needed. A review of the Minimum Data Set (MDS) Annual assessment, dated 05/25/2022, revealed that when the resident was interviewed, she stated it was very important to her to listen to music and to go outside when the weather was good. It was somewhat important to her to do her favorite activities and to do things with groups of people. (Copy obtained) A review of the MDS Quarterly assessment, dated 07/20/2023, revealed Resident #73's mental status could not be determined. The summary score was 00, indicating the resident was not able to complete the interview. The resident was assessed as being totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing and toilet use. She required extensive assistance for eating. (Copy obtained) A review of the Care Plan, dated 5/16/2023 with no revisions, revealed: Resident #73 is at risk for changed activity preferences due to advancing dementia. [Resident #73] primarily attends activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 12 of 36 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 11/16/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few passively and enjoys music. Resident will participate in preferred activities weekly through the review period. (A) Activity assistant will visit with [Resident #73] regularly for companionship and inform her of the current activities available. She watches her television and listens to music. (A) Offer and assist, to activity of choice. [Resident #73] enjoys music programs but will often sit as an observer for other activities. (A) Offer music therapy in room. Departments responsible for this care plan were Activities, All, Nursing and Social Services. (Copy obtained) A review of the facility's policy and procedure titled Activities (dated 12/2016 and revised 01/2020) revealed: The community should provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental and psychological well-being of each resident, encouraging both independence and interaction in the community. Residents are encouraged to choose the types of recreational, cultural and religious activities and social events in which they prefer to participate. As much as possible, the community will provide activities, social events, and schedules, that are compatible with the resident's interests, physical and mental assessment, and overall plan of care. Activities are scheduled 7 days a week and residents are given an opportunity to contribute to the programs. Activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include activities not necessarily limited to formal activities. Other community activities associates, volunteers, visitors and residents and family members may also provide activities. Activity schedules are also provided individually to residents who can not access the posted schedule (e.g. bed bound or visually impaired residents). Attendance and participation is recorded for every resident in group and individual activities on a daily basis. Residents who choose not to attend group activities will maintain an independent program. It is the responsibility of the community and the activity associates to make regular contacts and offer supplies, as needed. Residents requiring assistance to and from scheduled activities will be assisted by the Activity Department, Nursing Services and community volunteers. A list of activities scheduled for the month is posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g. bed bound). Each resident's activities care plan relates to her comprehensive assessment and reflects her individual needs. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 13 of 36 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 11/16/2023 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent falls for one (Resident #135) of seven residents reviewed for falls, from a total sample of 41 residents. The findings include: A review of Resident #135's medical record revealed that he was admitted to the facility on [DATE], with his most recent readmission occurring on 7/31/23. Resident #135's diagnoses included unspecified fall, unspecified motor vehicle accident with injury; other injury of unspecified body region; and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. A review of the resident's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 6/14/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. No behaviors were documented. His functional status was documented as follows: Bed Mobility/Self Performance - Total dependence, full staff performance of one staff member Transfer Self-Performance: Activity occurred only once or twice during the look-back period. Assistance of two staff members required. The resident was documented as non-ambulatory. Locomotion on the unit did not occur during the look-back period. Locomotion off the unit only occurred once or twice during the look-back period and required one-person physical assistance. Range of Motion to both upper extremities was impaired. He was always incontinent of bladder and bowel. (Copy obtained) A review of the resident's active Care Plans revealed the following Focus Areas: Focus: Falls [Resident #135] has potential for fall/fall-related injury due to deconditioning with functional decline secondary to motor vehicle accident with fractured pelvis, spinal cord injury status-post C-spine surgery, PEG tube (feeding tube) placement for dysphagia. Start date: 7/31/23. Interventions included: Keep bed at the appropriate height. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 14 of 36 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 11/16/2023 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 Keep personal items within reach. Level of Harm - Actual harm Patient educated to call for assistance if needing to be repositioned. Residents Affected - Few Low bed with mats. Start date: 7/31/23. Focus: Pressure Ulcers/Skin Prevention [Resident #135] is at risk for pressure ulcers and other skin related injuries due to healed wounds to right upper coccyx, healed area to left hip, impaired mobility, and bowel and bladder incontinence. Start date: 11/1/23. Focus: Pain [Resident #135] has risk for pain related to spinal cord injury status post stabilization. Start date: 7/31/23. [Resident #135] states exertion makes it worse. Interventions include: Offer and encourage as indicated nonpharmacological pain management and repositioning. Focus: Neurological Conditions [Resident #135] will not develop complications of spinal cord injury requiring outside medical intervention. Start date: 7/31/23. Interventions included: Maintain spinal stability as ordered. Utilize log rolling for bed mobility and avoid twisting the spine. Start date: 7/31/23. Focus: ADL (Activities of Daily Living) Functional/Rehab Potential [Resident #135] needs assistance with daily ADL care. Start date: 7/31/23. Interventions included: Bed Mobility: I need total assistance with one-person staff support. I use slide sheet assistive devices. Transfers: I need total assistance with two person staff support. I use a total lift assistance device. Mobility: I need total assistance of one-person staff support. I use wheelchair assistive device(s). (Copies of all Care Plans obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 15 of 36 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 11/16/2023 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 - Actual harm Residents Affected - Few On 11/14/23 at 12:28 p.m., Resident #135 was observed in his room. His sister, who was his Power of Attorney (POA), was also present. The resident's bed was in the lowest position. Blue fall mats were present on each side of the bed. The resident was asked if he had fallen. He confirmed that he had fallen on 7/30/23. He stated a Certified Nursing Assistant (CNA), later identified as CNA N, was on her cell phone as she was providing him incontinence care. He stated he gave her several warnings that he was going to fall, however, she denied it and walked away before she had finished providing care. When she did, he rolled off the bed onto his side. The bed was in high position, and the resident stated the fall resulted in a laceration to his forehead which required five sutures. The resident's sister stated the facility notified her of the fall after the resident was transferred to the hospital. She was advised that he was found on the floor and was being transferred to the hospital for an injury he sustained. She stated this was unusual, as the resident had fallen in the past, however, because his bed had always remained in the lowest position, he had never sustained any injuries. She stated when she arrived at the hospital she observed the resident with blood over his right eye. When she asked the resident how he had sustained the injury, he advised her that his bed was raised up high while CNA N was providing incontinence care. He told her that CNA N was talking on her cell phone while providing his care and walked away before she was finished. Resident #135 told her he made attempts to warn CNA N that he was falling before she walked away. Prior to this incident, the resident rolled out of bed on 7/23/23, however the bed was low to the floor, so he didn't get hurt. The sister stated the nurse on duty at the time of the incident confirmed that CNA N was in the room at the time of the incident. She further stated the nurse was no longer employed by the facility. She was advised that the incident was reported, but she was never told to whom it was reported. She was never provided with any detailed information. She stated prior to this interview (11/14/23 at 12:28 p.m.), the facility provided her with a printout of an Interdisciplinary Note entered into the resident's record on the date of the fall. Per the note, Around 1800 p.m. (6:00 p.m.) today, the CNA called for assistance of staff RN to room [ROOM NUMBER]. Found patient lying on his right side on the floor . The entry was electronically signed by the registered nurse (RN) on 7/30/23 at 20:48 (8:48 p.m.). (Photographic evidence obtained) On 11/15/23 at 11:08 a.m., a facility staff member advised the survey team that the resident's sister/POA asked to speak with the team. The resident's sister entered the conference room where an interview was conducted in the presence of the entire survey team. She confirmed the full name of the nurse she had spoken with regarding the details of the fall Resident #135 sustained on 7/30/23. She stated both she and the resident gave specific details regarding the fall, including the fact that CNA N was on her cell phone while providing care. They explained to the facility that the resident attempted to warn CNA N several times that he was falling prior to the actual fall. She was asked for the details of the investigation of the fall. She advised the survey team that she was not aware of any investigation. The sister stated she, Resident #135, and the previous nurse (who was no longer employed by the facility) had advised Risk Manager S that CNA N had been on her cell phone while providing care and after that, no one came to ask them anything else regarding the incident. She was asked about the nurse and CNA N. She stated the nurse was no longer employed at the facility, but CNA N was still employed and was working on another nursing unit. During an interview with Licensed Practical Nurse (LPN)/Risk Manager S on 11/15/23 at 3:19 p.m., she was asked to provide the details of Resident #135's fall. She stated it occurred on 7/30/2023. He had a laceration across his eyebrow. She stated she interviewed the resident, and he told her he was trying to sit on the side of the bed, which was too high, when he fell and hit the floor. She stated he told her he did not press his call light. He told her that it was within reach. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 16 of 36 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 11/16/2023 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 - Actual harm Residents Affected - Few resident was given a low bed with mats and was educated to use his call bell for help. She confirmed that the incident was unwitnessed. She was asked why it was not reported. She replied: I don't know. She was asked whether the facility typically reported a fall if it was unwitnessed, and the resident sustained an injury requiring them to be transferred out of the facility for a higher level of care. She replied, It should've been reported. On 11/16/23 at 12:32 p.m., CNA N was contacted via telephone for an interview. She stated she was familiar with Resident #135. She was asked if she was aware of any accidents the resident had while in the facility. She stated she was in the resident's room when the resident fell on 7/30/23. She was asked to provide details of the incident. She stated it happened at the end of her shift. She was in the room changing the resident and his sheets. She stated the bed was raised and when she went to turn the resident over, he wasn't on his other side or on the edge of the bed. When she went to the other side of the bed, he was slightly in the middle. She stated she was not sure if the resident jerked or moved over, but he rolled and hit the floor. She grabbed at his leg to try to prevent him from falling. She stated she didn't touch the resident while he was on the floor, but she did ask him several times if he was okay. He responded each time that he was okay. She stated she noticed that He nicked his head, and he was bleeding. At that time, she went to tell the nurse. She could not remember the nurse's name. She stated the resident denied pain. He was sent out to the hospital overnight and came back the next day. She was asked about the resident's functional status and whether he could sit up on the side of the bed without assistance. She referred to the resident as a total assist x 1, indicating that he was totally dependent, requiring one-person assistance for all of his ADLs. She gave him bed baths, as the shower bed was too uncomfortable for him. She stated the resident was unable to sit up on his own and required assistance due to lack of trunk support. She was asked about any statements and/or investigations regarding the incident. She stated she was required to submit a written statement to LPN/Risk Manager S with the details of the fall. She confirmed she documented that she was in the room with Resident #135 at the time he fell. On 11/16/23 at 2:37 p.m., Resident #135 was observed lying in bed. The bed was in the lowest position with fall mats present on each side. When asked, the resident denied pain. The resident was asked again about the falls he sustained in the facility. He stated the first incident (7/23/23) occurred when he rolled out of bed. He did not sustain any injuries as the bed was in the lowest position. The second fall (7/30/23) occurred when CNA N was on the phone while changing him with the bed raised in the high position. He was asked if the CNA held the phone by hand, used earbuds, or used another hands-free device. He stated she had the phone in her hand, and he told her he was falling, but she turned her back. He stated as he began to fall she quickly turned around and tried to catch him, but she didn't have time to, and he fell to the floor hitting his head. During an interview with LPN F on 11/16/23 at 1:43 p.m., she stated she was familiar with Resident #135. She stated the resident was unable to sit up unassisted and that she felt keeping his bed low was the best thing for him. The resident was not able to apply pressure to his arms to move himself, nor did he have enough tone in his legs to bear weight. He was able to make his needs known and would let her know if he was experiencing pain when she administered his medications. He can make his needs known. He hasn't had any falls recently. They do all of his ADLs, and his sister tells them to brush his teeth. She stated the resident was totally dependent for all his ADLs. During an interview with CNA G on 11/16/23 at 3:19 p.m., she stated she was familiar with Resident #135. The resident didn't like to sit up, and when he was placed in a sitting position, he would holler and scream out in pain. She stated the resident told her it hurt him to sit up, and that he would not stay in his wheelchair. The resident was unable to sit up unassisted. He required total (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 17 of 36 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 11/16/2023 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 - Actual harm Residents Affected - Few assistance from staff. He could feed himself and move his arms but was unable to sit up or get out of bed unassisted. She stated the resident preferred to remain in a fetal position, and when attempts were made to move him out of that position, he would ask to be returned to that position. A review of a facility report, dated 7/30/23 at 6:00 p.m., revealed that following the fall, Resident #135 stated he was okay. He was asked what he was trying to do, and he stated he was trying to sit on the side of the bed, but the bed was a little too high. The fall was documented as unwitnessed. The resident was documented as not incontinent at the time of the incident, and range of motion was documented as within normal limits. Interventions included a low bed with mats. The nurse's signature was illegible. (Copy obtained) A review of a facility Huddle Report dated 7/30/23 at 6:00 p.m., revealed the following: What human factors impacted the outcome? Answer: No assist at time of fall. The report indicated that staff were competent and no changes to in-servicing or orientation were necessary. Safety measures documented were non-skid socks. Two team members were documented as having attended the Huddle meeting. Their signatures were illegible. (Copy obtained) A review of a facility report dated 7/31/23 at 11:00 a.m., revealed that Resident #135 was interviewed by the QD (Quality Director). The resident stated he was trying to sit on the side of the bed, and it was too high. He stated he lost his balance and fell hitting his head. It was documented that the QD asked the resident whether he had used his call light for assistance and he responded that he did not. According to the report, the QD explained to the resident that he had been educated before to call for assistance. Interventions: low bed and mats. (Copy obtained) A review of an undated, unsigned, typed statement from the assigned nurse on duty at the time of the resident's fall, revealed that the name typed on the statement was the same name that was given to the survey team by the resident's sister, who stated this was the nurse who assessed the resident after he fell on 7/30/23. This name was also listed on the Interdisciplinary Note. The statement indicated that at 6:00 p.m. on 7/30/23, the nurse was summoned to Resident #135's room to find him lying on the floor on his right side. The resident said he was trying to sit on the edge of the bed and fell to the floor, sustaining a laceration to his right eyebrow. The laceration was draining a moderate amount of sanquinous fluid. A pressure dressing was applied. The resident was alert and oriented x4 (person, place, time, and event). The nurse assisted support staff in getting the resident back in bed while awaiting emergency transport to the emergency room for further evaluation due to the laceration to his eyebrow. The bed was noted in high position. His call bell was clipped to the sheet and had not been activated. The nurse educated the resident by reminding him to use the call light for assistance with sitting up. (Copy obtained) An interview was conducted on 11/16/23 at 4:40 p.m. with the survey team, the current Administrator, the new Administrator, the Director of Nursing (DON), and LPN/Risk Manager S. The DON was asked about the nurse's unsigned and undated statement. She was specifically asked when the statement was written and why the nurse was not required to sign it. She stated, I don't know when she wrote it. She didn't sign it. We have it in our records. The LPN/Risk Manager S stated the resident gave her his statement the day he returned from the hospital (7/31/23). He was alert and oriented. She was asked about the resident's functional status. She replied, I have never transferred him, so I can't say what his functional status is. I just met with him in his room. That was the only time that I saw him. There were no follow-up interviews with him. She was asked about the assigned nurse's unsigned statement. She replied, We attempted to have her come back in many times to have her sign it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 18 of 36 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 11/16/2023 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 - Actual harm Residents Affected - Few On 11/16/23 at 4:59 p.m., the DON was accompanied to Resident #135's room. The resident was greeted and stated he did not know the DON. The DON greeted the resident. The resident was asked about the falls he sustained while in the facility. He explained during his first fall (7/23/23), he rolled out of bed on his own but wasn't hurt because the bed was in the low position. He then stated he fell when CNA N was changing him. She had the bed raised too high and she was on the phone. He stated she tried to catch him, but she couldn't because her back was turned. He stated he was sent out to the hospital because he had a cut over his right eye that required five sutures. The DON asked Resident #135 if anyone had come in to talk to him about the fall the day it occurred. He replied no. She asked if anyone came to speak with him the next day when he returned from the hospital and again he said no. She asked him if he was able to sit up on the side of the bed and he replied that he could not. He stated the aides had to help him get up. He stated he could not sit up on the side of the bed independently. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 19 of 36 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 11/16/2023 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** Residents Affected - Few 2. A review of Resident #20's medical record revealed an admission date of 01/31/18, hospitalization on 09/15/23, and readmission to the facility on [DATE]. The resident's diagnoses included urinary tract infection (UTI), sepsis, encephalopathy, supraventricular tachycardia, dysphagia, overactive bladder, pneumonia, nosocomial condition, acute respiratory failure with hypoxia, bradycardia, tachycardia, thrombocytopenia, acute kidney failure, atrial fibrillation, unspecified dementia, and unspecified severity. On 11/14/23 at 11:43 a.m., the resident was observed resting in bed with a nasal cannula dislodged and hanging beneath her nose. The resident's oxygen concentrator flow rate was set at 2.5 LPM. (Photographic evidence obtained) The resident showed no signs of cyanosis (i.e., blue tone to the skin and mucous membranes); hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion), or oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing). A review of the resident's physician's order, dated 09/29/23, revealed: Oxygen at 3 LPM to keep oxygen saturation levels above 92%. 3 LPM inhalation every shift. On 11/15/23 at 10:13 a.m., a second observation was made of the resident resting in bed with her eyes open. The resident's nasal cannula was dislodged and hanging beneath her nose. The resident explained that she did not like the nasal cannula, and told staff she did not like wearing the nasal cannula because it felt uncomfortable. The oxygen concentrator flow rate was observed to be set at 2.5 LPM. (Photographic evidence obtained) The resident said she was incapable of adjusting the oxygen flow rate herself. The resident showed no signs of cyanosis, hypoxia, or oxygen toxicity. On 11/16/23 at 10:14 a.m., a third observation was made of the resident resting in bed and with her nasal cannula inserted and delivering oxygen. The oxygen concentrator was set at a flow rate of 2.5 LPM. (Photographic evidence obtained). The resident showed no signs of cyanosis, hypoxia, or oxygen toxicity. A review of the Quarterly MDS assessment, dated 11/13/23, revealed a BIMS score of 5 out of 15 possible points, indicating severe cognitive impairment. The resident was assessed with limited range of motion with impairment on one side of the upper extremities. The assessment further noted the resident required partial to moderate assistance with eating, and she was totally dependent for toileting, showers, bathing, upper and lower body dressing, putting on and taking off footwear and personal hygiene. The assessment also documented oxygen therapy as continuous through a nasal cannula. A review of the resident's care plan, dated 10/06/23, documented a pulmonary focus area, noting the resident had Potential for Shortness of Breath and/or Respiratory Complications related to a recent hospitalization secondary to respiratory failure and on oxygen via nasal cannula. The care plan goal noted the resident would have no respiratory complications or signs or symptoms of shortness of breath (SOB). Interventions were to administer medications per order and monitor for response, observe for side effects, and inform the physician as needed. The care plan also must be administered per physician's orders and monitor for response. A review of the resident's physician's order, initiated on 09/29/23, documented oxygen was to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 20 of 36 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 11/16/2023 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 administered at 3 LPM to keep oxygen saturation levels above 92%. Three liters to be administered per minute via inhalation every shift. A review of the resident's electronic treatment administration record (eTAR) documented an oxygen flow rate set at three liters per minute. Residents Affected - Few On 11/16/23 at 11:49 a.m., Certified Nursing Assistant (CNA) D was interviewed. The employee reported she had worked at the facility for two years and always checked oxygen levels first thing in the morning while checking residents' vital signs. She explained that she was not aware of what oxygen flow rates should be and only viewed the set flow rate on the oxygen concentrator, recorded the flow rate on paper and provided it to the resident's nurse. It was the nurse's responsibly to enter the oxygen flow rate into the facility's eTAR. On 11/16/23 at 11:59 a.m., Licensed Practical Nurse (LPN) E was interviewed. She stated she had worked at the facility since 09/25/23. She further explained that she was familiar with the resident and her oxygen needs. LPN E checked the electronic medical record and stated the physician's order for Resident #20's oxygen was for a flow rate of 3 LPM via nasal cannula. She said the resident often moved the nasal cannula out of her nose but did not remove it completely from her face. LPN E further explained the process for ensuring oxygen flow rates were accurate included CNAs checking oxygen flow rates and documenting them on a piece of paper and providing it to the nurse. The nurse entered the oxygen flow rate into the eTAR. She stated the night nurse changed the tubing and documented it in the eTAR. She explained that she checked resident oxygen flow rates in the morning and during rounds. On 11/16/23 at 12:06 p.m., LPN E was accompanied into Resident #20's room. She stood above the oxygen concentrator [NAME] and reported the resident's oxygen flow rate was set at 3 LPM. Upon further inspection and viewing the oxygen concentrator [NAME] at eye level, LPN E admitted the oxygen concentrator [NAME] read 2.5 LPM. On 11/16/23 at 6:49 p.m., an interview was conducted with the Director of Nursing (DON), who reported that she had worked at the facility for three and a half years. She explained the process to ensure oxygen flow rates were set per the physicians' orders and included that CNAs did not administer oxygen. If a CNA noticed a concentrator was empty or observed another issue with an oxygen concentrator, they should report it to a nurse. Nurses must check resident oxygen flow rates during each shift and oxygen flow rates should be documented on the medication administration record (MAR). Based on observation, interview, and record review, the facility failed to ensure that two (Residents #53 and #20) of three residents sampled for review of respiratory care, from a total sample of 41 residents, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The findings include: 1. On 11/13/23 at 2:45 p.m., Resident #53 was observed in her room. She was sitting up in a wheelchair receiving oxygen via a nasal cannula. A dark blue oxygen concentrator was positioned behind the resident next to her bed. The oxygen flow rate was set at 3 liters per minute (LPM). The resident was asked what the flow rate should be set at and she replied that the flow rate should be 2 LPM. (Photographic evidence obtained) On 11/15/2023 at 12:02 p.m., Resident #53's oxygen flow was observed to be set at 3 LPM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 21 of 36 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 11/16/2023 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 - Few On 11/15/2023 at 4:25 p.m., Resident #53's oxygen flow rate was observed to be set at 3 LPM. (Photographic evidence obtained) A record review revealed the resident was admitted to the facility on [DATE]. Her diagnoses included fluid overload; end stage renal disease; dependence on renal dialysis; chronic obstructive pulmonary disease (COPD); chronic respiratory failure; heart failure; pulmonary hypertension; peripheral vascular disease; type 2 diabetes with diabetic chronic kidney disease; hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease or end-stage renal disease. A review of the resident's active physician's orders revealed: O2 (oxygen) at 2 LPM; Eliquis 2.5 mg (milligrams) every 12 hours; Novolog 100 unit/ml (units per milliliter), inject per sliding scale four times a day; change oxygen tubing and humidifier bottle weekly. A review of the 8/3/2023 Quarterly Minimum Data Set (MDS) assessment, revealed that Resident #53 scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating that she was cognitively intact. The assessment did not capture the resident's functional abilities and goals. She was listed as being always continent of bladder and bowel. The assessment did not document the administration of oxygen during or prior to being a resident. A review of the most recent Care Plan with a start date of 7/20/23, revealed a focus area of Pulmonary: [Resident #53] has the potential for SOB (shortness of breath) and/or respiratory complications related to history of congestive heart failure (CHF) and pulmonary edema. The goals included: Administer medications per orders and monitor for response. Observe for side effects and inform physician PRN (as needed). The interventions included: Provide treatment per physician's orders and monitor for response, observe for side effects and inform physician; monitor oxygen saturation and administer O2 per physician's orders; monitor for complications such as dyspnea, shortness of breath, cyanosis, or tachypnea. Registered Nurse (RN) M was observed at a medication cart positioned outside of Resident #53's room. When approached he stated he was familiar with Resident #53. He was asked about the resident's order for oxygen. After reviewing the resident's physician's orders, he confirmed that the resident's oxygen should be administered at 2 LPM. He stated the night shift nurse was responsible for changing the tubing weekly. RN M was accompanied into the resident's room. The resident was seated in a wheelchair at the foot of her bed. She was receiving oxygen via a nasal cannula. Observation of the oxygen concentrator positioned next to the head of the resident's bed revealed that the flow rate was set at 3 LPM. RN M confirmed this and stated it should have been set at 2 LPM and not 3 LPM. He immediately began to adjust the dial on the front of the concentrator so that the setting was on 2 LPM. The resident was asked about her oxygen. She again stated it should be set at 2 LPM. She added that the nurse from the previous night's shift had set the concentrator. A review of the facility's policy titled Procedure: Oxygen Administration (original date of 12/2016, last revised on 10/2018 and last approved on 12/2022) revealed: Purpose: 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 oxygen administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 22 of 36 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 11/16/2023 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 (B) Review the resident's care plan to assess for any special needs of the resident. Level of Harm - Minimal harm or potential for actual harm (C) Assemble the equipment and supplies as needed. Residents Affected - Few A review of the facility's policy titled Medication and Treatment Orders (original date of 12/2016, last revised on 12/2017 and last approved on 1/2022) revealed: Purpose: Orders for medication and treatment will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation: (A) Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 23 of 36 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 11/16/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 ensure that two (Residents #41 and #17) of five residents sampled for medication review, from a total of 41 residents sampled, were free from unnecessary drugs. An unnecessary drug includes any drug used without adequate monitoring. Residents Affected - Few The findings include: 1. A review of Resident #41's medical record revealed and admission to the facility on 7/18/2018. Her most recent readmission was on 8/18/2023. Her diagnoses included acute kidney failure; chronic systolic (congestive) heart failure; delusional disorder; atherosclerotic heart disease of native coronary artery; visual hallucinations; Parkinson's disease; unspecified dementia; type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). A review of the resident's active physician's orders revealed she was receiving Seroquel (antipsychotic) 50 mg (milligrams) daily; Namenda XR (cognition-enhancing medication) 14 mg daily; Buspar (anxiolytic) 5 mg twice a day; Novolog U-100 insulin aspart 100 unit/ml (units per milliliter), inject subcutaneously per sliding scale four times a day. A review of the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR), revealed that the medications were being administered as ordered however, there was no documented evidence of monitoring for behaviors and/or side effects related to the medications. A review of the 10/31/2023 Quarterly Minimum Data Set (MDS) assessment, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severe cognitive impairment. There were no documented moods or behaviors. She was reported with occasional incontinence of bladder and always incontinent of bowel. During an interview with Registered Nurse (RN) M on 11/15/2023 at 4:26 p.m., he stated he was familiar with Resident #41. He stated she took her medications whole and had no recent behaviors. He referred to her as diabetic and insulin dependent. He stated she had diagnoses which included delusional disorder, visual hallucinations, Parkinson's disease, unspecified dementia without mood issues, and anxiety. She had active physician's orders which included Aricept (cognition-enhancing medication) 5 mg at 8:00 p.m. nightly; Namenda XR 14 mg daily for dementia, Seroquel 50 mg twice a day for delusions, Buspar for her anxiety and he added that she also took insulin. He stated there was no specific diagnosis of anxiety, adding that it was only attached with the diagnosis of unspecified dementia. He was asked about behavior monitoring related to the resident's antipsychotic and anxiolytic medications. He stated there was a section of the resident's eMAR that listed the purpose of the medication along with the mood and behaviors to monitor. He stated the nurse was to document any behaviors in the eMAR every shift. After reviewing the November 2023 eMAR for Resident #41, he was unable to locate any documentation of behavior monitoring and/or medication side effects in the resident's electronic medical record. He confirmed the resident had consistently received the aforementioned medications as ordered. He called for RN O/Unit Manager, who was located in a nearby office. Upon approaching the medication cart RN M asked RN O for the location of the behavior monitoring and/or medication side effect monitoring in the electronic record for Resident #41. RN O advised him that the information should have been located in the eTAR. She then accessed Resident #41's eTAR. There was no documentation verifying monitoring for behaviors and/or medication side effects for this resident. Upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 24 of 36 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 11/16/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seeing this she stated, It doesn't look like there are any in there. Both RNs continued attempting to locate the information in the resident's electronic chart. They were unsuccessful. RN O stated the resident had been transferred out to the hospital and that often when residents went out and came back, not all of the orders were added back into the system. She stated nursing should have added the orders back in when the resident returned from the hospital. She stated anytime a resident was transferred and remained out of the facility beyond midnight, the orders had to be manually added back into the system. If the nurse on duty was Agency staff or new, they may not be aware of that. She was asked for the date the resident returned to the facility after being hospitalized . She stated she would need to verify that. She returned at 4:57 p.m. and stated she misspoke earlier. Resident #41 had not been transferred out to the hospital as she originally stated. Again, it was confirmed there was no documented evidence of behavior and/or side effect monitoring in the resident's eTAR prior to the 11/15/23 4:26 p.m. interview. A record review revealed that Resident #41 was seen in the facility on 10/16/2023 by a third-party provider for mental health services. Mental Health Services documentation noted the following: CHIEF COMPLAINT: Patient exhibits changes in mental status or behavior consisting of: Depression, anxiety, agitation, confusion, psychosis Other: Follow up visit with medication review HISTORY OF PRESENT ILLNESS: Chief complaint has been occurring for several: Months But appears to be: Better For the past: Days History of mental illness, depression, anxiety, and psychosis MENTAL STATUS EXAMINATION: Level of consciousness: Alert Thought processes: Normal Insight/judgement: Poor Oriented to: Person, place, circumstances Immediate memory: Partially impaired Recent memory: Partially impaired Remote memory: Intact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 25 of 36 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 11/16/2023 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 0757 Thought content and perceptions: Delusions Level of Harm - Minimal harm or potential for actual harm Mood/Affect: Depressed, anxious, irritable SIGNS AND SYMPTOMS: Residents Affected - Few Patient has sleep disturbances. Patient is feeling depressed and sad. Patient feels restless and anxious. Resistive to care. Difficult to redirect. Patient is psychotic with: Delusions DIAGNOSES: Unspecified dementia with behavioral disturbance Major depressive disorder, recurrent, moderate Generalized anxiety disorder Unspecified psychosis not due to a substance or known physiological condition Primary insomnia 2. During an observation of Resident #17 on 11/13/2023 at 12:59 p.m., she was found in bed with a pillow over her head. There were fall mats present on the floor on each side of the bed. The resident was greeted and responded pleasantly. When asked about the observation of the fall mat the resident denied having any falls. The resident then began asking about being discharged home. She stated she had multiple properties which were currently being occupied by other people. It was suggested that she contact the facility's Social Services Director (SSD). The resident continued to repeat her questions regarding discharge and talking about the many properties she owned. She was increasingly confused, so the interview was concluded. A record review for Resident #17 revealed she was re-admitted to the facility on [DATE] after being hospitalized for acute care. Her diagnoses included unspecified convulsions; unspecified dementia; unspecified psychosis not due to a substance or known physiological conditions; metabolic encephalopathy; acute kidney failure; personal history of other specified conditions; dysphagia; personal history of other infectious and parasitic disease; atherosclerotic heart disease; hemiplegia affecting left non-dominant side, and type 2 diabetes mellitus. A review of the current, active Physician's orders included Quetiapine (Seroquel - antipsychotic) 25 mg, two tablets every 12 hours; Escitalopram (for treating depression and generalized anxiety), 20 mg daily; Lacosamide (anticonvulsant) 250 mg twice a day; Topiramate (anticonvulsant and nerve pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 26 of 36 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 11/16/2023 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 0757 medication) 100 mg twice a day; Levetiracetam (anticonvulsant) 1000 mg twice a day. Level of Harm - Minimal harm or potential for actual harm A review of the 9/22/2023 Quarterly MDS assessment, dated 09/22/23, revealed that Resident #17 scored 5 out of 15 possible points on her BIMS assessment, indicating significant cognitive impairment. She required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. She was independent with eating. Residents Affected - Few A review of the November 2023 eMAR revealed no concerns. The aforementioned medications were administered as ordered. Review of the November 2023 eTAR revealed no documented evidence of monitoring for medication side effects or resident behaviors. During an interview with Social Worker P on 11/15/2023 at 2:23 p.m., he confirmed that Resident #17 had a diagnosis of unspecified psychosis. During an interview with RN M on 11/15/2023 at 5:00 p.m., he stated he was familiar with Resident #17. He cited her diagnoses as dementia, unspecified psychosis and added that she also had seizures. He listed her medications as Escitalopram 20 mg daily for depression, Lacosamide 250 mg twice a day for seizures, Topiramate 200 mg every 12 hours for seizures, and Seroquel 25 mg every 12 hrs. He noted the resident orders and eMAR listed the medication was for depression. He stated the diagnosis was inaccurate. Sometimes they put the wrong diagnosis. After reviewing the eMAR, RN M confirmed the resident had received the aforementioed medications as ordered. He was asked about medication side effects and behavior monitoring for the medications. He stated the resident had not had any side effects that he was aware of. He then attempted to access the eTAR for review. There were no behavior monitoring or side effect monitoring orders there. He confirmed there was no documented evidence of behavior or side effect monitoring for this resident. He again contacted RN O/Unit Manager for assistance. An interview was then conducted with RN O at this time. She stated Resident #17 had been readmitted after a transfer to the hospital. She confirmed the orders for behavior and side effect monitoring were not on the eTAR. She stated the orders had not been added back when the resident was readmitted to the facility on [DATE]. She stated the orders needed to be signed. She was asked who was responsible for ensuring all orders were added back into a resident's chart upon readmission. She stated it was the responsibility of the nurse conducting the assessment and putting in the hospital orders upon the resident's return to the facility. She stated sometimes the monitoring was documented in the progress notes. She then reviewed all progress notes entered for Resident #17 from 9/16/2023 through 11/15/2023. During her search RN M commented that the information needed to be documented. You can't give a medication like that without monitoring it. After searching in multiple locations of the resident's electronic record, RN O confirmed there was no evidence of documentation of resident behavior and/or medication side-effects during that time. Further record review revealed that Resident #17 was seen in the facility on 10/16/2023 by a third-party provider for mental health services. The Mental Health Services documentation revealed the following: CHIEF COMPLAINT: Patient exhibits changes in mental status or behavior consisting of: Depression, anxiety, confusion, psychosis Other: Follow up visit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 27 of 36 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 11/16/2023 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 0757 HISTORY OF PRESENT ILLNESS: Level of Harm - Minimal harm or potential for actual harm Chief complaint has been occurring for several: Months But appears to be: Better Residents Affected - Few For the past: Weeks History of mental illness, depression, anxiety, and psychosis MENTAL STATUS EXAMINATION: Level of consciousness: Alert Thought processes: Blocking Insight/judgement: Poor Oriented to: Place Immediate memory: Partially impaired Recent memory: Partially impaired Remote memory: Partially impaired Thought content and perceptions: Delusions Mood/Affect: Depressed, anxious SIGNS AND SYMPTOMS: Patient shows apathy with poor social interaction. Patient has sleep disturbances. Patient is feeling depressed and sad. Patient feels restless and anxious. Patient is psychotic with: Delusions DIAGNOSES: Vascular dementia with behavioral disturbance Major depressive disorder, recurrent, moderate Generalized anxiety disorder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 28 of 36 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 11/16/2023 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 0757 Unspecified psychosis not due to a substance or known physiological condition Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled Medication and Treatment Orders (original date of 12/2016, last revised on 12/2017 and last approved on 1/2022): Residents Affected - Few Purpose: Orders for medication and treatment will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation: (A) Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. (C) Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Though requested, no additional policies related to medication side effect monitoring or behavior monitoring were provided for review during the survey period. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 29 of 36 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 11/16/2023 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, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5% based on 32 opportunities for error with two errors identified, resulting in an error rate of 6.25 %. The errors affected two (Residents #454 and Resident # 86) of seven residents observed during medication administration, from a total of 41 residents in the sample. Failure to administer medications correctly, as ordered, could result in side effects including serious harm to a resident. Residents Affected - Few The findings include: During medication administration observation on 11/14/23 at 12:34 p.m., Licensed Practical Nurse (LPN) Q was observed administering insulin to Resident #454. LPN Q obtained a blood glucose reading of 167. After reviewing the resident's sliding scale order, LPN Q stated the resident needed 2 units of NovoLog insulin. He obtained a NovoLog kwik pen and dialed the pen to 2 units. He administered the insulin in the resident's lower abdomen. In an interview with LPN Q on 11/14/23 at 12:45 p.m., he was asked how he ensured that there were no air bubbles in the kwik pen. He replied, by looking through the pen. He was then asked how the kwik pen should be primed. He replied, To be honest, I don't know how to prime it. I never prime it. He added that he would consult with the Unit Manager. He confirmed that without priming the pen, it would not be possible to tell whether or not the resident received the 2 units. Another medication administration observation was made on 11/15/23 at 9:40 a.m. LPN R was observed administering medication to Resident #86. She obtained a tube of Diclofenac gel 1%. She went to the resident's room and squeezed some of the gel on her gloved hand and applied it on both of the resident's hands. A review of medication label, dated 10/27/23, revealed: Diclofenac gel 1%. Apply 2 grams (gm) topically to both hands every 12 hours for pain. In an interview on 11/15/23 at 9:45 a.m., LPN R was asked how she ensured that she administered 2 gm of the medication. She replied, To be honest, I don't know. I just squeeze a little on my hand. She further stated, Sometimes the label is not accurate and we have to go with what is in the computer. She looked at the computer order and stated it did not include the medication dosage. When she was asked to describe the components of a medication order, she stated there should be a dosage. She stated she should have clarified the order. A review of the facility's policy and procedure for Administering Medication (last revised on 12/2021), revealed: Medications shall be administered in a safe and timely manner and as ordered. The policy interpretation and implementation indicated that medications shall be administered in accordance with the orders. The individual administering medication must check the label three times to verify the right resident, right medication, right dosage and right method of administration before administering the medication. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 30 of 36 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 11/16/2023 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 observation, interview, and a policy and procedure review, the facility failed to secure/store medications in locked compartments to limit unauthorized access to medications for two (Residents #35 and #57) of 41 sampled residents. Failure to ensure medications are secure and/or inaccessible could result in residents ingesting medications and suffering significant adverse consequences. The findings include: 1. On 11/13/23 at 12:26 p.m., Resident #35 was observed resting in bed. Bottles of over-the-counter Systane ultra dry eye relief and Systane complete dry eye relief were observed on the resident's bedside table. (Photographic evidence obtained) When he was asked whether the facility had evaluated him to self-administer medication, Resident #35 stated he liked to administer the eye drops at night to help reduce his dry eyes. On 11/15/23 at 10:36 a.m., Resident #35's eye drops were still observed at bedside. A review of Resident #35's active physician's orders revealed no orders for the Systane eye drops and no assessment for self-administration of medication. In an interview with LPN B on 11/16/23 at 4:34 p.m., she confirmed that she was assigned to Resident #35. When asked if the resident administered his own medication, she replied, Only his eye drops. When asked if the resident had an assessment conducted for self-administration of medications, she stated she was not sure because she could not find one in the computer. She was then asked if the resident had an order for the Systane eye drops. She replied, I added the orders today. 2. During another observation on 11/13/23 at 2:12 p.m., Resident #57 was observed with medication on his bed side table. He stated, I have to keep these (cough drops, Albuterol inhaler, Refresh eyedrops, saline mist nasal spray, Fluticasone nasal spray, and Budesonide inhaler) because these new and Agency nurses don't always know what they are doing, and they don't give them to me when I need them. (Photographic evidence obtained) The resident was asked if he was assessed by the facility to self-administer his medication. He replied no. He added, I take this yellow one (Budesonide) two times a day. The blue one is my rescue; I use it as needed, and my eye drops and nasal spray I use as needed. A review of Resident #57's active physician's orders, dated 3/19/23, revealed Fluticasone nasal spray 50 micrograms (mcg) twice a day as needed. Saline Mist 0.65% nasal spray, one spray in each nostril three times a day as needed for allergic rhinitis. Refresh Optive advanced 0.5%-1%-0.5%, one drop in both eyes every 8 hours as needed for dry eyes. Albuterol sulfate 90 mcg/actuation aerosol, two puffs every 4 hours as needed for COPD (chronic obstructive pulmonary disease). Cepacol extra lozenges. One lozenge every 8 hours as needed for sore throat. Budesonide 0.25 mg/2 ml suspension for nebulization, 2 ml (milliliters) inhalation every day for chronic respiratory failure with hypoxia. In an interview with Licensed Practical Nurse (LPN) A on 11/16/23 at 2:42 p.m., she stated there were no residents in her section of the facility who administered their own medications. When asked about Resident #57's eye drops, nasal spray and inhalers, she said, He does not administer his own medication. He has severe COPD and we always do his medications. She checked the assessments and stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 31 of 36 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 11/16/2023 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 Resident #57 did not have an assessment for self-administration of medications. She was accompanied to the resident's room and confirmed that the resident had two inhalers, two bottles of nasal spray, one bottle of eye drops, and a bag of cough drops at bedside. In an interview with Registered Nurse (RN) C/Unit Manager on 11/16/23 at 4:36 p.m., she confirmed that neither Resident #35 nor Resident #57 had assessments for self-administration of medication. A review of the facility's policy and procedure titled Storage of Medication (last reviewed on 12/2017), revealed: The community shall store drugs and biologicals in a safe, secure and orderly manner. The nursing associate shall be responsible for maintaining medication storage and preparation area in a clean, safe and sanitary manner. A reviewed of the facility's policy and procedure titled Administering Medication (last revised on 12/2021), revealed: The policy interpretation and implementation (w.) indicated that residents may self administer their own medication only if the attending physician, in conjunction with the nurse assessment, has determined that they have the capacity to do so safely. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 32 of 36 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 11/16/2023 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 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, staff interviews, facility document review, and facility policy and procedure review, the facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene and disposable glove use during meal service, as well as proper sanitation practices when cleaning and using the meat slicer to prevent cross contamination, with the potential to affect all of the residents in the facility who received food from the facility's kitchen. Specific instruction on hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Failure to thoroughly clean and sanitize the meat slicer could result in the development of a cross-contamination infection and clinical compromise. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial tour of the kitchen on 11/13/2023 at 9:30 a.m., the meat slicer was covered with a large sheet of plastic. The Certified Dietary Manager (CDM) confirmed that the slicer had been cleaned and was always stored with the plastic covering after it was cleaned. She stated it was used to slice deli meats mostly because it was more economical to purchase the meat in bulk and then slice it. The plastic was removed and the slicer was observed to have encrusted food debris on the blade, the backplate and the collection area. (Photographic evidence obtained) The CDM was asked to remove the cover for the blade sharpener on the top of the machine. She asked Dietary Employee I to remove it. Employee I removed the cover and food debris was observed stuck on the inside of the cover. (Photographic evidence obtained) The CDM stated the machine had not been cleaned appropriately. She stated she did not have a procedure for cleaning the machine. During the lunch meal service on 11/14/2023 from 12:38 p.m. to 1:00 p.m. in satellite dining rooms on the 1 North unit and the 2 South unit, Dietary Supervisor J was observed assisting Dietary Employee L in the process of plating food. Employee J failed to wash her hands for a minimum of 15 seconds when she washed her hands. She washed her hands 4 times and only washed them for 3 seconds each time. Employee L failed to wash her hands after opening the drawer handle for the garbage can to discard her disposable gloves. She then donned new gloves to continue the meal service. During the lunch meal service on 11/15/23 at 11:31 a.m. on the 2 South unit, Employee L failed to wash her hands appropriately. The Assistant Director of Dining (ADD) stopped her and made her re-wash them. She failed to wash them for a minimum of 15 seconds. The ADD again stopped her and made her re-wash her hands. Employee L turned off the faucet with her bare hand. The ADD again made her re-wash her hands and use a towel to turn off the faucet. The ADD acknowledged that Employee L needed retraining on hand hygiene. On 11/15/2023 at 12:54 p.m., the meat slicer was observed covered with a large sheet of plastic. The plastic sheet was removed. The slicer had water standing on the base. The blade and backplate had food debris stuck on them. (Photographic evidence obtained) The CDM was asked to remove the cover for the blade sharpener on the top of the machine. She could not get it to release. Employee I was asked if she was finished using it today and if she had washed it. She confirmed that she was finished and had washed it. She was asked to take the cover off the machine. She struggled with it for 10 minutes. The CDM and Employee I were shown the food debris and water standing on the slicer and they acknowledged it. Employee I stated, Does it need to air dry? and then stated, I need to wash it again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 33 of 36 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The CDM agreed that she would have to disassemble it, wash and sanitize it again. Employee I confirmed she had been trained by another dietary staff member on how to clean the meat slicer. During an interview with the CDM on 11/16/2023 at 2:45 p.m., she confirmed that she did not have a procedure for cleaning the meat slicer. She would have to develop one and train the staff. She also confirmed that the staff needed training on hand hygiene. A review of the Facility Associate Food Safety & Sanitation Handbook used to train the dietary staff (revised 8/2022), revealed: Cleaning - Removal of visible soil from the surfaces of equipment and utensils. Includes removal of large soils, washing with soap and rinsing. Food contact surface - a surface that comes into direct contact with foods. Examples are slicers. Biological cross-contamination. Cross-contamination usually occurs when germs from raw food are transferred to a cooked or ready-to-eat food via contaminated equipment. Cross - contamination can occur during preparation, storage, and display. Unclean or improperly cleaned food contact surfaces. Hand Washing is a key factor in preventing food contamination. When to wash: Before putting on gloves, or when changing gloves. After changing gloves. How to wash: Wet hands, apply soap, vigorously scrub hands, arms (up to elbows if exposed), between fingers and under fingernails for 10-15 seconds. Rinse thoroughly. Dry hands using single-use paper towel. Use the towel to turn off the faucet to prevent contaminating your hands after washing them. Sanitation Practices: Cleaning means removing the things we can see such as the visible food debris, grease, and other dirt from the surface. Food contact surfaces MUST be cleaned and sanitized. Clean-in-place - Used for equipment that is too big or not able to be moved into the dish machine or three-compartment sink. Food contact surfaces must be cleaned and sanitized after each use. Steps to clean and sanitize: Pre-scrape, wash, rinse, sanitize and air-dry. Never store items until they are dry. The acknowledgment of the handbook training was signed by Employee I on 07/26/2023. The New Associate Orientation checklist for Employee I, dated 07/17/2023, revealed she received instruction on use of the slicer and a return demonstration was required. Sanitation standards were covered during the training she received on 8/31/2023. A review of the Attendance Verification Sheet, dated 8/31/2023, for the staff in-service training on handwashing revealed that Employees J and L both received training that day. A review of the Attendance Verification Sheet dated 3/15/2023 for the staff in-service training on infection prevention and control revealed that Employees J and L both received training that day. A review of the facility's policy and procedure titled Food Handling Guidelines (Policy #B007, issued 5/1995 and revised 1/2023), revealed: Food shall be protected against cross-contamination by appropriately separating types of raw animal products such as beef, fish, lamb, pork and poultry during processing with the use of separate equipment or areas or by scheduling and cleaning; and appropriately separating raw and ready-to-eat foods during preparation. Cutting boards and other food contact surfaces are cleaned and sanitized between different food preparation steps. Use clean sanitized equipment and food contact surfaces (e.g. slicers, etc.) for each task. A review of the facility's policy and procedure titled Cleaning of Food and Nonfood Contact Surfaces (Policy #F013, issued 5/1995, revised 1/2023), revealed: To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 34 of 36 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of the facility's policy and procedure titled Hand Hygiene (Policy #F007, issued 5/1995, revised 1/2023), revealed: In the Food and Nutrition Services Department: All associates handling food shall wash hands at the following times: Before putting on gloves, after handling garbage, after handling clean equipment, after removing gloves, after any other activity that may contaminate the hands. Hands must be washed with soap and water when plating food on the resident units. Wet hands with warm water and apply a disinfectant soap, lathering up to mid-arm. Work lather into hands for 20 seconds, including areas under fingernails, between fingers, on the inside and outside of hands. Rinse thoroughly under warm running water, allowing the water to flow from the arms down to the fingertips. Use a paper towel to turn off the faucet to avoid contact with faucet germs. Per the 2022 Food Code, Sections 2-301.13 Special Handwash Procedures. 2-301.14 When to Wash. (A-I). Page 79. U.S. Department of Health and Human Services Public Health Service, Food and Drug Administration. https://www.fda.gov/food/fda-food-code/food-code-2022: Hand Hygiene Employees must wash their hands after any activity which may result in contamination of the hands. All aspects of proper handwashing are important in reducing microbial transients on the hands. However, friction and water have been found to play the most important role. This is why the amount of time spent scrubbing the hands is critical in proper handwashing. It takes more than just the use of soap and running water to remove the transient pathogens that may be present. It is the abrasive action obtained by vigorously rubbing the surfaces being cleaned that loosens the transient microorganisms on the hands. Research has shown a minimum 10-15 second scrub is necessary to remove transient pathogens from the hands and when an antimicrobial soap is used, a minimum of 15 seconds is required. Soap is important for the surfactant effect in removing soil from the hands and a warm water temperature is important in achieving the maximum surfactant effect of the soap. Every stage in handwashing is equally important and has an additive effect in transient microbial reduction. Therefore, effective handwashing must include scrubbing, rinsing, and drying the hands. When done properly, each stage of handwashing further decreases the transient microbial load on the hands. It is equally important to avoid recontamination hands by avoiding direct hand contact with heavily contaminated environmental sources, such as manually operated handwashing sink faucets, paper towel dispensers, and rest room door handles after the handwashing procedure. This can be accomplished by obtaining a paper towel from its dispenser before the handwashing procedure, then, after handwashing, using the paper towel to operate the hand sink faucet handles and restroom door handles. Per the 2022 Food Code, Sections 4-603.15 Washing, Procedures for Alternative Manual Warewashing. Annex 3 - 179. U.S. Department of Health and Human Services Public Health Service, Food and Drug Administration. https://www.fda.gov/food/fda-food-code/food-code-2022: Equipment Some pieces of equipment are fixed or too large to be cleaned in a sink. Nonetheless, cleaning of such equipment requires the application of cleaners for the removal of soil and rinsing for the removal of abrasive and cleaning chemicals, followed by sanitization. Per the 2022 Food Code, Sections 4-901.11 Equipment and Utensils, Air-Drying Required. Annex 3 - 181. Department of Health and Human Services Public Health Service, Food and Drug Administration. https://www.fda.gov/food/fda-food-code/food-code-2022: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 35 of 36 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 11/16/2023 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 0812 Items must be allowed to drain and to air-dry before being stacked or stored. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 36 of 36