Health inspection·April 24, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Social Services Assistant (SSA). When asked what the complaint/grievance process was for the facility, SSD replied, The managers discuss complaint/grievances in morning meeting. The Quality Director (QD) logs them into the Electronic Reporting System (ERS) because she did not have access to the program. When asked why she didn't have access, the SSD only offered, they hadn't given her access. When asked how she followed up on the complaints/grievances, SSD replied, I write it down. When asked if she kept those documents, she did not offer a response. When asked who was sending the letters to the complainants (Residents #4, #5, #6, and #7), SSD replied, I'm not sure what letters you are talking about. When the SSD was told the facility policy regarding Complaints and Grievances, stated that final decisions would be provided in writing within 30 days of receipt. She replied, oh. The SSA stated that he didn't have access to ERS either. On 4/24/24 at 2:58 pm, a joint interview was conducted with the Administrator and Director of Nurses (DON). When the DON was asked who the Grievance Official was, she replied, the SSD. The DON was asked to describe the Complaint/Grievance process. She stated complaints typically come to either the staff or the managers. The managers try to resolve the issues at the bedside, if unable to resolve the issue, they relay the information to the team at morning meeting. The complaint is then assigned to the appropriate manager, such as SSD, Nursing, Pharmacy, Maintenance, Food Service. When asked where it is documented, the DON replied, it should be in the ERS. When asked who documents it the system, DON replied, whoever is handling the issue or its reported to the Quality Director (QD) and they enter it. When the DON was asked if she was aware the SSD didn't have access to the ERS, she replied, no. When asked how complaints and grievances are reported to the Quality Assurance and Performance Improvement (QAPI) committee. Both DON and Administrator replied, QD runs a report and presents it to the committee. The DON was asked if she questioned the lack of complaints/grievances on the report. She replied, no, I did not pick up on the report not showing them, I knew I was addressing issues. The Administrator stated, It is clear our process is ineffective, with multiple gaps in the process that need fixing; we will be working to fix this issue today. Review of the facility's Complaints and Grievances policy (last revised 5/2021) revealed the following: Page 1 of 5, Definitions Complaint - Any simple service issue or concern received from residents or family members regarding treatment or services provided in the community that are easily resolved by associates. Grievance - Any moderately complex complaint or service issue received verbally or in writing from residents or resident representative regarding treatment or services provided that require management intervention and a written resolution letter. All written complaints received by residents or resident representative through any means will be considered a grievance. Page 2 & 3 of 5, Minimum Requirements, item 2. Identifying a designated community Grievance Official Each community must designate a Grievance Official to oversee and ensure responses to complaints and grievances in accordance to policy. a. The Grievance Official or designee, will be responsible for the complaint and grievance process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 2 of 4 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 04/24/2024 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 0585 through their conclusion to include: Level of Harm - Minimal harm or potential for actual harm 1. Review and provide an acknowledgement of receipt of grievances to complainant Residents Affected - Some 2. Coordinating the investigation by the community to include but not limited to: i. Reviewing reports for any reportable issues ii. Interviewing complainant, staff, and/or witnesses iii. Reviewing the medical records (if applicable) iv. Coordinating with other departments, when needed 3. Maintaining confidentiality of all information associated with the complaint or grievance. 4. Acknowledge the grievance within 7 working days from receipt 5. Issuing a final written grievance decision to the resident and/or family members within a reasonable time frame but not to exceed 30 days. Page 4 of 5, item 4 Response timeline for complaints and grievances will be as follows. a. All complaints and grievances received by associates will be documented and reported by end of shift. b. Acknowledgment of grievance will be provided to complainant when available withing 7 working days from date of receipt c. Issuing of a final decision in writing on all grievances will be provided to the complainant when available within a reasonable time frame but not to exceed 30 days from date of receipt d. If resolution to grievance is delayed beyond 30 days, an extension letter will be provided to complainant to include an explanation for the delay and estimated resolution date. (Copy obtained) Ascension Living Complaint and Grievance Process (pamphlet given to residents on admission) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 3 of 4 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 04/24/2024 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 0585 Rights, Process, Timelines Level of Harm - Minimal harm or potential for actual harm Under Resident Rights, you have the right to file a complaint or grievance anonymously, orally or in writing. You also have right to receive a written response to all filed grievances within a reasonable timeline. Residents Affected - Some For all complaints, the community will make every attempt to resolve the issue/concern promptly. For all grievances, the following process and timelines will be followed. Grievance Official (or designee) will provide you (if contact information is available) a written acknowledgement within 7 working days. Final decisions will be provided in writing and within 30 days from receipt. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105358 If continuation sheet Page 4 of 4