Inspection·December 22, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if she was caring for Resident #47. She stated, Not today, but I have occasionally in the past, and I help other CNAs with her care. She was asked if the resident had ever complained to her about a rash on her arms and upper chest being itchy. She stated, Yes, she has. She was asked what she did when the resident complained that she was itchy. She stated, I go tell my nurse. On 12/21/22 at 3:05 p.m., in an interview with CNA C, she was asked if she was caring for Resident #47 today. She stated yes. She was asked if she usually had Resident #47 on her assignment. She stated yes. She was asked if Resident #47 had complained to her about a rash on her forearms and upper chest being itchy. She stated yes. She was asked how often the resident voiced this complaint. She stated, Well, I don't know about the days I'm not here, but every day I work, she tells me she's itchy. She was asked what she did when the resident told her she was itchy. She stated, I go tell my nurse. She was asked if she told her nurse today. She stated yes. She was asked which nurse she told. She said [LPN D]. She was asked if the nurse went to see the resident after she told her about the resident's complaint. She replied, I don't know. On 12/22/22 at 8:50 a.m., Resident #47 was observed lying in bed, awake, and scratching her upper chest. Her upper chest and both forearms were observed with a red rash. The rash was comprised of small, red, raised and open spots covering the top of each forearm and her upper chest. She was asked if she told staff her rash was itchy since yesterday. She stated, Yes I told them and they don't do anything. It's itching like crazy. She was asked if any staff applied lotion to her rash since yesterday. She stated, No, no one has at all. On 12/22/22 at 9:05 a.m., LPN D was asked if she was caring for Resident #47 today. She stated yes. She was asked if the resident had complained of her rash being itchy today. She stated, No, I haven't heard that. I haven't been in to see her yet today. She was asked to open the treatment cart and see if there was any hydrocortisone cream for Resident #47. She opened the cart and this cream was not in the cart for the resident. The nurse stated, She must have run out. I'll reorder it from the pharmacy. We have two treatment carts on the unit, it could be in that (the other) cart. On 12/22/22 at 9:07 a.m., RN E was asked if she had a treatment cart on her wing. She stated yes. She was asked how many treatment carts the facility had. She stated two. She was asked if she could open the treatment cart on her wing to check if there was Hydrocortisone cream for Resident #47 in the cart. She opened the cart and the cream was not found in the cart. She stated, I know she had it. I'm the one who ordered it for her to begin with for the rash on her arms, but I haven't cared for her in maybe over a month now, so I haven't seen her in that time. RN E was asked where she would sign out the treatment when it was administered. She stated, On the treatment sheet. That's where it's signed out when it's used because it's an as needed order. She was asked if signing the treatment out was an expectation when the treatment was provided. She stated yes. On 12/22/22 at 10:59 a.m., in an interview with the Director of Nursing (DON), she was asked what the expectation was when a treatment was provided to a resident. She stated, It should be signed out on the treatment sheet. She was asked if a treatment was not signed out, where would it be documented if it was provided. She stated, In a progress note, but it should also be initialed on the treatment sheet if it was done. In a medical record review for Resident #47, it was revealed that the resident had an MDS (Minimum Data Set) quarterly assessment completed on 11/23/22. The assessment revealed a BIMS (brief interview for mental status) score of 13 out of 15 possible points, indicating that that resident was cognitively intact. The same assessment further revealed an assessment of behaviors which revealed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105366 If continuation sheet Page 2 of 5 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 105366 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare University 3648 University Blvd S Jacksonville, FL 32216 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 the resident did not exhibit any behaviors for rejection of care. Level of Harm - Minimal harm or potential for actual harm A review of the care plan for Resident #47 revealed a focus identified on 5/12/17 (with most recent revision on 5/19/21) that stated, The resident is at risk for alteration in skin integrity related to limited mobility, obesity, diabetes, incontinence, and refusal to get out of bed. The goal stated, Decrease/minimize skin breakdown risks. The interventions stated, Body audits for skin observations (revised 8/5/21). Observe skin condition with ADL (activities of daily living) care daily; report abnormalities (revised 6/19/19), provide preventative skin care routinely and PRN. Residents Affected - Few A review of current physician's orders for Resident #47 revealed: 9/23/21: Hydrocortisone cream 1%: apply to right forearm and upper back topically every 8 hours as needed for itching. A review of the eTAR (electronic treatment administration record) for Resident #47 for the past three months revealed an order for hydrocortisone 1%: Apply to right forearm and upper back topically every 8 hours as needed for itching. The eTAR was not signed by nursing to indicate this medication had been administered on any date. A review of all progress notes (11/1/22 through 12/22/22) did not reveal any treatment had been provided for rash, nor was there any documentation concerning a rash. A review of weekly skin checks provided by the DON revealed: 12/20/22: rash on arms and chest 12/13/22: no new wound/injury 12/6/22: pt with itchy/rash on both forearms- under current treatment. The DON provided weekly nurse skin checks for Resident #47 for 12/6/22 and 12/20/22. On 12/22/22 at 11:15 a.m., in an interview with the DON, she stated, December 6th shows they noted a rash and it's being treated. She was asked if there was documentation that any treatment was provided for the rash. She replied no. A review of the facility's policy titled Administering Medications (revised 12/2012) read: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed. 21. Topical medications used in treatments must be recorded on the residents' treatment record (TAR). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105366 If continuation sheet Page 3 of 5 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 105366 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare University 3648 University Blvd S Jacksonville, FL 32216 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, staff interviews, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. There were four errors and 33 opportunities for error, resulting in an error rate of 12.12% and involving two errors for Resident #50, one error for Resident #69, and one error for Resident #28. Residents Affected - Few The findings include: On 12/21/22 at 4:20 p.m., Licensed Practical Nurse (LPN) F was observed preparing medications for Resident #50. One of the tablets (Bumex 2 mg (milligrams) was observed to fall onto the medication cart when popped out of the blister pack. LPN F was observed picking up the tablet with an ungloved hand and placing it in the medication cup with another tablet (Coreg 25 mg). LPN F was observed picking up the medication cup and then proceeded to walk toward the resident's room. He was stopped and asked if he was going to give the medication he had dropped and picked up with his ungloved hand to the resident. He stated, Yes, the cart is clean. If I dropped the pill on the floor, I would throw it away and get a new one. He was advised at that time that the medication cart and his ungloved hands were not considered clean. He then proceeded to pop two new pills for the resident from the blister pack. LPN F was then observed leaving the pills he wasn't going to administer to the resident on top of the cart in a medication cup. He walked into the resident's room. The medication cart was out of his sight for six minutes while he administered the medications. Upon returning to his medication cart, he saw the pills he had left out and threw them in the trash. He was asked if he should leave medications out on top of the medication cart and out of his sight. He stated, No, that's why I just threw them away when I saw I left them there. On 12/21/22 at 4:30 p.m., LPN F was observed preparing medications for Resident #28. LPN F entered the resident's room and handed him the medication cup with the pills in it. LPN F was asked if he had checked the resident's blood pressure for the ordered parameters before administering the medication. He stated, Hold on and left the room. He left the resident holding the medication cup, with three pills in the cup, unattended. He returned 90 seconds later and stated, His blood pressure is 119/69, and he instructed the resident to take the pills in the cup. On 12/21/22 at 4:50 p.m., LPN G was observed preparing medications for Resident #69 to be administered via gastric tube (feeding tube). These medications included Vitamin C 500 mg, give one tablet via gastric tube, and Ferrous Sulfate liquid 325mg/5ml (milligrams per milliliter), give 5 ml via gastric tube. LPN G was observed bringing separated medications in two medication cups into the resident's room and setting them on the bedside table. She then stated, Oh, I need my stethoscope, and left the room. She was observed leaving the two medications (Vitamin C and ferrous sulfate) unattended and out of her sight on the resident's bedside table. She was asked if she usually left medications unattended when she left a resident's room. She replied, Well, the med cart has to be plugged in and it won't reach to this room. She was asked about leaving the Vitamin C and Ferrous Sulfate on the resident's bedside table unattended while she went to go get her stethoscope. She stated, Oh, well generally I wouldn't do that. I guess I should have taken them with with me when I went to get my stethoscope. A review of the facility's policy titled Administering Medications (revised 12/2012) read: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105366 If continuation sheet Page 4 of 5 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 105366 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare University 3648 University Blvd S Jacksonville, FL 32216 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 16. No medications are kept on top of cart. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105366 If continuation sheet Page 5 of 5