Inspection·September 19, 2023

F 0583 Purpose: To provide general guidelines for resident rights while caring for residents. Level of Harm - Minimal harm or potential for actual harm Preparation: 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: Residents Affected - Some e. Confidentiality of protected health information. (Copy obtained) . 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 09/19/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to maintain and implement an infection prevention control program to provide a safe, sanitary and comfortable environment. The facility staff failed to ensure the proper use of protective equipment (PPE) in transmission base precaution (TBP)/COVID-19 isolation room for three (Residents #3, #7, and #6) of four sampled residents; and the facility failed to ensure all staff used proper hand hygiene in a TBP room/COVID-19 isolation room (rooms [ROOM NUMBERS]). Failure to adhere to infection control and prevention protocol increase the risk of transmitting communicable diseases and infection. Residents Affected - Some The findings include: During a tour of the facility on 09/19/2023 at 12:30 PM, room [ROOM NUMBER] was observed to have a sign posted for droplet precautions and isolation instructing staff to cover their eyes, nose and mouth completely. (Photographic evidence obtained) The storage cart for PPE next to the room door in the hallway had no gowns or eye protection stored in the cart. Observations of the PPE carts outside TBP rooms #202, #204, and #210 revealed there were no gowns. PPE was requested of a Certified Nursing Assistant (CNA), Employee L working in hallway. The CNA returned with one blue gown and no other PPE. She did not fill the storage carts with more PPE. During an interview with Resident #3 in her room on 09/19/2023 at 12:33 PM, she confirmed that she was in isolation for COVID-19. She expressed understanding of the need to remain in isolation. During this time, Employee L entered the room with no gown, gloves or eye protection on. She was wearing a facemask. Resident #3's roommate, Resident #7, asked Employee L to purchase a soda for her. Resident #7 handed Employee L two dollars. Employee L told Resident #7 she would and left the room. She returned to the room at 12:35 PM with a soda and a quarter and told Resident #7 it was her change. Employee L did not don PPE prior to entering the room for the second time. She went over to the B-bed side of the room and asked Resident #7 and Resident #3 if they needed anything. When asked about the garbage can for doffing the PPE gown, Employee L stated, Oh don't get me started. She stated that the facility sometimes does not provide the appropriate PPE or garbage receptacles for the contaminated PPE. When asked where the paper towels were for hand washing, she stated, See what I mean? She left the isolation room and went down the hall to get paper towels for this surveyor. She returned with a handful of towels and handed them to this surveyor. She did not fill the towel dispenser in the isolation room. She did not wash her hands prior to leaving the isolation room. On 09/19/2023 at 12:45 PM, Employee N, CNA was observed in room [ROOM NUMBER]. The room had signage posted that it was an isolation room. A cart with PPE was located outside the room in the hallway. Employee N had donned a gown, gloves and mask. He was stripping the A-bed (Resident #5's) and bagging up the dirty linens. He had three bags of dirty linens tied up on the floor near the door. The resident was not in the room. The resident's roommate was in the room on the B-bed side seated in his wheelchair. The CNA doffed the gown and gloves into the garbage can and tied up the garbage bag. He removed the garbage bag and picked up the three bags of dirty linens and walked out of the room. He explained that he was taking the soiled linen to the laundry room and the garbage to the soiled utility room. He takes the soiled linen directly to the laundry room because it is so close to that unit. He opened the door to the soiled utility room and threw the bag of garbage into a large bin full of garbage bags. He let the door go closed on its own and walked down to the laundry department door. He pushed the door open with his bare hand and went inside. He threw the three bags of soiled linens into a large linen cart. He then went back to the door and opened it with his bare hand and went (continued on next page) 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 09/19/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some out of the laundry room into the hallway. He did not wash or sanitize his hands at any point. He went down the hall and started talking to a male resident in the hallway. During an interview with Employee N on 09/19/2023 at 12:53 PM, he confirmed room [ROOM NUMBER] was an isolation room. He stated he is supposed to wash his hands before he leaves the isolation room. He confirmed that he had not done so. He asked if it would be okay to wash his hands in the laundry department. When asked if he could have washed his hands in the residents' bathroom in room [ROOM NUMBER], he stated, yes and that is what he should have done. On 09/19/2023 at 2:20 PM, Employee M, CNA, was observed entering room [ROOM NUMBER] without donning a gown, gloves, face shield or goggles. She was wearing a facemask. The room had signage posted on the PPE cart in the hallway. The signage was for droplet precautions and isolation instructing the staff to cover their eyes, nose and mouth completely. She exited the room at 2:21 PM. She went down the hall to the nurse's station and returned to the room at 2:22 PM. She entered the room a second time without donning a gown, gloves or eye protection. During an interview with Employee M on 09/19/2023 at 2:23 PM, she stated she did not think room [ROOM NUMBER] was still an isolation room. She confirmed the signage was still on the PPE cart outside the room. During an interview with Employee J, Registered Nurse (RN) on 09/19/2023 at 2:23 PM, she went to her computer and looked up the physician's orders for Resident #6 in room [ROOM NUMBER]. She confirmed the resident had a physician's order for isolation with an end date of 09/22/2023. She confirmed the resident was on droplet precautions for COVID-19. She went to the room and posted the signage on the door frame at eye level. During an interview with the Director of Nursing (DON)/Infection Control Preventionist 09/19/2023 at 1:24 PM, she was informed of the infection control breaches observed during the survey. She stated that Employee L should have donned PPE prior to entering room [ROOM NUMBER] because it was an isolation room. She confirmed the two residents in that room are positive for COVID-19. She should have washed her hands prior to leaving the room both times. She confirmed that Employee N should have washed his hands prior to leaving room [ROOM NUMBER]. She confirmed that room [ROOM NUMBER] is an isolation room. Resident #6 in room [ROOM NUMBER] is positive for COVID-19. She confirmed that Employee M should have donned PPE prior to entering the room both times. Review of the clinical record for Resident #3 revealed a physician's order for droplet isolation times 10 days every day and night shift dated 09/12/2023 with an end date of 09/22/2023 (Copy obtained). Review of the clinical record for Resident #7 revealed a physician's order for droplet isolation times 10 days every day and night shift dated 09/12/2023 with an end date of 09/22/2023.(Copy obtained) Review of the clinical record for Resident #5 revealed a physician's order for contact precautions every day and night shift for Extended-spectrum beta-lactamases (ESBL) foot wound dated 09/7/2023 with no end date. (Copy obtained) Review of the clinical record for Resident #6 revealed a physician's order for droplet isolation times 10 days every day and night shift dated 09/12/2023 with an end date of 09/22/2023. (Copy (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 09/19/2023 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 0880 obtained) Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled Isolation-Categories of Transmission-Based Precautions (Revised January 2022) revealed: Residents Affected - Some Policy Statement: 1. Standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Contact Precautions: 1. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2. Examples of infections requiring Contact Precautions include, but are not limited to: a. Infections with multi-drug resistant organisms. 4. Gloves and Handwashing: b. While caring for resident, change gloves after having contact with infective material. c. Remove gloves before leaving room and perform hand hygiene. Droplet Precautions: 1. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). (Copy obtained) A review of the facility's policy and procedure titled Handwashing/Hand Hygiene revealed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 3. Hand hygiene products and supplies (towels, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use of alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after coming into direct contact with residents; f. before donning sterile gloves; k. after contact handling contaminated equipment; l. after contact with objects in the immediate vicinity of the resident; m. after removing gloves; n. before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: c. when in contact with a resident, or the equipment or environment of a resident who is on contact precautions. Procedure: Equipment and Supplies 1. The following equipment and supplies are necessary for hand hygiene: d. paper towels; e. trash can. Applying and Removing Gloves. 5. Perform hand hygiene. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105366 If continuation sheet Page 5 of 5