Inspection·October 8, 2021

F 0661 Level of Harm - Minimal harm or potential for actual harm 2. The resident and or representative will be provided publicly available standardized quality information such as CMS Nursing Home Compare, HH Compare, and LTCH compare websites and other resource use data such as readmission rates. (Copy obtained) . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 2 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #188) of three residents reviewed for accidents, from a total sample of 34 residents. The findings include: A record review for Resident #188 revealed an admission date of 10/16/2017. Her primary medical diagnosis was dementia with behavioral disturbance. Secondary diagnoses included schizophrenia and need for assistance with personal care. A review of Resident #188's annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 4, indicating severe cognitive impairment. The resident required extensive assistance with activities of daily living. On 10/04/2021 at 11:20 AM, Resident #188 was observed lying in bed. She was positioned diagonally in the bed with her feet hanging off the left side of the bed. Two floor mats were stacked against the wall. An event history note, dated 12/21/2020 at 10:13 AM, revealed the resident was found on the floor next to her bed and sustained a laceration to her forehead. She was transferred to the hospital for evaluation and treatment. A review of Resident #188's comprehensive care plan revealed a focus area for falls. The resident's goal was to remain free from serious injury. An intervention, dated 12/20/2020 directed staff to place the bed in low position and to place floor mats to both sides of the bed. An intervention dated 3/12/2020 directed staff to assist resident to her wheelchair for meals. An intervention dated 7/29/2019 directed staff to observe the resident frequently and place in a supervised area when out of bed. On 10/04/2021 at 12:15 PM, Resident #188 was observed lying in bed. Two floor mats were stacked against the wall. On 10/04/2021 at 2:45 PM, Resident #188 was observed lying in bed. Two floor mats were stacked against the wall. On 10/06/2021 at 10:55 AM, Resident # 188 was observed in her bed rocking back and forth. Two floor mats were stacked against the wall. On 10/06/2021 at 12:15 PM, Resident # 188 was observed lying in her bed with the head of the bed elevated. Her over-bed table was positioned in front of her, and her meal tray was on the table. The floor mats were stacked against the wall. On 10/06/2021 at 1:30 PM, an interview was conducted with Employee J, Certified Nursing Assistant (CNA) who was assigned to care for Resident #188. The CNA stated, she was familiar with the resident's care and explained that the resident was not a fall risk, and she wasn't sure why fall mats were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 3 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 in the resident's room. Level of Harm - Minimal harm or potential for actual harm On 10/06/2021 at 1:33 PM, Employee J, CNA stated she wished to correct her previous statement. She explained that the Resident #188 was a fall risk and confirmed the floor mats were to be placed on both sides of the bed when the resident was in bed. Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 4 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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** Based on observation, interviews, record review and policy and procedure review, the facility failed to ensure that two (Resident #228 and #229) of three residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician and failed to ensure one (Resident #17) of one resident reviewed for tracheostomies, received tracheostomy care as ordered by the physician, from a total sample of 34 residents. This could result in the resident not receiving appropriate care and/or clinical complications. Residents Affected - Some The findings include: 1. A review of Resident #228's medical record revealed an admission date of 10/01/21 with a primary diagnosis of Corona Virus 2019 (COVID 19) and type two diabetes. A review of the physician's orders revealed, oxygen at 2-3L/min continuous via nasal cannula. The baseline care plan did not indicate oxygen therapy. On 10/05/21 at 11:40 AM, Resident #228 was observed lying in bed in supine position with oxygen via nasal cannula. An observation of her oxygen concentrator revealed an oxygen rate of 5 Liters/minutes (L/min). (Photographic evidence obtained) On 10/06/21 at 12:06 PM, Resident #228's oxygen concentrator was observed at 3.5 L/min. On 10/06/21 at 1:45 PM, Resident #228's oxygen concentrator was observed at 5 L/min. (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 10/06/21 at 1:46 PM. She stated that she had adjusted Resident #228's oxygen to 5 L/min since her oxygen saturation had dropped to 88%. When asked about the oxygen orders, she stated the resident had orders for 2-3 L/min, but also had orders to administered oxygen at 5 L/min if saturation was below 90%. When she was asked to provide a copy of the orders for 5 L/min of oxygen, she rechecked the orders and confirmed the resident did not have orders for 5 L/min. During an interview with the Director of Nursing (DON) on 10/06/21 at 2:00 PM, she confirmed that the nurse should not increase the dosage of oxygen without orders and said she instructed Employee A, LPN to contact the physician regarding Resident #228. 2. A review of Resident #229's medical record revealed an admission date of 9/22/21 with diagnoses that included pneumonia, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease (COPD). A review of the physician's orders revealed, oxygen at 3L/min continuous via nasal cannula, oxygen saturation every shift, change tubing every week on Sundays, Spiriva 2 puffs once a day, CPAP - BIPAP at 3L/min, head of bed elevated to alleviate shortness of breath. (Copy obtained) A review of Resident #229's 5-day minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 14, indicating cognitively intact. The resident required extensive assistant with bed mobility, toileting, and transfer. The resident's care plan indicated she was at risk for cardiovascular complication, respiratory and diabetes. Interventions included to observe for shortness of breath, changes in sputum and report to physician and administer medication as ordered. (Copy obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 5 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/05/21 at 11:47 AM, Resident #229 was observed in her room receiving oxygen via nasal cannula at 4 L/min. A Continuous Positive Air Pressure (CPAP) machine was located sitting on the resident's bedside table. (Photographic evidence obtained) An interview was conducted with Resident #229 on 10/05/21 at 11:48 AM concerning how much oxygen she was supposed to receive. She stated, My oxygen should be on 3 L/min. The resident added that she used the CPAP machine at night and the nurses help with the set up. When asked about the care of the CPAP, she stated she was not sure who was supposed to do it. A review the October 2021 treatment administration record (TAR) for Resident #229 revealed the oxygen cannula was not changed on 10/03/21, and there was no documentation for CPAP care. During an interview with Employee A, LPN on 10/06/21 at 1:48 PM, she confirmed that Resident 229 oxygen was supposed to be on 3L/min and added that the resident used the CPAP at night. She was not sure who was supposed to take care of the CPAP. When asked about the oxygen cannula being changed. She stated it should be changed on Sunday, but she was not sure if it was changed as she does not work on the weekends. 3. A review of Resident #17's medical record revealed an admission date of 4/19/21 with diagnoses that included anoxic brain damage, gastrostomy status, pneumonitis, viral pneumonia, shortness of breath, wheezing, cough and disturbance of salivary secretions. A review of the physician's orders revealed, Levsin 0.125mg three times a day for secretion, oxygen via tracheostomy at 2 L/min, tracheostomy suctioning every shift and tracheostomy care every shift. A review of Resident #17's annual MDS assessment dated [DATE] revealed the resident required two-person total dependence for bed mobility, transfer, eating and toilet use. The resident required oxygen, suctioning and trach care. The resident care plan revealed the resident had potential for complication related to tracheostomy. Interventions included change trach as ordered, O2 as ordered, and trach care every shift and as needed (PRN). A review of the October 2021 TAR for Resident #17 revealed, Trach care every shift was not documented. (Copy obtained) During an interview with Employee B, LPN on 10/07/21 at 3:07 PM, she confirmed that Resident #17 required trach care every shift and it should be documented on the TAR. After reviewing Resident #17's, October 2021 TAR, she acknowledged the trach care was not documented on the form. (Copy obtained) An interview was conducted with the Director of Nursing (DON) on 10/07/21 at 3:16 PM. She confirmed that Resident #17's trach care was not documented on the TAR or anywhere else. A review of the facility policy and procedure entitled Medication Administration dated 09/18 read: Page 3 Medication administration: 1. Medications are administered in accordance with the written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 6 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 clarification prior or administration of the of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. (Copy obtained) . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 7 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 ensure appropriate administration of medication for one (Resident #33) resident, failed to ensure accurate records of receipt and disposition of all controlled drugs for one (Resident #2) resident, and failed to assure accurate storage of eyedrops during medication storage review for two of two carts reviewed, from a total of four carts in the facility. The findings include: On 10/05/21 at 12:00 PM, medication for Resident #33 was observed at her bedside. (Photographic evidence obtained) A record review for Resident #33 revealed an admission date of 2/15/21. A review of her quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 14, indicating cognitively intact. The resident required glasses for impaired vision. On 10/05/21 at 12:33 PM, Resident #33 stated that the nurse left the medication at her bedside after she asked the nurse what the medication was. During a medication storage inspection on 10/06/21 at 9:45 AM, the 100-hall front medication cart was observed to contain an unopened box of latanoprost eye drops in the cart. The box revealed instructions to refrigerate until open. On 10/06/21 at 10:15 AM, an inspection of the 100-hall back medication cart was conducted. During a random narcotic count, Resident #2's hydrocodone acetaminophen10-325 milligrams (mg) revealed one tablet while the narcotic reconciliation sheet showed a balance of 3 tablets. (Photographic evidence obtained) During an interview with Employee D, Licensed Practical Nurse (LPN) on 10/6/21 at 10:16 AM, she confirmed that Resident #2's narcotic reconciliation sheet indicated 3 tablets and that only one tablet was available in the cart. Employee C, LPN then signed off one tablet from the narcotic sheet and stated that she had given the medication to the resident earlier and forgot to sign off. She then stated there should be two tablets. When she was asked about the process for narcotic reconciliation, she stated that two nurses count the medication at the beginning of the shift and that nurses are required to sign off the medication after administration. When asked about the reconciliation at the beginning of the shift, she stated that she counted the narcotic with the off going nurse and the count was accurate. She said, It's my fault and I will notify the DON right away. During an interview with Employee C, LPN on 10/06/21 at 10:47 AM, she stated that the eye drops box was unopened and in the medication cart because the resident had been refusing to take them. The nurse confirmed that the eye drops needed to be refrigerated per the instructions. Employee C, LPN was asked to conduct a random narcotic count. She obtained the narcotic book and started signing off the narcotic that she had already administered. When asked about the process of narcotic reconciliation, she stated that it should be documented after administration. On 10/06/21 at 1:45 PM, an interview was conducted with Employee A, LPN. She confirmed that she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 8 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some left medication for Resident #33 at the bedside. She stated that she thought the resident would take the medication. She sometimes refuses medication and takes them later. After she realized the resident had not taken the medication she went back to the room and took them. When she was asked what the policy was if a resident refuses medications, she stated, she would try to give the medication at a different time, and after three tries, she would document the medication as refused and notify the physician. Employee A, LPN confirmed she did not follow the facility policy. On 10/06/21 at 2:06 PM, an interview was conducted with the Director of Nursing (DON) concerning the process of narcotic reconciliation. She stated that the nurses are supposed to sign off each medication after administration and two nurses should witness the destruction of medication if is refused or accidentally dropped. During the change of shift, two nurses should count narcotics and report any discrepancies. The DON confirmed that she was informed by Employee D, LPN that the narcotic count was off, and she is conducting an investigation. The DON was informed of Resident 33's medication left at the bedside and the eyedrops observed in the medication cart with directions to refrigerate. The DON confirmed that the staff members involved did not follow the facility policy and procedures. A review of the facility policy and procedure entitled, Medication Storage: Storage of Medication with effective date of 09/18, read: 4.1 Storage of Medication Policy Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Procedure: 11. Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in the refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed as the cool temperatures are those between 8 degrees Celsius (46 degrees Fahrenheit) and 15 degrees Celsius (59 degrees Fahrenheit). Review of the facility's Controlled substance accountability form revealed the following: Guideline Use this form to verify that the controlled Drugs on hand have been counted and that each medication count agrees with the quantity stated on the residents individual controlled Drug record (s) and anytime when receiving or removing a scheduled II, III, IV, or V medication. 1. At each shift change or when keys are rendered a physical inventory of all controlled medication will be conducted by two stakeholders per state regulation: licensed nurse and/or Certified Medication Technician (CMT). This is completed as follows: a. The off going licensed nurse and/or CMT surrendering the keys will read from the Controlled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 9 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Substance Accountability book each resident's-controlled Drug Record and the medication to be counted. The oncoming nurse and/or CMT will validate each resident's-controlled Drug Record and the medication to be counted. b. Once the count is complete, both licensed nurse and/or CMT will also count the individual controlled drug record (s). Both licensed nurse and/or CMT will sign the Controlled Substance Accountability Count Sheet. c. At any time during the shift a new Scheduled II, III, IV or V medication is added, discontinued, or removed, the controlled Substance accountability form will reflect the name of the resident, medication and strength, number of cards added or removed, number of sheets added or removed, and verified by two licensed nurses and/or CMT. d. If at any time the narcotic count is incorrect or individual narcotic sheets are not accounted for the count will stop in which a member of the administration will be notified. No one leaves the cart or the facility until authorized by a member of the nursing administration. Review of Medication administration policy and procedure effective 09/18 Page 3 Medication administration: 4. Medication are to be administered at the time they are prepared. 20. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR and action taken as appropriate. Page 6 Documentation: 1.The individual who administers the medication dose, records the administration on the Resident's MAR immediately following the medication being given. In no case should the individual who administered the medication report off- duty without first recording the administration of any medication. 2.If a dose of regularly scheduled medications is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at the scheduled dose time, or a starter dose of antibiotic is needed,) the space provided on the front of the MAR for the dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 10 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to obtain routine dental care for one (Resident #47) of one resident sampled for dental services from a total sample of 34 residents. Residents Affected - Few The findings include: On 10/4/2021 during a tour of the facility at 11:13 AM, Resident #47 stated she was awaiting a dental consult to have two of her teeth removed before she could have knee surgery. A review of the clinical record for Resident #47 revealed a 7/9/2021 order for dental consult - Necrotic teeth extraction prior to knee surgery. On 9/30/2021 a second order for dental consult revealed - Extraction of decayed teeth. There was no documentation in the residents' record showing the dental consult order for 7/9/21 was completed. Further review of the clinical record for Resident #47 revealed an admission date of 8/14/20 with a primary diagnosis of unilateral primary osteoarthritis, right knee. A review of the annual minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. A review of the resident's comprehensive care plan revealed no care plan for dental care prior to surgery. A progress note, dated 7/8/2021, revealed the resident returned from orthopedic with orders for labs in 5 weeks, for f/u appts, for dental to extract necrotic teeth prior to knee surgery and for dietary to see to increase protein, 100 gm supplements to improve albumin, prealbumin levels prior to surgery (knee surgery) copies of orders to social service and dietary, labs scheduled, transport notified of f/u appt dates. During an interview with the Social Services Director (SSD) on 10/7/2021 at 10:18 AM, she stated, she was unsure if Resident #47 had a dental consult appointment. If it was scheduled, it was not scheduled through her. When asked about the communication of appointments, the SSD stated, if the appointment was scheduled, it normally would not be communicated to her. The SSD stated that the driver also schedules appointments. During an interview with the driver on 10/7/2021 at 2:20 PM, he was asked about his scheduling process. He stated that he receives the appointment requests from the nurses in his box. If a resident doesn't need to be scheduled, the form will have the resident's name, appointment location and appointment time. If the resident needs to be scheduled, the form will have the resident's name and appointment location. He was asked if a dental appointment was set for Resident #47 after the first recommendation from her physician on 7/9/2021. The driver stated that he was not aware of any dental appointment for the resident and confirmed, he had no record of her going out for a dental consult. When asked if there was a policy in place for scheduling appointments, he stated that he did not know of a policy. An orthopedic consultation report for Resident #47 dated 9/30/2021 revealed the following: Diagnosis: Left Knee osteoarthritis; Right Knee osteoarthritis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 11 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 0791 Findings: Severe osteoarthritis impacting ambulation Level of Harm - Minimal harm or potential for actual harm Recommendations/new orders: dental extraction of necrotic teeth, lab draw of CBC w/diff, albumin, prealbumin, transferrin, hemoglobin A/C, review in 2 weeks with PA. Residents Affected - Few An interview with the Director of Nursing (DON) was conducted at 2:56 PM on 10/07/2021. The DON was asked about a policy for scheduling appointments. The DON searched the online system but was unable to locate a policy. During an interview with the Administrator on 10/07/2021 at 3:01 PM, she confirmed there is no policy for setting medical appointments. If a patient receives an order for a consult, the facility reviews the providers they have coming in the building. If the person has their own provider, then they call that office and let transportation know about the appointment. Transportation usually makes the appointment because they know when the van is available. If the van is not available, then we will notify outside transportation. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 12 of 13 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review, the facility failed to ensure a refrigerator in the nourishment room was maintained at acceptable temperatures and failed to store and label items appropriately in 1 of 1 nourishment rooms. The findings include: On 10/7/21 at 12:00 PM, the facility's nourishment room was observed and revealed the following: - Refrigerator temperature log was missing dates for 9/2, 9/3, and 9/16. (Copy obtained) - The freezer had ice cream in it but did not have a thermometer in it. - Freezer temperature logs for September and October 2021 were blank. (Copy obtained) - Refrigerator had a blue spill on bottom of unit. (Photo obtained) - Pizza box with 1 slice of pizza in the refrigerator with no name or date on the box. (Photo taken) - One container of cheese and ham in the refrigerator with no name and a date of 7/22/21 on it. (Photo taken) - One small container of sauce in the refrigerator with no lid, date, or name on it. (Photo obtained) - Pepsi bottle in the refrigerator with no date or name. - A sub in the refrigerator with no name or date on it. (Photo obtained) On 10/7/21 at 12:15 PM, an interview was conducted with Employee C, Licensed Practical Nurse (LPN). She stated, she usually throws away expired food but forgot to do it yesterday. She confirmed that food should be labeled and thrown away after 3 days. She stated that nurses are responsible for keeping nourishment room clean and recording the refrigerator temperatures daily. During an interview with the Administrator on 10/7/21 at 1:39 PM, she stated that the nourishment room was the responsibility of the nurses. She confirmed that the refrigerator temperatures should be taken daily and that food should be properly dated and labeled in the refrigerator. On 10/7/21 at 5:50 PM, the administrator and DON confirmed there was no facility policy for nourishment room items, maintenance, or sanitation. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 13 of 13