Inspection·May 15, 2025

F 0644 increased agitation, restlessness, involuntary movement of mouth or tongue) every shift (9/6/23) Level of Harm - Minimal harm or potential for actual harm Observe closely for significant side effects of sedative/hypnotic medication including burning or tingling in hands or feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, weakness every shift (9/6/2023) Residents Affected - Few Psychiatric consult as needed (10/16/23) Observe closely for significant side effects of anti-depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift (2/27/2025) Monitor for the following behaviors: yelling, mood changes, sleeplessness, hallucinations, delirium every shift (3/6/2025) A review of the resident's active care plan revealed the following focus area: [Resident #11] receives antipsychotic medication related to diagnosis of schizoaffective disorder - bipolar type and psychosis (created 4/19/23, revised 5/13/24). Goals/Interventions in place. A review of the Psychiatric Evaluation progress note with date of service 10/6/23 revealed that the diagnoses of bipolar disorder, current episode mixed, severe, with psychotic features; generalized anxiety and insomnia. The note also documented instructions to Please update diagnoses accordingly. On 5/15/2025 at 12:38 PM, an interview was conducted with the Business Office Manager (BOM) who stated she had been in her current position for 6 to 7 months. Further, she had been employed by the facility for seven years. She stated she was responsible for ensuring PASRRs were current and in each resident's EMR. When asked how she would determine whether or not a PASRR was accurate, she replied, I would look at the diagnoses and make sure it (the PASRR) is filled out properly. If it was not filled out properly, she stated she would correct it. If a PASRR indicated that a level II screening was needed, she would verify the information was correct, gather any further information needed, and submit that to the State Mental Health/Intellectual Disability Authority's website. A review of the facility's policy titled Coordination-Pre-admission Screening and Resident Review (PASRR) Program (effective date: 1/14/2025), revealed: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 3. Coordination includes a preadmission screening for individuals with a mental disorder and individuals with an intellectual disability. 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for resident review. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 2 of 11 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 05/15/2025 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 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 staff interviews, record review, and a review of the facility's policies and procedures, the facility failed to provide one (Resident #25) of two residents reviewed for Preadmission Screening and Resident Review (PASRR) who had diagnoses indicating a serious mental illness (SMI) on admission, with a Level II PASRR screening. Residents Affected - Few The findings include: A review of Resident #25's electronic medical record (EMR) revealed that the resident was admitted to the facility on [DATE] with a completed PASRR Level I dated 10/18/2024, which was located in the miscellaneous section of the EMR. The 10/18/2024 Level I PASRR indicated the need for a Level II screening to be conducted. No Level II screening was found in the record. The 3008 Hospital Transfer Form dated 10/31/2024 noted a primary diagnosis of schizoaffective disorder. Other diagnoses found in the resident's record included cerebral palsy, schizoaffective disorder - depressive type; major depressive disorder - recurrent/severe with psychotic symptoms; post-traumatic stress disorder (PTSD), and persistent mood disorder. (Photographic evidence obtained) On 5/14/2025 at 3:40 PM, evidence of a completed level II PASRR for Resident #25 was requested of both the Administrator and the Director of Nursing (DON). They stated they would look for it. On 5/15/2025 at 8:50 AM, the Administrator was asked whether she had found the Level II PASRR screening for Resident #25. She stated it had not been found. She further stated a Level II screening was being conducted this morning. On 5/15/2025 at 12:38 PM, an interview was conducted with the Business Office Manager (BOM) who stated she had been in her current position for 6 to 7 months. Further, she had been employed by the facility for seven years. She stated she was responsible for ensuring PASRRs were current and in each resident's EMR. When asked how she would determine whether or not a PASRR was accurate, she replied, I would look at the diagnoses and make sure it (the PASRR) is filled out properly. If it was not filled out properly, she stated she would correct it. If a PASRR indicated that a level II screening was needed, she would verify the information was correct, gather any further information needed, and submit that to the State Mental Health/Intellectual Disability Authority's website. When asked about the PASRR that was included in Resident #25's records sent from the hospital and dated 10/18/2024, she stated she did not look at the admission paperwork since the resident had been in this facility before. She further stated she did not know there was a new PASRR and that a Level II needed to be completed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 3 of 11 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 05/15/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a staff interview, and a review of the facility's policies and procedures, the facility failed to develop a comprehensive care plan to address anticoagulant therapy for one (Resident #65) of 25 residents whose care plans were reviewed, from total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #65 was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease), traumatic amputation of the left great toe, PVD (peripheral vascular disease), bipolar disorder, major depressive disorder, partial traumatic amputation of the left 5th toe, chronic pain syndrome, and unspecified heart failure. A review of the admission MDS (minimum date set) assessment with an ARD (assessment reference date) of 4/18/25 revealed that the resident had a BIMS (brief interview for mental status) score of 15 out of 15 possible points, indicating intact cognition. Section N of the assessment indicated the resident received anticoagulant medication during the 7-day assessment period. On 5/12/25, a review of Resident #65's active Care Plan revealed there was no care plan/focus area for his current anticoagulant therapy. A review of the resident's active physician's orders revealed he was receiving Apixaban 5 mg (milligrams) by mouth BID (twice daily) for Atrial fibrillation with an order date of 4/12/25. A review of the May 2025 MAR/TAR (medication administration record/treatment administration record) revealed no monitoring was documented for anticoagulant therapy side effects or adverse reactions. On 5/15/25 at 4:30 PM, an interview was conducted with LPN (Licensed Practical Nurse/MDS (minimum data set) Coordinator A. When she was asked who was responsible for updating resident care plans, she replied, We both are, me and the other coordinator. The nurses also update them sometimes, but we'd rather do it ourselves. When she was asked about the process for updating care plans, she replied, I do all the Medicare Part A resident care plans and all long-term residents. The other coordinator does the managed care residents and she assists me as needed. LPN A was asked to explain the facility's process for updating the care plans. She stated, We run the orders in the morning and go through and update the care plans with the new orders. I also do updates quarterly when I complete the MDS that's due, and whatever information is shared by the clinical team, we also update that into the care plans. We attend the behavior meetings that are held once a week and we get updates, and we update new information during the actual care plan meetings. That's another opportunity to update the care plan. LPN A was asked to access the resident's care plan in the electronic medical record and provide evidence of the care plan for anticoagulant use. She confirmed that the care plan was updated to reflect anticoagulant therapy indicated for PVD on 5/12/25, and that prior to this date there had been no care plan for anticoagulant therapy. A review of the facility's policy and procedure titled Coumadin-Warfarin-Other Anticoagulant Management (dated April 2022), revealed: 3. Nursing will observe residents receiving Coumadin/Warfarin/Other Anticoagulants Therapy for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 4 of 11 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 05/15/2025 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 0656 adverse affects, signs and symptoms of bruising or bleeding throughout the course of the therapy. Level of Harm - Minimal harm or potential for actual harm 4. Per observation, the resident's individualized care plan will be modified/adjusted as needed. 5. Nursing will report symptoms or changes of condition to the prescribing physician. Residents Affected - Few 7. Nursing will consult with the pharmacist with questions and for clinical guidance related to drug interactions with current or new medications as indicated. A review of the facility's policy and procedure titled Care Plan-Comprehensive (dated January 2023), revealed: A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs shall be developed for each resident. 2. The Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; d. Reflect treatment goals and objectives in measurable outcomes; h. Ensure the care plan is individualized and person-centered and reflects the resident's goals for admission and desired outcomes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 5 of 11 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 05/15/2025 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide a consistent, viable means of communicating in a language that the resident understood for one (Resident #42) of 31 sampled residents. Failure to provide interpretation during care may result in the resident's needs not being recognized or met. Residents Affected - Few The findings include: During a tour of the facility on 5/13/2025 at 11:48 AM, Certified Nursing Assistant (CNA) L stated Resident #42 did not speak English. He spoke an African language. She was not sure which one; she had never heard of the language before. She did not know what country he was from. CNA L stated the resident had learned to say yes and no or shake/nod his head when asked questions. When he spoke, she did not understand him because he spoke in his native language. During an observation of Resident #42's room on 5/13/2025 at 11:49 AM , no communication board was observed. No interpreter services contact information was posted in the room. No information about an interpreter was posted. The room was dark, the resident was lying in bed and his head was covered with a blanket. During an interview with Licensed Practical Nurse (LPN) M on 5/13/2025 at 11:52 AM, she stated she was the assigned nurse for Resident #42 today. She stated she used simple gestures and words to speak and communicate with him. He understood a few English words. During an interview with Unit Manager J on 5/13/2025 at 12:00 PM, she stated the resident had a friend that spoke his language. They called his friend when they needed an interpreter. She was not sure which language the resident spoke. An interview with Resident #42 was attempted on 5/14/2025 at 10:12 AM. There was no communication board in his room. No interpreter services contact information was posted in the room. He did not appear to understand the questions asked of him in English. His friend's number was posted on the wall today; it was not posted there yesterday at 11:49 AM when the resident was visited. Resident #42 pointed at the piece of paper and spoke in his native language, Amharic (official language of Ethiopia). During an interview with LPN H on 5/14/2025 at 10:15 AM, she stated she was the assigned nurse for Resident #42 today. She stated she used simple gestures and words to speak and communicate with Resident #42. She did not think he understood English except for a few words. She was asked if the facility had an interpreter phone line they could use for an interpreter during an emergency with Resident #42. She looked through a large binder on her nursing cart twice and stated, Yes, we have one. I don't see it in here. I thought we had one. She left the cart and went to the Unit Manager to ask her. The Unit Manager was overheard telling LPN H that she thought the number was in the binder. LPN H told the Unit Manager she could not find it. The Unit Manager looked in the nurses' station. During an interview with Unit Manager J, LPN on 5/14/2025 at 10:15 AM, she was asked if there was a contracted interpreter for the facility in case of emergencies and in case Resident #42's friend could not be reached. She stated she believed there was a contracted interpreter service the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 6 of 11 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 05/15/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm used, but she could not remember where the information was located. She stated she would find out and she left the interview. She was observed walking to the other nursing unit. At 10:35 AM, LPN J returned and provided a sign on facility letter head that read: Securing Use of Language Line Services. The form had a phone number to use to access an interpreter. (Copy obtained) LPN J stated she was going to hang one of these signs in the resident's room and she went to his room. Residents Affected - Few During an interview with Resident #42 on 5/14/2025 at 1:40 PM via the interpreter line, he stated the facility staff did not understand him when he talked to them. They did not use an interpreter. They sometimes called his friend. He stated he understood some of what the staff said to him, but not much. During a telephone interview with the Psychiatric Advanced Practice Registered Nurse (APRN) for Resident #42 on 5/14/2025 at 2:11 PM, she stated she used the interpreter line when she saw him because she did not understand his language. She had the phone number in her cell phone. She stated she thought Amharic was a fairly rare language here in the U.S. She usually took a long time to assess him. She stated she thought the information she got was reliable, however, Some of the information gets lost in translation. On 5/14/2025 at 2:12 PM, an observation of Activities of Daily Living (ADL) care for Resident #42 was made. CNA I and LPN H proceeded to change his brief, clean him and change his sheets. They did not attempt to speak to the resident. Resident #42 did not attempt to speak with the staff. When they were finished, LPN H asked Resident #42 to drink a liquid supplement that was on the nightstand in a cup with a straw. The resident spoke in his native language and LPN H did not appear to understand him; she did not respond to him. She kept putting the cup in front of him telling him to drink it. He kept responding in his native language. After some time, he took the cup and drank the supplement. He spilled it on his gown. After he finished drinking it, he spoke again in his native language. LPN H and CNA I proceeded to change his gown and bed linens. The resident spoke in his native language during this process. Neither LPN H nor CNA I responded to him. When asked if they understood what the resident was saying to them, they both stated they did not understand what he is saying. LPN H stated, We just have to guess. CNA I stated he could say some words in English so she could understand him at times. LPN H stated Resident #42 could tell her if he had a headache or if his stomach hurt. He points to his head or stomach. She did not conduct pain assessments with him because he did not appear to be in pain. LPN H and CNA I made no further attempts to communicate with the resident and left the room. During an interview with Resident #42's emergency contact and friend on 5/15/2025 at 3:55 PM, he stated he did not think Resident #42 understood the staff and the staff did not understand him. That's why they called him to interpret. He stated he had some health problems himself, and had not been able to come to visit Resident #42 in person for approximately eight months now, but Resident #42 called him on the phone often. Resident #42's friend stated the reason Resident #42 refused to take his medication was because he did not trust the staff. He was paranoid and thought they wanted to harm him. He stated he thought Resident #42 had some cognitive issues, but for the most part, he could make his needs known in his language and his memory was intact. He did not know if Resident #42 participated in any activities at the facility. During an interview with the Activities Director on 5/15/2025 at 3:37 PM, he stated the facility provided in-room activities for Resident #42. They provided him with games and an I-Pad device that he could use for games. The games were in English. Nothing was offered to Resident #42 in his native language. He liked to listen to music on his cell phone and preferred to stay in his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 7 of 11 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 05/15/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm A review of the resident's medical record revealed on the face sheet that he was admitted on [DATE]. His diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, dysphagia, major depressive disorder, chronic heart failure, atherosclerotic heart disease, absence of left leg below knee, adult failure to thrive, and hypertension. (Copy obtained) Residents Affected - Few A review of the Significant Change Minimum Data Set (MDS) assessment, dated 4/1/2025, revealed that the resident's primary language was Amharic. The question Do you need or want an interpreter to communicate with a doctor or health care staff? was answered yes. The resident's hearing was documented as adequate, speech was clear, he understood and was understood by others, and his vision was adequate. His Brief Interview for Mental Status (BIMS) score was 10 out of a possible 15 points, indicating moderate cognitive impairment. He had no behaviors toward himself or others. (Copy obtained) A review of Resident #42's active Care Plan, dated 4/11/2025, revealed a focus area that read: Spends most of time alone/Potential for altered activity pattern, likes staying to himself due to language barrier. Another focus area read: At risk for impaired communication/memory deficit as evidenced by Speech problem - speaks little English, speaks Oroma/Amharic; Language line [phone number]. Contact on face sheet is an interpreter. Another focus area read: [Resident #42] has impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions: Ask yes/no questions in order to determine the resident's needs. Interventions included: Communcation: Use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions - turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues - stop and return if agitated. (Copy obtained) A review of the nursing progress note dated 3/30/2024 read: Refused to eat, stated he was not hungry, was upset when encouraged to eat, food left at bedside with resident not touching his food. He was talking in his own dialect and upset at this writer when told he needed to speak English. He denies that he was hurting. He was covering his head. LPN H signed this nursing progress note. (Copy obtained) A review of the nursing progress note dated 4/29/2025 read: Call placed to resident's friend in attempt to have friend talk to resident about his diet intake and to inquire about any particular food preferences, friend able to communicate in resident's language. No answer to multiple calls and friend's mailbox full. LPN M signed this nursing progress note. (Copy obtained) Nursing notes reviewed from 3/4/2024 through 5/15/2025 revealed no indication that the nursing staff was using an interpreter to assess/communicate with the resident. (Copies obtained) A review of the facility's policy and procedure titled Communication Training revealed: Intent: It is the policy of the facility to provide a Staff Education Plan in accordance with State and Federal regulations. Procedure: The facility will include effective communications as mandatory training for direct care staff. (Copy obtained) A review of the facility's staff training documents used for Cultural Diversity Training revealed: Culturally competent care improves communication, increases trust, improves treatment efficacy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 8 of 11 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 05/15/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few expands understanding of behaviors, decreases stress, facilitates clinical encounters for more favorable outcomes, increases interpersonal experiences, increases resident satisfaction, and improves health outcomes and quality of care. (Copy obtained). A review of the facility's policy and procedure titled Translation Services (dated 12/2024) read: When needed, the facility can utilize various translation services in order to communicate with a resident who is unable to understand English. 1. Staff may utilize Google Translation by going into Google and type in Google Translate and select the resident's native language. Staff or the resident can speak into the application and it will talk back. 2. Staff may utilize translation applications on their phone. 3. A representative of the resident, family member or employee may translate as needed. 4. Speech Therapy can work with the resident and create a communication board when needed. (Copy obtained) A review of the facility's form titled Securing Use of Language Line Services (dated 10/2016) revealed instructions, a telephone number, and an access code for accessing an interpreter 24 hours a day, 7 days a week. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 9 of 11 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 05/15/2025 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 kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, by failing to record dish machine temperatures, and by failing to seal and date mark open bundles of bread on the bread rack. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 5/12/25 at 11:00 AM. During the tour, the dish machine temperature log for April 2025 was reviewed and was incomplete. Temperatures were not recorded for breakfast or lunch on 4/25/25 or 4/26/25. Temperatures were not recorded for breakfast, lunch or dinner from 4/27/25 through 4/30/25. (Photographic evidence obtained) No date markings were observed on one open package of noodles or five open bundles of bread located on the bread rack in the dry storage room. Another observation of the kitchen was made on 5/14/25 at 10:55 AM. During this time, new observations were made of eight open bundles of bread on the bread rack in the dry storage room with no date markings. (Photographic evidence obtained) During an interview with Dietary Aide B on 5/15/25 at 1:30 PM, Dietary Aide B reported they were responsible for recording the dish machine temperatures, and temperatures were documented after each meal. Dietary Aide B stated a new dish machine was installed about three months ago, but there was never a period when the facility was without a dish machine. When asked what happened when bread was opened, used, and placed back on the bread rack, Dietary Aide B replied that the bread was sealed and dated. During an interview with [NAME] C on 5/15/25 at 1:37 PM, she reported that the Dietary Aides were responsible for recording the dish machine temperatures after every use. [NAME] C stated the dish machine had been down in the last month due to switching from a high-temperature machine to a low-temperature machine, and during that time, the three-compartment sink was utilized for dish washing. [NAME] C further reported that when bread was opened, used, and placed back on the bread rack, it was wrapped, labeled, and dated. During an interview with the Certified Dietary Manager (CDM) on 5/15/25 at 1:50 PM, he confirmed that the Dietary Aides were responsible for recording the dish machine temperatures. The CDM stated he reviewed the temperature log daily to ensure it was completed. He also confirmed that there was no time during the last month when the dish machine was down. Last month the facility switched from a high-temperature machine to a low-temperature machine, but the dish machine was not down. The CDM was asked to retrieve the temperature logbook. On 5/15/25 at 2:05 PM, the CDM provided the temperature logbook. A second observation of the dish temperature log for April 2025 revealed temperatures for breakfast and lunch on 4/25/25 and 4/26/25, and temperatures for breakfast, lunch and dinner from 4/27/25 through 4/30/25 were now complete. When asked to explain the facility policy related to date marking food. The CDM confirmed that everything coming in needed to be dated and rotated using the First In First Out (FIFO) method. He also confirmed that when bread was opened, used, and placed back on the bread rack, the bread was dated. (Photographic evidence of the April 2025 dish machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 10 of 11 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 05/15/2025 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 temerpature logs was obtained again on this date.) Level of Harm - Minimal harm or potential for actual harm A review of the R&K Services, LLC, Hospitality Alliance document (undated), revealed: Residents Affected - Few 2. Marking dates after opening or preparation: after opening or preparing food, mark the date or day on which the food needs to be served, sold, or discarded. If you plan to hold the food for longer than 24 hours, it's essential to keep track of when it was opened or prepared. (Copy obtained) A review of the R&K Services, LLC, Dish Machine Temperature Log policy (undated), revealed: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. The food service manager will provide the dishwashing staff with a log to be posted near the dish machine. 2. The food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. 3. Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. 4. The food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105381 If continuation sheet Page 11 of 11