Inspection·October 21, 2021

F 0550 A review of the facility's policy on Resident Rights (effective February 2021 without revision), revealed: Level of Harm - Minimal harm or potential for actual harm The facility strives to assure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. Residents Affected - Few 2. A record review for Resident #136 revealed a [AGE] year-old female admitted on [DATE] with a tracheostomy, respiratory distress, diabetes and depression. She was alert and oriented with a BIMS score of 13 out of a possible 15 points, indicating intact cognition. She required extensive assistance with transfers, bathing, toileting and dressing, and was independent with eating. She was incontinent of bowel and bladder. She was able to speak with the tracheostomy in place and could make her needs known. On 10/18/2021 at 11:30 a.m., upon entering her room, her call light was on. She was very upset because it took so long for someone to answer call light. She said she was wet and needed to be changed. She stated she had put her light on prior to this surveyor's arrival. She stated a certified nursing assistant (CNA) came in said she would be back, then turned off the light and left. She said that was 15 minutes ago. A second staff person came in and asked what she wanted, and said she would get someone. During the interview at 12:05 p.m., the Director of Nursing (DON) entered the room. Resident #136 was asked if she knew who he was, and she replied no. The DON listened to her concerns and told her he would send someone in to assist her and write up a grievance. At 12:15 p.m., no staff had arrived. At 12:20 p.m., CNA E entered the room and asked what the resident needed. Resident #136 explained she needed to be changed and CNA E stated she would help her. A review of the staffing on the 200 Unit on 10/18/2021, revealed there were 33 residents on the unit. There were two nurses and two CNAs. During an interview with CNA E on 10/18/2021 at 1:30 p.m., she was asked how many CNAs were on the unit. She said only two, there were suppose to be three, but one was taken off to care for a resident needing 1:1 monitoring. Call light response was observed on the 200 hallway on 10/18/2021 between 11:30 a.m. and 1:45 p.m. The response time was 30-45 minutes. During an interview with Resident #136 on 10/20/2021 at 12:30 p.m., she was asked about call light response today. She said she put her light on this morning at 7:30 a.m. to get changed. CNA F came in and Resident #136 told her she was wet and needed to be changed. The CNA said she would come back, but when she came back at 8:30 a.m., the resident had already been served her breakfast and was eating, so she said the CNA should come back later. She did not like the fact she had to eat when she was wet. She was asked if she had reported these occurrences to anyone, and she replied that she had, but nothing had been done about it. During an interview with Resident #136 on 10/20/2021 at 11:05 a.m., she reported that she couldn't get help during the night to get changed. She said when she put her light on, someone must have been turning it off from outside the room, as the light would go off at the wall. She said, You have to keep putting the light on and hope someone will come. Finally someone came in at 3:30 a.m. An interview was conducted with the Unit Manager G on 10/18/2021 at 2:10 p.m. She was asked if she had been made aware by the residents of the long wait time for call lights. She said she was new to the position but the facility was working on it. A review of the grievance logs for the past six months found multiple complaints regarding call light response. The resolution was more in-service training. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 2 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Social Worker on 10/21/2021 at 10:15 a.m., she was asked about the numerous complaints about long wait times for call light response. She said she was new to the facility and was not at the facility at the time. She said the facility was in the process of hiring new staff. A review of the Resident Council notes, dated 10/12/21, revealed call light response and long wait times were ongoing issues. An interview was conducted with the Director of Nursing (DON) on 10/21/2021 at 11:10 a.m. He was asked whether he was aware of the issue with long wait times for call lights and that staff were turning off the call lights and not returning to the residents' rooms. He said he had been in the position for only a few weeks and was evaluating what was going on in the facility. He was in the process of hiring more staff. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 3 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #45's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnoses were muscle wasting and atrophy. Additional diagnoses included encephalopathy, hypertension, restlessness and agitation, chronic embolism and thrombosis of other specified veins, angina pectoris, panic disorder, major depressive disorder, protein-calorie malnutrition, and dysphagia. According to the 9/2/2021 Minimum Data Set (MDS) assessment, Resident #45 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. According to a 9/27/2021 progress note, the resident was alert and oriented times 2 to 3. Resident observations: -10/18/2021 at 1:05 p.m. the tube feeding pump was infusing at 70 ml (milliliters)/hour -10/19/2021 at 8:25 a.m. the tube feeding pump was infusing at 70 ml/hour -10/19/2021 at 2:10 p.m. the tube feeding pump was infusing at 70 ml/hour -10/19/2021 at 3:10 p.m. the tube feeding pump was infusing at 70 ml/hour -10/21/2021 at 9:45 a.m. the tube feeding pump was infusing at 70 ml/hour A record review revealed a physician's order dated 10/12/2021 for enteral feeding every shift with Jevity 1.5 Cal (calorie) continuous via tube to infuse at a rate of 65 ml/hour (milliliters per hour). Total volume of 1560 ml infused in 24 H (hours). May turn off for care/services. Start at 2:00 p.m. Verify infusing Q (every) shift. Clear pump when total volume has infused. A record review revealed the last interdisciplinary team (IDT) progress note was written on 10/13/2021. It documented that the resident was on an enteral feeding, Jevity 1.5 via feeding tube. The tube was patent and intact. The RD (registered dietitian) reviewed and adjusted the rate. A care plan, initiated on 8/10/2021 without revision, stated the resident was receiving enteral nutrition because of dysphagia. Interventions included to administer enteral nutrition as ordered (refer to physician's orders for current orders); to administer flushes as ordered; and to have the RD consult and follow PRN (as needed). An interview was conducted with Registered Nurse (RN) G on 10/21/2021 at 9:54 a.m. She said that residents on a feeding tube would be monitored by the nurse on duty, the IDT and the RD. She said they had a nutritional at risk meeting each Friday to discuss residents identified with dietary concerns, including all of those on tube feedings. She said only the nurses would handle the pumps, and would be responsible for making sure the pumps were infusing correctly, according to the physician's order. RN G reviewed the orders for Resident #45 and said that the resident had an order for her tube feeding pump to infuse at 65 cc (cubic centimeters). RN G observed the resident's feeding tube pump infusing at 70cc, changed it to 65 cc, and said it should not be at 70 cc. She said the unit manager should also be checking on the pump infusions to be sure the right order was in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 4 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with LPN D on 10/21/2021 at 9:59 a.m. She said she had noticed the other day that Resident #45's pump was infusing at 70 ml/hour, so she had to adjust it manually back to 65 ml/hour. She said that when she replaced the daily tube feeding bag of Jevity 1.5 Cal (calorie) for a new one, and turned it on, the machine pump would reset itself back to the last programmed physician's order. The last order was for 70 ml/hour. She said she documented daily what her flush volume had been, but there was no place on the electronic medication or treatment administration record to document the resident's daily volume of enteral feeding. An interview was conducted with the Director of Nursing (DON) on 10/21/2021 at 10:10 a.m. He said the interdisciplinary team met each week for a nutritional at risk meeting, which would include residents with tube feeding orders. He said the RD would also attend. He said the residents reviewed each week were also triggered as at risk due to the documented weight levels. He said the IDT would make a progress note in the resident's chart regarding what the team had decided or assessed for those residents' dietary needs. He said that the nurses did not document a resident's daily total volume of enteral feed, but instead relied on the weights. An interview was conducted with the Registered Dietitian (RD) on 10/21/2021 at 10:17 a.m. She confirmed that the facility did not document a resident's total volume from the tube feeding. Instead, she reviewed weights and attended the nutritional at risk meeting. She said she had changed Resident #45's tube feeding order on 10/12/2021 to 65 ml/hour instead of 70 ml/hour. She said she was not aware that the resident was not receiving her enteral feeding according to the order. An interview was conducted with the DON and the RD on 10/21/2021 at 10:20 a.m. Neither staff member was aware the resident was receiving her tube feeding at 70 ml/hour instead of the current order of 65 ml/hour. Neither staff member was aware that the tube feeding pump was resetting itself to a prior order. The DON said he would look into the potential programming issue of the pump infuser in order to correct the concern. Based on record reviews, observations, and staff and resident interviews, the facility failed to ensure enteral feeding orders were followed per the physician's orders for two (Residents #78 and #45) of two residents sampled for enteral feedings, from a total sample of 31 residents. The findings include: 1. A record review for Resident # 78 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including cerebral vascular accident with left side hemiparesis, aphasia, dysphagia and diabetes. She was alert and oriented with a Brife Interview for Mental Status (BIMS) score of 14 out of a possible 15 points. She required extensive assistance with transfers, dressing , bathing, and toileting, and she was dependent for meals/nutrition due to use of a feeding tube. A review of the October 2021 Physician's Order Sheets, revealed the current enteral feeding orders included: Every shift Glucerna 1.2 continuous via tube at a rate of 55 ml/hour (milliliters per hour) for 22 hours a day. Total volume of 1210 ml infused in 22 hours. May turn off for care. Start at 8pm, verify infusing every shift. Clear pump when total volume infused. Water flush 100 ml every 4 hours. During an observation on 10/18/2021 at 11:30 a.m., the tube feeding pump was not running. There was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 5 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a container of Glucerna 1.2 tube feeding hanging on the IV (intravenous) pole. The container label was blank, there was no date or time the product was hung, the resident's name was not written on the product, nor was the flow rate ordered. An interview was conducted with Licensed Practical Nurse (LPN) D on 10/18/2021 at 11:45 a.m. She was asked why the tube feeding for Resident #78 was not running. She said the resident stated she felt full and complained of nausea. When asked how long the feeding had been off, she said since about 8:00 a.m. When asked if the physician had been notified she said no. She was asked when the tube feeding would be restarted, and she said she would ask the resident how she felt and then would turn it back on. Observation of the tube feeding pump on 10/18/2021 at 2:05 p.m., found it was running. LPN D was asked if Resident #78 had an order for nausea medication, and she stated she would check. After reviewing of the orders, she said no. An interview was conducted with Resident #78 on 10/18/2021 at 12:05 p.m. She was asked if she had asked that the tube feeding be stopped this morning. She said she did. Her stomach felt very full and she had nausea. She was asked if she had had this issue before, and she replied yes, for awhile now. When asked if she was given any medication for the nausea, she said not that she knew of. An observation on 10/19/2021 at 9:10 a.m., found the tube feeding pump was not running. There was a full bottle of Glucerna 1.2 hanging with no date or time, flow rate or resident name. During an interview with Resident #78 on 10/19/2021 at 9:15 a.m., she was asked why the tube feeding was off. She said she had nausea again and requested it be stopped. The tube feeding pump was observed on 10/19/2021 at 4:10 p.m. It was turned on and indicated 343 ml had infused. The time started was not noted. An order was found on 10/19/21 at 2:30 p.m. to stop the tube feeding for three hours per resident request. A review of the nursing notes revealed on 10/11/21 she complained of nausea and requested the tube feeding be disconnected. On 9/27/2021, the resident requested the tube feeding be disconnected due to feeling full. Dietary consult to adjust feeding volume. There was no documentation the physician was notified, nor dietary consulted. An interview was conducted with the Registered Dietitian (RD) on 10/20/2021 at 9:35 a.m. She was asked when the last time was that she had reviewed the tube feeding orders for Resident #78. She said her last review was on 10/12/2021. The order included: Glucerna 1.2 at 55 ml/hour for 22 hours. She said the resident complained of feeling full and she decreased the water flush from 125 ml to 100 ml every 4 hours. She was asked if she was aware that Resident #78 had been complaining of nausea and fullness, and the tube feeding was being held during the day. She stated she was not told, but would follow up today. An observation of the tube feeding pump on 10/20/2021 at 11:05 a.m., found the tube feeding pump was off. An interview was conducted on 10/20/2021 at 11:15 a.m. with Agency LPN C. She was asked if the tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 6 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feeding was running for Resident #78 when she came in today. She said it was running and she shut it off at 10:30 a.m., as the pump read she had received 1210 ml. When asked what the physician's order was for tube feeding, she reviewed the record and stated Glucerna 1.2 at 55 ml/hour, continuously for 22 hours. She said because the resident sometimes requested the feeding be stopped, the schedule did not remain the same. When asked when the pump would be turned on, she replied 2:00 p.m. She was asked how she determined what time to restart the feeding. She replied that she gave the resident's stomach time to rest. When asked if the physician was aware that she was not receiving the tube feeding as ordered, she said she didn't know. An interview was conducted 10/21/2021 at 9:15 a.m. with the RD. She reported that she had spoken with the nurse and resident about the tube feeding schedule and the issue with the resident's nausea. The nurse told her that the feeding was not being given for 14 hours because the resident had been complaining about fullness and nausea. There was no indication of how much feeding she was receiving or when it was turned on or off. She said she spoke to the resident about the tube feeding schedule, and the resident wanted to have her tube feeding on during meal times so she could get up out of bed. She wanted to go to therapy. She did not want to be hooked up to the pump while out of bed. She told the RD that she wanted to be able to eat again. Speech therapy was in to see her today and conduct a swallow study and trial feeding. The RD stated there was an interdisplinary team meeting to discuss the issue with tube feeding, the pump being off, complaints of fullness and nausea, and the resident's request to be able to eat and have therapy. Orders had been obtained for Zofran (nausea medication) and speech therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 7 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 Based on observation, interview and record review, the facility failed to provide appropriate oxygen therapy to one (Resident #34) of 33 residents sampled, per the physician's orders, that would include the type of oxygen delivery system; administration instructions, such as continuous or intermittent, and/or the equipment settings for the prescribed flow rates. Residents Affected - Few The findings include: A review of the medical record revealed that Resident #34 was admitted into the facility on 1/8/2016. Her last readmission was on 11/13/2017. Diagnoses for Resident #34 included muscle wasting and atrophy; chronic obstructive pulmonary disease; heart failure; atherosclerotic heart disease of native coronary artery without angina pectoris; cognitive communication deficit; congestive heart failure; hypertensive heart disease with heart failure; presence of cardiac pacemaker; major depressive disorder, and metabolic encephalopathy. A review of the quarterly Minimum Data Set (MDS) assessment, dated 08/15/2021, revealed that Resident #34 scored 14 out of a possible 15 points on the Brief Interview for Mental Status (BIMS), indicating her cognition was intact. She required total assistance with transfers, and extensive assistance with bed mobility, locomotion on/off the unit, dressing, toilet use and personal hygiene. She required supervision with meals/eating. Based on the MDS assessment, Resident #34 did not receive oxygen prior to nor while residing in the facility. On 10/18/2021 at 2:15 p.m., Resident #34 was observed receiving oxygen via nasal cannula from a portable oxygen tank. The resident was unsure of the proper setting and could not explain why she was receiving oxygen. The flow rate could not be read, and the electronic medical record review rendered no orders for the resident to receive oxygen. On 10/19/2021 at 10:42 a.m., a record review for Resident #34 revealed there were no orders for oxygen. The latest written physician's orders for Resident #34 were on 8/10/2021 and did not include an order for oxygen. On 10/19/2021 at 10:50 a.m., Resident #34 was observed resting in bed with a nasal cannula present. The oxygen concentrator in her room was set at a flow rate of 4 LPM (liters per minute). A review of the most recent Care Plan for Resident#34 annotated oxygen as ordered and referred to the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for orders. On 10/19/2021 at 11:18 a.m., a record review of the MARs, TARs and orders from November 2019 through present failed to reveal an active order for oxygen for Resident #34. On 10/20/2021 at 11:04 a.m., Resident #34 was observed lying in bed. She was receiving oxygen via nasal cannula. Her oxygen concentrator was set at 4LPM. During an interview on 10/20/2021 at 11:07 a.m. with Agency Licensed Practical Nurse (LPN) D, she stated she was familiar with the resident and that she received continuous oxygen. When asked about the oxygen order, she consulted the online medical record then responded that she could not find an order and would have to consult the Assistant Director of Nursing (ADON) for additional assistance. She also stated per professional nursing standards, the oxygen tubing was to be changed weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 8 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 - Few On 10/20/2021 at 12:17 p.m., the ADON presented a copy of a verbal physician's order for oxygen at 4LPM via nasal cannula received on 10/20/2021 at 11:26 a.m., along with an order to change the tubing weekly on Saturdays on the 11pm-7am shift. She confirmed the order was dated for the current date and a previous order was not found. During an interview on 10/21/2021 at 2:48 p.m., the Director of Nursing (DON) provided additional documentation confirming the physician's order for oxygen for Resident #34 was not active until 10/20/2021. He could not provide an explanation as to why the oxygen was being administered prior to the order. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 9 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff and resident interviews, the facility failed to serve food that was palatable and at an appetizing temperature for three (Residents #67, #71 and #136) of 33 sampled residents. Residents Affected - Few The findings include: During an interview with Resident #67 on 10/18/21 at 11:43 a.m., she said, The food here leaves much to be desired, has no taste, there is no seasoning in the food at all, and no condiments or salt and pepper are on the trays. She further stated the food was always served cold and there was no way to get it warmed up. She stated part of the problem was that the trays sat in the food carts for long periods of time before the staff started giving them out. The metal lids that covered the plates didn't fit and were usually half of the plate, so the food was cold before you received it. During an observation of the lunch meal on 10/18/21 at 12:45 p.m., the food cart arrived at 12:50 p.m., however no staff was present at the time. At 1:00 p.m., the first staff arrived and pushed the cart down the hall. When the certified nursing assistant (CNA) opened the food cart, the metal covers over the plates were tipped over and were no longer covering the food on the plates. In an interview with CNA E at 1:05 p.m., she was asked about the lids not covering the plates. She said the covers weren't the right ones. They don't fit these plates and will not stay in place. When asked if the residents had concerns regarding cold food, she said all the time. Also, there was one glass of water or juice on the trays and no other fluids were offered. CNA E was asked if other staff were available to assist with serving the trays. She said the other CNA was on her way. She said there were two CNAs on today for 33 residents. There had been three CNAs but one was taken off their assignment to provide one to one (1:1) supervision for a resident with behaviors. During an observation of the lunch meal on 10/19/21 at 12:50 p.m., a meal cart arrived on the floor, but no staff were present to start serving. One CNA started at 12:55 p.m. When she opened the cart, the metal covers over the plates were observed tipped over and not covering the plates. The trays were observed with one glass of fluid and they were only half full. There was no serving cart with coffee or other fluid choices. An interview was conducted with Resident #71 on 10/19/21 at 1:05 p.m. She was asked if she had eaten lunch. She said not yet but was hoping it was something decent. She said the food had no taste and it was always served cold. She was asked if she had asked for an alternate meal. She said they don't offer anything else. She stated she was diabetic and went to dialysis three times a week. On the days she went to dialysis, she had to remind them she was back or she didn't get dinner. It is not good if I miss dinner, because we don't get snacks in the evenings. We use to get snacks at night, but its been months since that happened. If you ask for something to eat at night, you are told they don't have anything not even crackers. In an interview with Resident # 67 on 10/19/21 at 1:15 p.m., she was asked about her lunch meal. She said the meal ticket stated barbequed ribs and beans. It had no taste and it was as usual, served cold. I am grateful my daughter sends in food for me. During an interview with Resident #136 on 10/19/21 at 12:37 p.m., she stated, The food is horrible with absolutely no taste, and it is always served cold. The green beans and peas are served frozen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 10 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few barely warmed. There are no choices given. If food is cold, they will not heat it up. She was upset about the meal served last night for dinner. She said she had peas, corn, mashed potatoes and some kind of ground meat. None of the food was seasoned. It was worse than bland. Nothing is put on the tray like condiments, salt, pepper or sauces. During an interview with the Registered Dietitian (RD) on 10/20/21 at 9:30 a.m., she was asked if she had any complaints of cold food. She said there were complaints at the Resident Council meeting last week. She was asked what had been done to improve services. She said they would be doing a QAPI (Quality Assurance and Performance Improvement) plan. She was asked how often she was in the facility, and she said she worked full time. When asked if she was aware that the metal lid domes did not fit on the plates and when observed in the cart, all lids were on their sides and staff had to put the covers back over the plates. She was asked if she observed the staff when serving meals and if alternates were offered. When asked if she was aware of the meal trays were not served when the food carts went to the units, she said no but would be monitoring. She was asked if she was aware residents had multiple complaints about unseasoned, tasteless food, and she said she was told by the cook that no salt or seasonings were added to the food and they were not following the recipes. On 10/20/21 at 12:50 p.m., staff were observed serving the meal trays. The only fluids served on the trays were water or orange juice. There was no serving cart with coffee or other fluid choices. After all trays were distributed, the CNA was asked if there was coffee or other fluids available. She said she did not know. Another CNA said it is in the pantry. At 1:10 p.m., the CNA retrieved the cart from the pantry and placed it next to the empty food cart. The CNA was asked if someone would go down the halls and ask residents if they wanted coffee, ice tea or water. The CNA took the cart and went down the hall. During an interview with Resident #71 on 10/20/21 at 2:30 p.m., when she returned from dialysis, she was asked if the facility sent her to dialysis with a lunch. She said they did but it was just a sandwich. She said she hopes there is something decent to eat for supper because she was hungry. She was asked if she had reported her concerns. She said she had, but staff come and go so fast, nothing changes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 11 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 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 reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Residents Affected - Many The findings include: On 10/18/21 at 1:30 p.m., an observation of the low-temperature dishwasher machine was made. The dishwasher temperature log was observed with no area to record sanitizer strength on it. The Certified Dietary Manager (CDM) was asked about the log at this time, and he stated he had just started working here three weeks ago. He never noticed that the log had no area to document the sanitation of the dishwasher. An observation of lunch service was made on 10/18/21. Meal plates had plastic and metal covers that were not sitting directly on the plates. The plate coverings had slipped off the plates during transport from the kitchen to the resident rooms while in the food cart. At this time, it was also observed that not all residents had an insulated dome plate cover. Some residents' plates had metal plate covers, while others had no plastic bottom or metal pellet and only had an insulated dome covering the plate. On 10/18/21 at 1:40 p.m., the CDM was interviewed about the insulated plastic dome covers, and he stated more had been ordered but were backordered. He could not produce the original order from the previous CDM that he stated were backordered. At this time, the CDM produced a copy of the order for insulated dome plate coverings, which was dated 10/18/21, the same day the interview was conducted. When asked about the date on the order, he stated he had placed a new order because he could not find the original order. On 10/19/21 at 4:03 p.m., the CDM was asked to show the cooked temperatures and the trayline temperatures for the chicken served at lunch. The CDM showed the temperature log book, which had only one temperature recorded for chicken cooked at lunch, which was 155°F (Fahrenheit). The CDM stated the hold and cooking temperatures were the same. He reported the chicken should get to 165°F and that it was baked for about an hour. On 10/20/21 at 11:31 a.m., an observation was made in the kitchen to watch lunch service. The Assistant Food Service Manager (AFSM) was asked how the lunch food was cooked, and he confirmed he had cooked the foods for lunch. The lunch recipes were reviewed with the AFSM. At this time, the AFSM was interviewed, and he reported he had prepared and cooked the fresh zucchini, and reported he followed the recipes. He was asked if he added the salt in the recipe. He stated no, just garlic seasoning. He stated he didn't add salt because some residents were on a no added salt diet. The AFSM was asked if he liked the food. He stated, It doesn't matter what I like, I have to go by what the residents' needs are. The Director of Food Services was interviewed on 10/20/21 and confirmed the recipes should be followed, and salt should be added to the recipes when stated on the recipes. She confirmed all recipes were for all residents. The CDM reported that Dietary conducted weekly and daily audits. He produced no weekly audit forms. The Quality Assessment tool dated 1/14/21, had no additional dates or follow-up assessments on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 12 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 - Many form. (Copy obtained) A copy of another Quality Assessment and Performance Improvement Plan, dated 8/14/2021, with a completion date of 9/14/2021, was provided for review. Both of these Quality Improvement plans had no plan to improve food temperatures despite multiple grievances about cold food in grievance logs for the past six months. The CDM was interviewed on 10/20/21 at 12:20 p.m. He confirmed that the insulated bottoms and dome plate covers did not fit properly together with the metal base pellet, and reported they were purchased separately. A test tray at lunch on 10/20/21 at 1:09 p.m., revealed the vegetable quiche and zucchini were bland. At this lunch service, the kitchen ran out of knives and several residents were not given knives on their lunch trays. An additional interview was conducted with the CDM on 10/21/21 at 2:26 p.m. He reported he had just gotten a delivery of knives today. The box was unopened. The knives had not been cleaned or prepared for the next meal service yet. A review of the facility's policy on Cooking revealed, Cook food to a proper internal temperature to prevent foodborne illness. Facility procedures in this policy also read, Follow recipes for proper cooking times and temperatures. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 13 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff and resident interviews, the facility failed to provide rehabilitative services to maintain/restore the highest level of physical, mental, functional and psychosocial well-being for one (Resident #78) of two residents sampled for rehabilitative services, from a total of 31 sampled residents. Residents Affected - Few The findings include: A record review for Resident #78 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including cerebral vascular accident, left sided hemipareisis, aphasia, dsyphagia, diabetes and gastrostomy tube. She was alert and oriented and able to make her needs known. She had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. A review of the Minimum Data Set (MDS) assessment, dated 6/27/21, revealed she required extensive assistance of one person with bed mobility, transfers, bathing, dressing and toileting. She was not steady and only able to stabilize herself with staff assistance. She was totally dependent with eating related to her tube feeding. During an interview with Resident #78 on 10/18/21 at 11:30 a.m., she was asked if she got up out of bed. She said not often. She was asked the reason, and she replied, They don't get me up and I am hooked up to the tube feeding. She was asked if she was receiving therapy services, and she said no, but she wanted to have therapy so she could walk and eat again. Her roommate stated she could walk and they use to get her up. She didn't understand why they stopped. The roommate said she had been encouraging her everyday to get up. An interview was conducted with Unit Manager G on 10/18/21 at 1:30 p.m. She was asked how often Resident #78 got out of bed. She said they do ask her, but she didn't know how often she actually got up. She said she had only been in the position for a few weeks. Observations of Resident #78 on 10/19/21 at 10:30 a.m. and 3:45 p.m., found she was in bed. During an interview at 3:45 p.m., she was asked if she had been out of bed today, and she said no. When asked if the staff had offered to get her up, she said no. When asked if she had a wheelchair, she said there was one in the room, and it was not her roommate's; she could walk independently. An interview was conducted with Certified Nursing Assistant (CNA) F on 10/19/21 at 10:30 a.m. She was asked if Resident #78 got up out of bed, and she said she was fairly new and didn't know. CNA E stated she had seen Resident #78 up in a wheelchair but not for awhile. She said Resident #78 used to be able to walk to the nursing station with therapy, but that was when she came back in in June. An interview was conducted with the Occupational Therapist (OT) on 10/20/21 at 10:10 a.m. She was asked if Resident #78 was receiving therapy services. She said the facility could not provide therapy because she had no payor source. She was asked if she was receiving restorative nursing. The OT said the facility had no restorative program. An interview was conducted with the Rehabilitation Director (RD) on 10/20/21 at 10:20 a.m. She was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 14 of 15 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked if Resident #78 was receiving therapy. She said, No, she did have Occupational Therapy and Speech Therapy for one week from 7/29-8/5/21. She was asked if the resident was screened by Physical therapy (PT) or OT for the use of a wheelchair, and she said she would check and if not would have her screened by PT. The RD was asked if she was aware that when OT was asked if Resident #78 was receiving therapy, she stated the facility could not provide therapy because she had no payor source. She said if any resident needed therapy, even if there was no insurance, she went to the Administrator and got approval. She said there must have been some miscommunication with the staff, and she would conduct an in-service. She was asked if Resident #78 had been screened by Speech therapy (ST), as the resident was having issues with her tube feeding and was anxious to be able to eat again. The RD said she would have ST screen her today. During an interview with Resident #78 on 10/20/21 at 10:30 a.m., she was made aware that therapy had been consulted and that PT, OT and ST would be coming to evaluate her needs and obtain orders from the physician for therapy. She was very pleased and was hopeful that she could eat food again. A review of the physician's orders, dated 10/20/21, revealed PT was ordered three times a week for four weeks, OT was ordered three times a week for four weeks and ST was ordered six times a week for two weeks. An interview was conducted with the Speech Therapist on 10/21/21 at 3:20 p.m. She was asked if she had evaluated Resident #78. She said she saw her yesterday. She said she did a trial with pureed food and nectar thick liquid, and the resident did very well. She ordered a Modified Barium Swallow (MBS) to ensure there was no aspiration. She said she was a good candidate for an oral diet. She said the resident complained she had been having nausea lately with her tube feeding, and had asked for it to be turned off at times. She said an interdisplinary meeting (IDT) meeting was held today, and the nausea was brought up and an order was obtained for Zofran (nausea medication). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 15 of 15