Inspection·May 27, 2021

F 0558 could not reach it. Level of Harm - Minimal harm or potential for actual harm During a 05/27/2021 interview with Employee A, Certified Nursing Assistant (CNA), at 3:35 PM, she was shown the call light and was asked if the resident was able to reach it. She stated, Oh, I forgot to put it back. I just changed him. I just forgot to put it back. Resident #11 stated, See what I mean? They do it all the time. They come in and take it away from me. The CNA did not respond to the resident's statement. Residents Affected - Few A review of the facility's policy and procedure entitled Call Lights, revealed: Purpose: To use a light and/or sound system to alert staff to patient needs/requests. Procedure: 6. Always position call light conveniently for use and within reach. 8. Check call lights daily when providing care to ensure that cord length is appropriate and that light is in working order. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 2 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to provide services which met professional standards of quality for during medication administration. Residents Affected - Few Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The findings include: On 5/25/21 at 9:30 AM, an observation of medication administration was conducted for Resident #75 with Employee E, Licensed Practical Nurse (LPN). The nurse unlocked the medication cart and removed two Styrofoam cups from the top drawer. Resident #75's first name was written on one cup. Resident #76's first name was written on the second cup. Each cup contained medications. The nurse was unable to recall the contents of either cup when asked. The nurse was asked to dispose of the cups and prepare new medications for one resident at a time. The nurse noted that Resident #75 had an order to receive furosemide (a diuretic) 40 milligrams (mg) and explained that it was not available. She was asked about the facility's process for medications that were unavailable. She explained that the facility did have an emergency drug supply, but she wasn't sure whether the furosemide was available in the supply. She continued preparing medications and did not attempt to check the emergency drug kit for furosemide. On 5/25/21 at 9:35 AM, an observation of medication administration was conducted for Resident #67 with Employee E, LPN. The nurse unlocked the cart and removed a plastic 30 ml (milliliter) medication cup from the top drawer of the cart with Resident #67's last name written on it. The cup contained medications. The nurse was unable to recall the contents of the cup. The nurse was asked whether pre-pouring and storage of medications was an appropriate practice in the facility. She stated, I label everything. I don't see why it matters. The nurse was asked to dispose of the pre-poured medications and prepare new ones for administration to the resident. On 5/25/21 at 9:38 AM, an observation of medication administration was conducted for Resident #17 with Employee E, LPN. The nurse noted an order for the resident to receive an Eliquis (blood thinner) 5 mg tablet. She stated, This one has been on order for over two weeks. The nurse then noted an order for the resident to receive phenytoin sodium (Dilantin) 100 mg capsules for a diagnosis of seizure disorder. The nurse stated, This one has been on order from the pharmacy since 4/28/21. When asked whether she had been obtaining these medications from another source, she stated, No. I just can't give them if they aren't here. The nurse further explained that she hadn't notified the physician but stated she had called the pharmacy a couple of times to remind them. When asked whether the nurse was going to check the emergency drug supply for the medications she stated, I could, but it's way over there. referencing the other nursing unit in the building. On 5/26/21 at 12:51 PM, an interview was conducted with the Director of Nursing (DON) concerning the facility's medication administration practices. Regarding medications that were unavailable for administration, the DON explained that the nurse should notify the pharmacy to reorder the medications. Additionally, the nurse should notify the physician to obtain a hold order and check the facility's emergency drug kit. The DON explained that the facility had initiated an audit of medications on 5/25/21 and had determined there were quite a few medications not available for administration. The DON produced three handwritten pages of medications from the audit conducted on the 300/400 hall and acknowledged that there was definitely a problem. The DON was asked to contact Resident #17's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 3 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician and ensure he/she was aware that the resident had missed his medications for the prevention of seizures and blood clots. The DON returned and explained that a Dilantin level had been ordered, and that the medications were being sent from the pharmacy as soon as possible. The DON also confirmed that medications should not be pre-poured and stored in the medication cart for later administration. A review of Mosby's Guide to Nursing Skills and Procedures, Ninth Edition, p.365 (Accessed on 5/27/21 at 3:30 PM), directs nurses not to leave medications unattended to ensure the correct medications are prepared for the correct patient. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 4 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident/staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure that a resident with a pressure ulcer, received necessary care and services, consistent with professional standards of practice, to promote healing and prevent worsening of the pressure ulcer for one (Resident #75) of four residents reviewed for pressure ulcer development, from a total of 35 residents in the sample. The facility failed to reposition the resident to reduce the pressure on her coccyx/sacral area, and failed to provide the resident with a pressure-reducing mattress when the wound was discovered on 05/12/2021. This contributed to worsening of the pressure area from a Stage II to an unstageable wound. Residents Affected - Few The findings include: Resident #75 was observed on 05/24/2021 at 9:30 AM, 10:22 AM, 12:40 PM, 1:45 PM and 2:50 PM. Each time she was in her room, lying in bed on her back. She was on a standard mattress. Resident #75 was observed on 05/25/2021 at 10:05 AM lying in bed on her back. She was awake and alert. She was pleasant and moderately confused when asked to put on her call light. She did not know how to use it. She did not know what a call light was. After an explanation and demonstration, she continued to say she did not know how to use it. She stated she could not turn herself in the bed; she needed staff to help her. She could not confirm that staff were repositioning her. She was not aware that she had a wound on her coccyx/sacral area. She was lying on a standard mattress. Resident #75 was observed on 05/25/2021 at 12:20 PM, lying in bed on her back. She was on a standard mattress. On 05/25/2021 at 11:20 AM, an interview was conducted with the Unit Manager (UM)/Registered Nurse (RN) for the short-term rehabilitation side of facility. She stated she was also the wound care nurse for assessments. She rounded with the Advanced Registered Nurse Practitioner (ARNP) for wounds on Wednesdays and took photographs and measurements of each wound. She produced a photograph of the wound she took two weeks ago. No slough/eschar was observed. She stated it was a Stage II. She stated she had not seen it for two weeks, and she was going to look at it today. She had been informed by the floor nurses that it was healing. Resident #75 was observed on 05/25/2021 at 12:20 PM, lying in bed on her back. She was on a standard mattress. Resident #75 was observed on 05/26/2021 at 8:50 AM, seated in her wheelchair in the common area of the 200 hall. At 11:50 AM, she was observed sitting in her wheelchair in the same position in the common area of the 200 hall. Resident #75 was observed on 05/26/2021 at 1:35 PM, 2:45 PM and 4:37 PM. Each time, she was in her room lying in bed on her back. She was on a standard mattress. Her heels were resting directly on the mattress. Wound care was observed on 05/26/2021 at 12:10 PM. The wound depth could not be measured due to slough covering the wound bed. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 5 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0686 Level of Harm - Actual harm Residents Affected - Few During a telephone interview with the facility's wound care ARNP on 05/26/2021 at 12:37 PM, she stated the wound had been a Stage II, however, it was now a Stage III. The wound depth had increased. Although the margins are smaller, pressure has made it go deeper and it has progressed to a Stage III. During an interview with Employee B, Certified Nursing Assistant (CNA), on 05/26/2021 at 12:45 PM, she stated Resident #75 did not have an air mattress. She repositioned her every two hours and put a pillow between her legs. During an interview with the Unit Manager (UM) on 05/26/2021 at 2:22 PM, she stated there was no policy and procedure for repositioning. The expectation is every two hours. It is a nursing standard of practice. Resident #75 was observed on 05/27/2021 at 9:50 AM and at 12:05 PM. Each time, she was lying in bed on her back. She was on a standard mattress. Her heels were resting directly on the mattress. During an interview with Resident #75's Hospice nurse on 05/27/2021 at 1:40 PM, she stated she was not aware that the resident had a pressure ulcer. When she was informed that the resident's wound was first identified on 05/12/2021, she stated she was not aware that new orders had been written for wound care and an air mattress. Hospice CNAs were bathing Resident #75, but they had not informed her of the wound. She stated the Hospice Provider could get the resident an air mattress. Resident #75 was observed on 05/27/2021 at 3:40 PM, lying in bed on her back with a pillow between her knees. She was lying on a standard mattress, and this was the first observation of a pillow being used between her knees. Her heels were resting on the mattress. Resident #75 was observed on 05/27/2021 at 4:05 PM, lying in bed on her back. She was on a standard mattress. Her heels were resting on the mattress. During an interview with the Administrator and the Unit Manager (UM) on 05/26/2021 at 2:45 PM, the UM stated the facility did not have a policy instructing staff to reposition a resident every two hours. The Administrator stated the understanding for the CNAs was that they reposition the resident as needed. Neither the Administrator nor the UM could explain what that meant for Resident #75 whose pressure ulcer had worsened. The Administrator was asked to clarify what as needed meant, however no explanation was provided. A review of Resident #75's clinical record revealed she was admitted on [DATE]. Her diagnoses included cerebral infarction unspecified, hemiplegia and hemiparesis (weakness, paralysis on one side) following cerebral infarction affecting the left, non-dominant side, contracture of left hand, pressure ulcer of the sacral region - unspecified stage, muscle wasting and atrophy, dysphagia following cerebral infarction, facial weakness, hypertension, repeat falls, dysarthria and anarthria, sarcopenia, hyperlipidemia, and dementia without behavioral disturbances. (Copy obtained) A review of the Minimum Data Set (MDS) assessment, dated 05/08/2021, revealed the resident was assessed as requiring extensive physical assistance of one-person for bed mobility, transfers, dressing, eating, grooming and toileting. She was totally dependent on the physical assistance of one person for bathing. Her Brief Interview for Mental Status (BIMS) score was documented as a 99, indicating that the resident was unable to answer four or more questions, or she gave a nonsensical response. Per the MDS assessment, a subsequent interview with facility staff about the resident's cognition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 6 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0686 indicated she had both short- and long-term memory impairment, and daily decision-making was moderately impaired - decisions poor; cues/supervision required. (Copy obtained) Level of Harm - Actual harm A review of the care plan dated 05/20/2021 revealed: Residents Affected - Few Pressure ulcer to sacrum. Goal: Will heal within the limits of the disease process. Interventions: Administer treatment per physician's orders, follow up care with physician as ordered, report evidence of infection such as purulent drainage, swelling , localized heat, increased pain, etc. Notify physician as needed. A review of the care plan dated 05/03/2021 revealed: Hospice/Palliative care need due to terminal illness-hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Goal: Will be comfortable. Interventions: Assist to reposition, report skin breakdown. A review of the care plan dated 05/01/2021 revealed: At risk for alteration in skin integrity related to left-sided weakness, impaired mobility. Goal: Decrease/minimize skin breakdown risks. Interventions: Observe skin condition with ADL care daily; report abnormalities, provide preventative skin care routinely and as needed. A review of a physician's order with a wound care start date of 05/13/2021read: Wound care: sacrum open area: Cleanse with normal saline, apply calcium alginate and cover with dry dressing. Every day shift and as needed. A physician's order for wound care with a start date of 05/26/2021 read: Coccyx: start honey sheet with dressing every other day and as needed. Air mattress/turn per facility policy/float heels. Registered Dietician consult for pressure ulcer. (Photographic evidence obtained) A review of the Skin and Wound Evaluation, dated 05/12/2021, revealed: Pressure ulcer. In-house acquired. New. Stage 2. 100% granulation of wound bed. No slough. (Copy obtained) A review of the Skin and Wound Evaluation, dated 05/26/2021, revealed: Presents today with stage 3 pressure ulcer to the coccyx. Wound edge macerated and viable. 15a Stage: 7. Unstageable: obscured full-thickness skin and tissue loss due to slough. In-house acquired. Length: 0.8 cm, width: 0.5 cm., depth was not applicable. 20% granulation of wound bed. Slough 80% of wound bed. (Copy obtained) A review of the ARNP's progress note, dated 05/26/2021 at 5:02 PM, revealed: Addendum Note. This is an unstageable pressure ulcer to the coccyx, not a Stage 3. (Photographic evidence obtained) A review of the May 2021 CNA repositioning documentation in the electronic medical record, revealed the staff documented they repositioned the resident on the following dates and times: 05/01/2021 Documented 22:59 05/02/2021 Documented 00:24 , 10:04, 17:44 05/03/2021 Documented 00:30, 10:57 and 16:15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 7 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0686 05/04/2021 Documented 04:44 and 08:48 Level of Harm - Actual harm 05/05/2021 Documented 01:10 and 11:32 Residents Affected - Few 05/06/2021 Documented 01:03, 09:45, 17:33 and 23:48 05/07/2021 Documented 10:47 and 16:14 05/08/2021 Documented 02:38, 11:30, 19:06 and 22:21 05/09/2021 Documented 01:50, 12:56, 16:59 05/10/2021 Documented 00:02 and 13:46 05/11/2021 Documented 00:07, 11:00 and 19:37 05/12/2021 Documented 00:31, 11:51, 18:34 05/13/2021 Documented 23:36, 11:43 05/14/2021 Documented 01:19, 10:20, 17:15 05/15/2021 Documented 00:16, 17:36 05/16/2021 Documented 00:59, 16:27 05/17/2021 Documented 01:36, 11:09 05/18/2021 Documented 01:20 and 11:08 05/19/2021 Documented 01:10, 14:59 and 16:49 05/20/2021 Documented 00:26 and 18:38 05/21/2021 Documented 01:54, 12:27 and 16:17 05/22/2021 Documented 01:45, 09:16, 16:31 and 22:50 05/23/2021 Documented 02:11, 09:44, 18:23 05/24/2021 Documented 22:57 05/25/2021 Documented 00:21, 12:17, 18:34 and 23:38 (Copy obtained) A review of the facility's policy and procedure entitled Skin Practice Guide revealed: The purpose of the guide is to describe the process/steps for identification of patients at risk for the development of pressure ulcers, identify prevention techniques and interventions to assist with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 8 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0686 Level of Harm - Actual harm Residents Affected - Few management of pressure ulcers and skin alterations. There are additional contributing factors which impact an individual's risk for development of and healing potential of any skin alteration including pressure resulting from immobility. Prevention Interventions: Reposition frequently in bed and chair. Select appropriate support surfaces. Pressure points: Identification of risk factors and potential pressure points for a particular patient is important in developing a skin prevention care plan. Pressure points are areas of risk for skin breakdown. Patient position can assist with reducing the risk for breakdown. Supine Position: Dorsal thoracic area and sacrum. Wheelchair position: Sacrum. Pressure ulcer prevention pathway. Care plan for actual skin problems. Mobility, activity, or sensory perception. Bed support surface: turn/reposition schedule, pressure redistribution-bed/chair. Daily body audits. Phase 3: Implement. Skin Evaluations: Patients at risk for skin breakdown have a head-to-toe skin evaluation weekly by a licensed nurse. Patients with pressure ulcers have a head-to-toe skin evaluation completed daily by the licensed nurse to identify additional skin changes. Positioning, mobility, restraints: Body positioning provides for pressure redistribution and can decrease pressure, friction, and shear. The use of support surfaces and positioning devices can provide for additional pressure redistribution. Examples of possible interventions include: minimize direct pressure over vulnerable areas and actual pressure ulcers. Reposition frequently; use friction reducing devices for assistance. (Copy obtained) Reference: Support surfaces are an important element in pressure injury prevention and treatment because they can prevent damaging tissue deformation and provide an environment that enhances perfusion of at risk or injured tissue. Support surfaces alone neither prevent nor heal pressure injuries, but support surfaces play a significant role in an individualized comprehensive management plan for pressure injury prevention and treatment. Pressure injury risk factors vary from person to person. Choosing a support surface for an individual should take into account their specific needs. Individuals should not lie on a pressure injury. Implementation Considerations: Continue to reposition individuals placed on a pressure redistribution support surface. Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure of the body surface can result in sustained deformation of soft tissues and ultimately, tissue damage. Prevention and Treatment of Pressure Ulcer/Injuries: Clinical Practice Guideline. The International Guideline 2019. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. [NAME] Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 9 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and resident/staff interviews, the facility failed to ensure one (Resident #75) of one resident sampled for mobility, from a total of 35 sampled residents, received appropriate treatment and services to prevent further worsening of a left hand contracture. The findings include: A review of Resident #75's clinical record revealed she was admitted on [DATE]. Her diagnoses included cerebral infarction unspecified, hemiplegia and hemiparesis (weakness, paralysis on one side) following cerebral infarction affecting the left, non-dominant side, contracture of left hand, pressure ulcer of the sacral region - unspecified stage, muscle wasting and atrophy, dysphagia following cerebral infarction, facial weakness, hypertension, repeat falls, dysarthria and anarthria, sarcopenia, hyperlipidemia, and dementia without behavioral disturbances. (Copy obtained) A review of the Minimum Data Set (MDS) assessment, dated 05/08/2021, revealed the resident was assessed as requiring extensive physical assistance of one-person for bed mobility, transfers, dressing, eating, grooming, and toileting. She was totally dependent on the physical assistance of one person for bathing. Her Brief Interview for Mental Status (BIMS) score was documented as a 99, indicating that the resident was unable to answer 4 or more questions, or she gave a nonsensical response. Per the MDS assessment, a subsequent interview with facility staff about the resident's cognition indicated she had both short- and long-term memory impairment, and daily decision-making was moderately impaired - decisions poor; cues/supervision required. Functional limitation in range of motion, to include the hand and wrist was marked as no impairment. (Copy obtained) A review of the care plan dated 05/01/2021 revealed: At risk for alteration in skin integrity relate to left sided weakness, impaired mobility. Goal: Decrease/minimize skin breakdown risks. Interventions: Observe skin condition with ADL care daily, report abnormalities, provide preventative skin care routinely and as needed. A review of the care plan dated 05/03/2021 revealed: Hospice/Palliative care needed due to terminal illness-hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Goal: Will be comfortable. Interventions: Assist to reposition, report skin breakdown. No focus areas or interventions specific to the resident's left hand contracture were located in the care plans. (Copies obtained) Resident #75 was observed on 05/24/2021 at 9:30 AM lying in bed. Her eyes were closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/24/2021 at 10:22 AM lying in bed. Her eyes were closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/24/2021 at 12:40 PM lying in bed. Her left hand appeared to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 10 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0688 contracted, and no splinting device was being used. Level of Harm - Minimal harm or potential for actual harm Resident #75 was observed on 05/24/2021 at 1:45 PM lying in bed. Her left hand appeared to be contracted, and no splinting device was being used. Residents Affected - Few Resident #75 was observed on 05/24/2021 at 2:50 PM lying in bed. Her eyes were closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/25/2021 at 10:05 AM lying in bed. She was awake and alert. She was pleasant and expressed gratitude for being checked on. She was moderately confused when asked to put on her call light. She did not know how to use her call light. She did not know what a call light was. After explanation and demonstration, she continued to say she did not know how to use it. She stated she could not turn herself in the bed; she needed the staff to help her. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/25/2021 at 12:20 PM, lying in bed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 11:50 AM, seated in her wheelchair in the common area of the 200 hallway. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 1:35 PM, lying in bed with her eyes closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 2:45 PM, lying in bed with her eyes open. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 4:37 PM, lying in bed with her eyes open. Her left hand appeared to be contracted, and no splinting device was being used. During an interview with Employee B, Certified Nursing Assistant (CNA), on 05/26/2021 at 12:45 PM, she confirmed that Resident #75 had no splinting device for her left hand. Resident #75 was observed on 05/27/2021 at 9:50 AM, lying in bed on her back. No splinting device was being used on her left hand. Resident #75 was observed on 05/27/2021 at 12:05 PM, lying in bed. No splinting device was being used on her left hand. During an interview with the MDS (Minimum Data Set) Coordinator on 05/26/2021 at 12:55 PM, she stated she was not aware that the MDS was coded inaccurately for Resident #75 regarding the impairment/contracture of her left upper extremity. During an interview with the MDS Coordinator on 05/27/2021 at 3:30 PM, she stated she had filed an amended assessment to correct the section that indicated no impairment in Resident #75's upper extremities. She stated the resident did have a contracture of the left hand. She did not think there was any splinting device being used, however. On 05/27/2021 at 10:00 AM, an interview was conducted with Employee N, Speech Therapist. She was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 11 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked whether Resident #75's left hand had been assessed for contracture and a splinting device. She stated she would check the resident's record. At 10:20 AM the same morning, Employee N stated there had been no assessment/evaluation/screening conducted of the resident's left hand for contracture or the need for a splinting device. On 05/27/2021 at 3:17 PM, Employee N stated the therapy department had now conducted an assessment of the resident's left hand, and they were going to recommend the use of a rolled washcloth and range of motion (ROM) exercises. Resident #75 was observed on 05/27/2021 at 3:40 PM, lying in bed. Her eyes were closed. No splinting device was being used on her left hand. Resident #75 was observed on 05/27/2021 at 4:05 PM, lying in bed with her eyes closed. No splinting device was being used on her left hand. A review of the physician's orders revealed an order dated 05/28/2021 instructing the following: OT eval for right splint placement to decrease possible skin breakdown (End date 05/29/2021) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 12 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 reviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (Resident #20) of one resident reviewed for accidents, from a total of 35 residents in the sample. The findings include: A review of Resident #20's medical record revealed he was admitted to the facility on [DATE] with a primary diagnosis of Parkinson's disease. His secondary diagnoses included anemia and arthritis. Resident #20 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating he was cognitively intact. He required extensive assistance from staff with activities of daily living (ADLs), including toileting. On 5/24/21 at 11:22 AM, Resident #20 was observed sitting up on the side of his bed. A large, crusted laceration was observed on the right side of his forehead. Resident #20 was yelling out repeatedly, Bathroom! The resident's room lights were off, and the window blinds were closed. He was asked whether he needed assistance to the restroom and he replied, yes. His call light was observed lying on the floor between his bedside table and the bed. Staff were immediately notified of the resident's request for assistance. Further review of Resident #20's medical record revealed he had sustained falls on 3/4/21, 4/13/21, 4/23/21, 4/28/21 and 5/17/21. Following the falls on 3/4/21 and 5/17/21, psychiatric consults were requested. A psychiatric evaluation dated 3/10/21, indicated the resident was complaining of poor sleep at night. It was recommended that a bedside commode be placed near the resident's bed. A second psychiatric evaluation dated 5/19/21, recommended to open the blinds in the room and have the resident sit by natural light to promote circadian rhythm. This evaluation further recommended staff to be sure the resident's room was bright during the day and to limit daytime sleeping. A review of the resident's comprehensive care plans revealed a focus area for falls. An intervention dated 4/28/21 directed staff to provide the resident with a bedside commode. (Photographic Evidence Obtained) On 5/24/21 at 12:00 PM, an interview was attempted with Resident #20. He was lying in his bed with his eyes closed. The room lights were off, the window blinds were closed, and no bedside commode was noted in the room. On 05/25/21 at 3:26 PM, an interview was attempted with Resident #20. He was lying in his bed with his eyes closed. The room lights were off, the window blinds were closed, and no bedside commode was noted in the room. On 5/27/21 at 3:54 PM, Resident #20 was observed lying in bed. He was awake and attempting to make a call using his telephone. The room was dark, the blinds were closed, and no bedside commode was noted in the room. The resident was asked whether he was able to see his phone well enough to dial a number. He replied, No I can't. The resident was then asked whether he would like the lights to turned on and/or the window blinds opened. He replied, Yes, that would be great! The resident's room lights were turned on and the window blinds were opened. The resident was then asked whether he used a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 13 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 bedside commode. He stated he was unsure. Level of Harm - Minimal harm or potential for actual harm On 05/27/21 at 4:02 PM, an interview was conducted with the resident's assigned nurse. She explained that she was familiar with the resident and his fall history. She further explained that the resident did have a bedside commode in his room at one time, and that she was not sure what happened to it. She explained that the resident did use it and it had been missing for about two weeks. Regarding the lighting in the room, the nurse wasn't aware of any reason why the lights wouldn't be on, or the window blinds wouldn't be open. Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 14 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record reviews, the facility failed to provide routine drugs for two (Resident #17 and Resident #75) of seven residents reviewed for compliance with medication administration, from a total of 35 residents in the sample. The findings include: On 5/25/21 at 9:30 AM, an observation of medication administration was conducted for Resident #75 with Employee E, Licensed Practical Nurse (LPN). The nurse noted that the resident had an order to receive furosemide (a diuretic) 40 milligrams (mg) and explained that it was not available. The nurse was asked about the facility's process when medications were unavailable. She explained that the facility did have an emergency drug supply, but that she wasn't sure if the furosemide was available in the supply. She then continued preparing medications. On 5/25/21 at 9:38 AM, an observation of medication administration was conducted for Resident #17 with Employee E, LPN. The nurse noted an order for the resident to receive an Eliquis (blood thinner) 5.0 mg tablet. She stated, This one has been on order for over two weeks. The nurse then noted an order for the resident to receive phenytoin sodium 100 mg capsules for a diagnosis of seizure disorder. The nurse stated, This one has been on order from the pharmacy since 4/28/21. When asked whether she had been obtaining these medications from another source, the nurse replied, No. I just can't give them if they aren't here. The nurse further explained that she hadn't notified the physician, but stated she had called the pharmacy a couple of times to remind them since 4/28/21. When asked whether the nurse was going to check the emergency drug supply for the medications she stated, I could but it's way over there. referencing the facility's other unit. The facility's policy titled, Medication Shortages/Unavailable Drugs was reviewed. The policy was last revised in 8/2018. The policy indicated that if a medication shortage was discovered, a licensed nurse should contact the pharmacy and determine the status of the order. Then, if the next available delivery caused the resident to miss a dose, the facility should obtain the medication from the emergency medical supply to administer the dose. A list of the emergency drug supply contents was requested. The printed contents indicated that the facility had a total of 12 phenytoin sodium 100 mg capsules on hand and a total of 8 Eliquis 2.5 mg tablets on hand. On 5/26/21 at 12:51 PM, an interview was conducted with the Director of Nursing (DON) regarding the facility's medication administration practices. Regarding medications that were unavailable for administration, the DON explained that the nurse should notify the pharmacy to reorder the medication. Additionally, the nurse should notify the physician to obtain a hold order and check the facility's emergency drug kit (Omnicell). The DON explained that the facility had initiated an audit of medications on 5/25/21 and had determined there were quite a few medications not available for administration. The DON produced three handwritten pages of medications from the audit conducted on the 300/400 hall and acknowledged that there was definitely a problem. She also explained that she wasn't sure all staff knew how to reorder medications, and she planned to conduct education. The DON was asked to contact the physician for Resident #17 and ensure the physician was aware that the resident had missed his medications for the prevention of seizures and blood clots. The DON returned and explained that a dilantin level had been ordered and that the medications were being sent from the pharmacy as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 15 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 soon as possible. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 16 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record reviews and interview, the facility failed to monitor targeted behaviors for residents who were receiving psychotropic medications, and/or failed to monitor for drug-related side effects for four (Residents #25, #72, #330 and #381) of five residents reviewed for the use of psychotropic medications, from a total of 35 residents in the sample. The findings include: 1. A review of Resident #25's medical record revealed an admission date of 3/12/21. Her primary medical diagnosis was quadriplegia. Her cognition was intact, and she required total assistance from staff with activities of daily living (ADLs). A review of Resident #25's physician's orders revealed: An order dated 3/13/21 for bupropion (an antidepressant) 100 mg (milligrams) via g-tube (feeding tube) two times daily for depression. Monitoring of potential side effects related to the use of bupropion did not commence until 5/24/21. A second order, dated 3/13/21, for trazodone (an antidepressant) 50 mg via g-tube at bedtime for depression. Monitoring of potential side effects related to the use of trazodone did not commence until 5/24/21. 2. A review of Resident #72's medical record revealed an admission date of 4/30/21. Her primary medical diagnosis was an open wound of the right leg. Her cognition was intact, and she required limited assistance with ADLs. A review of Resident #72's physician's orders revealed: An order for mirtazapine (an antidepressant) 15 mg by mouth at bedtime for depression, dated 5/1/21. An order dated 5/24/21 directed staff to monitor for side effects related to the use of mirtazapine. There was no evidence of monitoring for targeted behaviors related to the medication. An order for sertraline (an antidepressant) 100 mg by mouth once a day for depression, dated 5/1/21. An order dated 5/24/21, directed staff to monitor for side effects related to the use of sertraline. There was no evidence of monitoring for targeted behaviors related to the medication. An order for clonazepam (an anti-anxiety agent) 1.0 mg by mouth two times daily for anxiety, dated 5/5/21. An order dated 5/24/21 directed staff to monitor for side effects related to the use of clonazepam. There was no evidence of monitoring for targeted behaviors related to the medication. 3. A review of Resident #330's medical record revealed an admission date of 5/18/21. Her cognition was intact, and she required limited to extensive assistance with ADLs. A review of Resident #330's physician's orders revealed: An order dated 5/19/21 for bupropion 150 mg, give one tablet by mouth two times daily for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 17 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0758 depression. Monitoring of side effects for this medication did not commence until 5/24/21. Level of Harm - Minimal harm or potential for actual harm 4. A review of Resident #381's medical record revealed an admission date of 5/12/21. His diagnoses included dementia in other diseases classified elsewhere without behavioral disturbance, gastroesophageal reflux disease (GERD), and major depressive disorder. Residents Affected - Some A review of Resident #381's physician's orders revealed: Mirtazapine tablet (an antidepressant) 15 mg, 1 tablet by mouth at bedtime, start date 5/12/21. Buspirone HCL (hydrochloride) tablet 5 mg, 1 tablet by mouth every 8 hours for anxiety/depression, start date 5/19/21. The order to monitor for side effects related to use of psychotropic medications (Mirtazapine) every shift for side effects of psychotropic medications, had a start date of 5/24/21. The order to monitor for side effects related to use of psychotropic medications (Buspirone) every shift for side effects of psychotropic medications, had a start date of 5/24/21. (Photographic evidence obtained) A review of Resident # 381's May 2021 Medication Administration Record (MAR) revealed the facility had no documentation in place to monitor for side effects related to use of Mirtazapine and Buspirone (psychotropic medications) from 5/12/21 through 5/23/21. An interview was conducted with the Director of Nursing (DON) on 5/27/21 at 4:29 PM. After reviewing Resident #381's May 2021 MAR, the DON confirmed that monitoring for side effects related to use of psychotropic medications did not start until 5/24/2021. She also acknowledged that the facility should have started monitoring for side effect the same day the resident received his psychotropic medications. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 18 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure medication error rates were not five percent or greater. There were 44 opportunities for error with a total of three errors, resulting in a medication error rate of 6.81% and involving two (Residents #75 and #17) of seven residents observed during medication administration. Residents Affected - Few The findings include: On 5/25/21 at 9:30 AM, an observation of medication administration was conducted for Resident #75 with Employee E, Licensed Practical Nurse (LPN). The nurse noted that the resident had an order to receive furosemide (a diuretic) 40 milligrams (mg) and explained that it was not available. The nurse was asked about the facility's process for medications that were unavailable. She explained that the facility did have an emergency drug supply, but she wasn't sure whether the furosemide was available in the supply. She continued preparing medications and did not attempt to obtain furosemide for the resident. On 5/25/21 at 9:38 AM, an observation of medication administration was conducted for Resident #17 with Employee E, LPN. The nurse noted an order for the resident to receive an Eliquis 5 mg tablet. She stated, This one has been on order for over two weeks. The nurse then noted an order for the resident to receive phenytoin sodium 100 mg capsules for a diagnosis of seizure disorder. The nurse stated, This one has been on order from the pharmacy since 4/28/21. When asked whether she had been obtaining these medications from another source, she stated, No. I just can't give them if they aren't here. The nurse further explained that she hadn't notified the physician but stated she had called the pharmacy a couple of times to remind them. When asked whether the nurse was going to check the emergency drug supply for the medications she stated, I could, but it's way over there. referencing the other nursing unit in the building. She made no attempt to obtain either medication from the emergency drug supply. On 5/26/21 at 12:51 PM an interview was conducted with the Director of Nursing (DON) regarding the facility's medication administration practices. Regarding medications that were unavailable for administration, the DON explained that the nurse should notify the pharmacy to reorder the medication. Additionally, the nurse should notify the physician to obtain a hold order and check the facility's emergency drug kit. The DON explained that the facility had initiated an audit of medications on 5/25/21 and had determined there were quite a few medications not available for administration. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 19 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for one (Resident #17) of seven residents reviewed for medication administration, from a total of 35 residents in the sample. Residents Affected - Few The findings include: A review of Resident #17's medical record revealed he was admitted to the facility on [DATE]. His primary medical diagnosis was heart failure. His secondary diagnoses included epilepsy, atrial fibrillation, and a history of venous thrombosis. His cognition was intact and he required extensive assistance from staff with activities of daily living (ADLs). On 5/25/21 at 9:38 AM, an observation of medication administration was conducted for Resident #17 with Employee E, Licensed Practical Nurse (LPN). The nurse noted an order for the resident to receive an Eliquis (blood thinner) 5.0 mg (milligram) tablet. She stated, This one has been on order for over two weeks. She then noted an order for the resident to receive phenytoin sodium (Dilantin) 100 mg capsules for a diagnosis of seizure disorder. The nurse stated, This one has been on order from the pharmacy since 4/28/21. When asked whether she had been obtaining these medications from another source, she replied, No. I just can't give them if they aren't here. The nurse further explained that she hadn't notified the physician, but stated she had called the pharmacy a couple of times to remind them. When asked whether the nurse was going to check the emergency drug supply for the medications, she stated, I could, but it's way over there. referencing the other nursing unit in the building. A review of the resident's physician's orders revealed an order for Eliquis 5.0 mg to be given by mouth twice daily for a diagnosis of atrial fibrillation. A second order was noted for phenytoin sodium (Dilantin) 100 mg to be given by mouth twice daily for seizures. A review of the resident's 3/17/21 Dilantin level indicated it was 8.9. It was out of range (low) with a reference range of 10.0 to 20.0. (Photographic evidence obtained) On 5/26/21 at 12:51 PM, an interview was conducted with the Director of Nursing (DON) regarding the facility's medication administration practices. For medications that were unavailable for administration, the DON explained that the nurse should notify the pharmacy to reorder the medication. Additionally, the nurse should notify the physician to obtain a hold order and check the facility's emergency drug kit. The DON explained that the facility had initiated an audit of medications on 5/25/21 and had determined there were quite a few medications not available for administration. The DON produced three handwritten pages of medications from the audit conducted on the 300/400 hall and acknowledged that there was definitely a problem. She also explained that she wasn't sure that all staff knew how to reorder medications and that she planned to conduct education. The DON was asked to contact Resident #17's physician to ensure he/she was aware that the resident had missed his medications for the prevention of seizures and blood clots. The DON returned a few minutes later and explained that a Dilantin level had been ordered, and the medications were being sent from the pharmacy as soon as possible. The Dilantin level ordered on 5/26/21 for Resident #17 was produced by the DON on 5/27/21 at 3:00 PM. The result was 8.2. It was out of range with a reference range of 10.0 to 20.0 and was lower than (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 20 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0760 the level drawn on 3/17/21. Level of Harm - Minimal harm or potential for actual harm According to Mayo Clinic Laboratories at https://www.mayocliniclabs.com (accessed on 6/15/21 at 2:20 PM): Residents Affected - Few The phenytoin dose should be adjusted to achieve steady-state concentrations of total phenytoin between 10.0 and 20.0 mcg/mL. Phenytoin exhibits zero-order pharmacokinetics; the rate of clearance of the drug is dependent upon the concentration of drug present. Therefore, phenytoin does not have a classical half-life like other drugs, since it varies with blood concentration. At a blood concentration of 15 mcg/mL, approximately half the drug in the patient's body will be eliminated in 20 hours. As the blood concentration drops, the rate at which phenytoin is excreted increases. According to Lab Tests Online at https://labtestsonline.org (accessed on 6/15/21 at 2:28 PM): Some people will experience seizures at the low end of the therapeutic range and some people will experience excessive side effects at the upper end. People should work closely with their healthcare practitioner to find the dosage and concentration that works the best for them. The facility's policy titled, Medication Shortages/Unavailable Drugs was reviewed. The policy was last revised on 8/2018 and indicated that if a medication shortage was discovered, a licensed nurse should contact the pharmacy and determine the status of the order. Then, if the next available delivery caused the resident to miss a dose, the facility should obtain the medication from the emergency medical supply to administer the dose. A list of the emergency drug supply contents was requested. The printed contents indicated that the facility had a total of 12 phenytoin sodium (Dilantin) 100 mg capsules on hand and a total of 8 Eliquis 2.5 mg tablets on hand. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 21 of 22 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations and interviews, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for three (Residents #75, #76 and #67) of seven residents observed during medication administration. The facility staff pre-poured medications and stored them in a medication cart with only the residents' first names written on the medication cups. The findings include: On 5/25/21 at 9:30 AM, an observation of medication administration was conducted for Resident #75 with Employee E, Licensed Practical Nurse (LPN). The nurse unlocked the medication cart and removed two Styrofoam cups from the top drawer. Resident #75's first name was written on one cup. Resident #76's first name was written on the second cup. Each cup contained medications. The nurse was unable to recall the contents of either cup when asked. The nurse was asked to dispose of the cups and prepare new medications for one resident at a time. On 5/25/21 at 9:35 AM, an observation of medication administration was conducted for Resident #67 with Employee E, LPN. The nurse unlocked the cart and removed a plastic 30 ml (milliliter) medication cup from the top drawer of the cart with Resident #67's last name written on it. The cup contained medications. The nurse was unable to recall the contents of the cup. The nurse was asked whether pre-pouring and storage of medications was an appropriate practice in the facility. She stated, I label everything. I don't see why it matters. The nurse was asked to dispose of the pre-poured medications and prepare new ones for administration to the resident. During an interview with the DON on 5/26/21 at 12:51 PM, she confirmed that pre-pouring medications and storing them in the cart for later administration was an unacceptable facility practice. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 22 of 22