Inspection·January 6, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no communication board/device for the resident in her room, and that the resident pointed to the things she wanted. She used the example that if the resident had pain, she would point to where she had the pain. She did not know the word for pain in the language of French Creole. She confirmed that she did not know the resident well enough to determine if she understood English. During an interview with LPN/Unit Manager (UM) P of the COVID-19 unit on 01/04/2023 at 5:25 PM, she stated she did not know the translator service telephone number, but she would get it. She walked down the hall to the Director of Nursing's (DON's) office. She returned a few minutes later with the DON, who provided a piece of 8 x 11.5 inch paper with the contracted translator services name and telephone number printed on it. It was handed back to her, and she was asked to make sure LPN N had the information in case of an emergency. She agreed. The Regional Nurse Consultant (RNC) then took the paper and made several copies. She began to provide an in-service for the staff present, and she gave a copy to the UM. The DON stated she would post the information on the wall in the resident's room, then took the paper to LPN N. During an interview with LPN Q on 01/05/2023 at 9:18 AM, he confirmed that he was assigned to Resident #41 and had already passed her medications to her. He was familiar with some of the residents because they came to this unit from the long-term care unit on the other side of the building. He had only worked on this newly established COVID-19 unit today. He knew of the translation service phone number and pointed to it on the wall. He stated he had never used it. He was Spanish-speaking himself. He did not know how to speak French Creole, but he did not think he would need to use the translation line to speak with Resident #41. He stated that Spanish and French are similar and, for example, the word for pain was very similar. He did not have the translation telephone line on the medication cart. He stated he had administered the resident's medications already this morning with no problem. He confirmed that there were no communication devices in her room. He then moved the cart down the hallway away from the nurses' station. The RNC walked down the hall, handed LPN Q the phone number for the translation line, and told him to keep it on the cart and use it when he needed to obtain information from the resident. On 01/05/2023 at 11:23AM, an interview was attempted with Resident #41. She was lying in her bed on her right side. Her eyes were closed, and she appeared to be asleep. She did not wake up or respond when her name was called. An attempt was made to reach the translation service provider via telephone using the number posted in the resident's room. The automated system asked for a location number that was not on the signage posted in the resident's room. An identification number was on the form along with a Branch number. A representative came on the line after several attempts to input the information on the form. The representative requested the location number. After giving the information on the form to the representative, the line was disconnected by the service provider. During an interview with the Assistant Director of Nursing (ADON) on 01/05/23 at 11:40 AM, she was asked for the location number for the translation services. The sign with the telephone number was no longer posted at the nurses' station. She went to her office and stated she had taken the sign down from the nurses' station to make copies. She did not know that the location number was not on the form, only the Branch number. She went to find the DON. The DON arrived on the unit, and when asked for the location number, she went to Social Services Director's (SSD's) office and asked the SSD if she knew the location number for the translation service. The SSD pointed to the sign for the contracted translation service posted on her bulletin board. The Branch number was crossed off and a different number had been handwritten on it. She stated that number was the correct number. The DON took the information and stated she would verify whether the information was correct, then make a new sign for the staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 2 of 21 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 01/06/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the RNC and Registered Nurse (RN) S on 01/05/23 at 12:00 PM, the RNC stated she did not know why the translation line was not working, but they were working on it. She had placed communication forms in the resident's room this morning. During an interview with the Administrator on 01/05/23 at 12:28 PM, she stated the facility had contracted with the translation services provider in September 2022 when the facility was purchased. She had called the new translation services provider number today and could not get through. She was not sure why, and stated the company was located in another country and may not be available right now. She stated, They may be asleep. She stated she did not know how long it had been that the translation services provider number did not work. She stated she was going to conduct an in-service for the staff to use an internet application in the meantime until they could get the service provider to fix the problem. She produced emails to show her attempts. (Copies obtained) At 12:51 PM, the Administrator produced copies of all correspondence with the translation service provider, and stated she set up a temporary work around with the other service provider available on the internet. She had tried it, knew it worked, and they would have the staff use it, if necessary, until they could get the contracted provider to fix the problem. She confirmed that there were no other residents in the building that spoke French Creole, and she was not sure, but thought there might be a couple who spoke Spanish. She stated they would post the temporary provider information for the staff at the nurses' station and in Resident #41's room. During an interview with the RNC on 01/05/2023 at 4:39 PM, she produced documentation to indicate the telephone number for the translation service was now operational. She stated the problem had been fixed. A new sign with the correct information was posted on the wall of the nurses' station. During an interview with LPN T on 01/06/2023 at 12:43 PM, he stated he was assigned to Resident #41, and that today was his first day working the COVID-19 hallway. He had just started working at this facility and was unfamiliar with Resident #41. He did not know she only spoke French Creole. He administered her medications today. He stated he did not think he would need to have a translator, and if he needed information, he would call the family. Resident #41 was observed on 01/06/2023 at 2:10 PM. She was lying in bed looking at her television. An attempt was made to interview the resident using the new translation telephone line obtained from the sign at the nurses' station. Resident #41 made good eye contact but would not respond to the interpreter or this surveyor. The telephone number for the translation line was not posted in the resident's room. (Photographic evidence obtained) During an interview with the DON on 01/06/2023 at 2:20 PM, she was informed that the new telephone number for the translation/interpreter line was not posted in the resident's room. She appeared surprised and said Oh no, I'll fix that. It probably didn't get replaced because it has changed so much recently. A review of the clinical record for Resident #41 revealed that on the Minimum Data Set (MDS) assessment, dated 12/16/2022, the resident was initially admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to thrombosis of the right, middle cerebral artery, pain, and hemiparesis following cerebral infarction affecting left non-dominant side. Her hearing was documented as adequate, and her vision was moderately impaired. She was sometimes understood, and sometimes understood others. She did not exhibit inattention, disorganized thinking, or an altered level of consciousness. A Brief Interview for Mental Status (BIMS) score could not be determined. She was rarely/never understood. She required extensive assistance of one to two persons for her Activities of Daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 3 of 21 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 01/06/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Living (ADLs), and she was totally dependent for transfers and bathing. She did not walk during the assessment period. The section for preferred language was left blank. She was assessed as not needing or wanting an interpreter to communicate with a doctor or health care staff. The assessment was documented as having been completed with the assistance of the resident's family. (Copy obtained) A review of the January 2023 Physician's Order Sheets for Resident #41 revealed no orders for the use of a communication device or translation service. (Copy obtained). A review of the current, electronic Care Plan on 01/04/2023, revealed no care plan for the use of a communication device. The phone numbers for the translation service were not the same as the numbers posted at the nurses' station during this survey. The Focus read: [Resident #41] has difficulty communicating related to a decline in cognitive status, language barrier, as patient only speaks Creole. Patient can sometimes understand others and can sometimes make self-understood with Creole-speaking translator. Initiated on 06/03/2021. Last update on 01/07/2022. The Goals read: Will have needs met through normal daily routine without having to express them. Needs will be met with comfort and dignity. Speak in a manner that can be understood. The interventions included: Gain individual's attention before beginning to converse. Initiated 06/14/2018. Speaks only Creole. Initiated 06/23/2021. Utilize French/Creole interpreter hotline as needed [Telephone number]. Initiated 11/03/2021. (This telephone number was for the previous, contracted provider service used prior to this facility being purchased in September 2022.) Utilize French/Creole interpreter hotline as needed [Telephone number] [Branch number]. Initiated 05/25/2021. Revised 08/05/2021. (This telephone number was for the previous, contracted provider service.) Utilize interpreter/Creole-speaking staff to translate as needed. Initiated on 06/14/2018. Last revised 05/25/2021. When talking to patient, use gestures and simple sentences while maintaining eye contact. Initiated 06/06/2018. Revised 05/25/2021. (Photographic evidence obtained) A review of the facility's policy and procedure entitled Translation and/or Interpretation of Facility Services (Version 1.2 (H5MAPL0897, revised March 2012) revealed: This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 11. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 4 of 21 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 01/06/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm facility): a. A staff member who is trained and competent in the skill of interpreting, b. A staff interpreter who is trained and competent in the skill of interpreting, c. Contracted interpreter service, d. Voluntary community interpreters who are trained and competent in the skill of interpreting, and e. Telephone interpretation service. (Copy obtained) Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 5 of 21 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 01/06/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and facility policy and procedure review, the facility failed to provide necessary care and services to ensure a resident's ability to communicate, by failing to provide assistive devices for communication and correct contact information for the contracted translator services for one (Resident #41) of three residents whose primary language was not English, from a total sample of 33 residents. The staff did not have a way to communicate with Resident #41 except to have her point at things. They relied on her family and staff who spoke her language if they were available or on duty. The staff was unable to consistently communicate effectively with Resident #41 in a language she understood. Inability to make her needs known due to a language barrier may result in isolation, depression and unmet needs. Residents Affected - Few The findings include: On 01/03/2023 at 11:10 AM, Resident #41 was observed lying in bed watching television. When she was greeted, she began to speak in French Creole. She did not speak English. There were no communication devices in her room. There was no information posted regarding a translation line for staff to call to have an interpreter assist with obtaining vital information from the resident. During an interview with Certified Nursing Assistant (CNA) M on 01/03/2023 at 11:18 AM, she confirmed that there were no communication devices in Resident #41's room. She stated the staff told Resident #41 to point to what she wanted. She stated she did not speak French Creole and was unaware of whether there was a staff member who did. She did not work with Resident #41 often, but she knew she did have family and they visited on New Year's day. During an interview with Occupational Therapist (OT) O on 01/04/23 at 4:26 PM, she stated she did not work with Resident #41, however, she was familiar with her. She stated Resident #41 spoke French Creole. She confirmed that she herself did not speak French Creole, but there were several staff members who did. She named a night shift nurse that spoke French Creole and worked with the resident. She stated there were several CNAs who spoke French Creole. She was not sure about the translator service phone line. She had never used it and did not know where the information could be located. During an interview with Licensed Practical Nurse (LPN) N on 01/04/2023 at 5:20 PM, she stated this was the third time she had worked this hallway since it became the COVID-19 unit. She had only worked with Resident #41 during those three shifts. She was asked how she communicated with the resident. She stated she did not speak French Creole. There was a telephone number they could call for translator services. She was not sure where the number was located, but she thought it was at the nurses' station. She did not have the number on the medication cart. She confirmed that there was no communication board/device for the resident in her room, and that the resident pointed to the things she wanted. She used the example that if the resident had pain, she would point to where she had the pain. She did not know the word for pain in the language of French Creole. She confirmed that she did not know the resident well enough to determine whether she understood English. During an interview with Employee LPN/Unit Manager (UM) P of the COVID-19 unit on 01/04/2023 at 5:25 PM, she stated she did not know the translator service telephone number, but she would get it. She walked down the hall to the Director of Nursing's (DON's) office and returned a few minutes later with the DON, who provided a piece of 8 x 11.5 inch paper with the contracted translator services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 6 of 21 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 01/06/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm name and telephone number printed on it. It was handed back to her, and she was asked to make sure LPN N had the information in case of an emergency. She agreed. The Regional Nurse Consultant (RNC) then took the paper and made several copies. She began to provide an in-service for the staff present and gave a copy to the UM. The DON stated she would post the information on the wall in the resident's room and then took the paper to LPN N. Residents Affected - Few During an interview with Employee LPN Q on 01/05/2023 at 9:18 AM, he confirmed that he was assigned to Resident #41 and had already administered her medications. He was familiar with some of the residents, because they came to this unit from the long-term care unit on the other side of the building. He had only worked on this newly established COVID-19 unit today. He knew of the translation service phone number and pointed to it on the wall. He stated he had never used it. He was Spanish-speaking, himself, but did not know how to speak French Creole. He did not think he would need to use the translation line to speak with Resident #41. He stated that Spanish and French were similar and, for example, the word for pain was very similar. He did not have the translation telephone line on the medication cart. He stated he had administered the resident's medications already this morning with no problem. He confirmed that there were no communication devices in her room. He then moved the cart down the hallway away from the nurses' station. The RNC walked down the hall and handed LPN Q the phone number for the translation line, and told him to keep it on the cart and use it when he needed to obtain information from the resident. Resident #41 was observed on 01/05/2023 at 11:23AM, and an interview was attempted. She was lying in her bed on her right side. Her eyes were closed, and she appeared to be asleep. She did not wake up or respond when her name was called. An attempt was made to reach the translation service provider via telephone at the number posted in the resident's room. The automated system asked for a location number that was not on the signage posted in the resident's room. An identification number was on the form along with a Branch number. A representative came on the line after several attempts to input the information on the form. The representative requested the location number. After giving the information on the form to the representative, the line was disconnected by the service provider. During an interview with the Assistant Director of Nursing (ADON) on 01/05/23 at 11:40 AM, she was asked for the location number for the translation services. The sign with the telephone number was no longer posted at the nurses' station. She went to her office and stated that she had taken the sign down from the nurses' station to make copies. She did not know that the location number was not on the form, only the Branch number. She went to find the DON. The DON arrived on the unit, and when asked for the location number, she went to Social Services Director's (SSD's) office and asked the SSD if she knew the location number for the translation service. The SSD pointed to the sign for the contracted translation service posted on her bulletin board. The Branch number was crossed off and a different number had been handwritten on it. She stated that number was the correct number. The DON took the information and stated she would verify whether the information was correct and make a new sign for the staff. During an interview with the RNC and Registered Nurse (RN) S on 01/05/23 at 12:00 PM, the RNC stated she did not know why the translation line was not working, but they were working on it. She had placed communication forms in the resident's room this morning. During an interview with the Administrator on 01/05/23 at 12:28 PM, she stated the facility had contracted with the translation services provider in September 2022 when the facility was purchased, but when she called the new translation services provider number today, she could not get through. She was not sure why and stated that the company was located in another country and may not be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 7 of 21 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 01/06/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few available right now. She stated, They may be asleep. She stated she did not know how long it had been that the translation services provider number did not work. She stated she was going to conduct an in-service for the staff to use an internet application in the meantime until they could get the service provider to fix the problem. She produced emails to show her attempts. (Copies obtained) At 12:51 PM, the Administrator produced copies of all correspondence with the translation service provider, and stated she set up a temporary work around with the other service provider available on the internet. She had tried it, knew it worked, and they would have the staff use it, if necessary, until they could get the contracted provider to fix the problem. She confirmed that there were no other residents in the building that spoke French Creole, and she was not sure, but thought there might be a couple who spoke Spanish. She stated they would post the temporary provider information for the staff at the nurses' station and in Resident #41's room. During an interview with the RNC on 01/05/2023 at 4:39 PM, she produced documentation to indicate the telephone number for the translation service was now operational. She stated the problem had been fixed. A new sign with the correct information was posted on the wall of the nurses' station. During an interview with LPN T on 01/06/2023 at 12:43 PM, he stated he was assigned to Resident #41, and today was his first day working the COVID-19 hallway. He had just started working at this facility and was unfamiliar with Resident #41. He did not know she only spoke French Creole. He administered her medications today and stated he did not think he would need to have a translator. If he needed information, he would call the family. Resident #41 was observed on 01/06/2023 at 2:10 PM. She was lying in bed looking at her television. An interview was attempted using the new translation telephone line obtained from the sign at the nurses' station. Resident #41 made good eye contact, but would not respond to the interpreter or this surveyor. The telephone number for the translation line was not posted in the resident's room. (Photographic evidence obtained) During an interview with the DON on 01/06/2023 at 2:20 PM, she was informed that the new telephone number for the translation/interpreter line was not posted in the resident's room. She appeared surprised and said Oh no, I'll fix that. It probably didn't get replaced because it has changed so much recently. A review of the clinical record for Resident #41 revealed that on the Minimum Data Set (MDS) assessment, dated 12/16/2022, the resident was initially admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to thrombosis of the right, middle cerebral artery, pain, and hemiparesis following cerebral infarction affecting left non-dominant side. Her hearing was documented as adequate, and her vision was moderately impaired. She was sometimes understood, and sometimes understood others. She did not exhibit inattention, disorganized thinking or an altered level of consciousness. A Brief Interview for Mental Status (BIMS) score could not be determined. She was rarely/never understood. The section for preferred language was left blank. She was assessed as not needing or wanting an interpreter to communicate with a doctor or health care staff. The assessment was documented as having been completed with the assistance of the resident's family. (Copy obtained) A review of the January 2023 Physician's Order Sheets for Resident #41 revealed no orders for the use of a communication device or translation service. (Copy obtained). A review of the current, electronic Care Plan on 01/04/2023, revealed no care plan for the use of a communication device. The phone numbers for the translation service were not the same as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 8 of 21 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 01/06/2023 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 0676 numbers posted at the nurses' station during this survey. Level of Harm - Minimal harm or potential for actual harm The Focus read: Residents Affected - Few [Resident #41] has difficulty communicating related to a decline in cognitive status, language barrier, as patient only speaks Creole. Patient can sometimes understand others and can sometimes make self understood with Creole-speaking translator. Initiated on 06/03/2021. Last update on 01/07/2022. The Goals read: Will have needs met through normal daily routine without having to express them. Needs will be met with comfort and dignity. Speak in a manner that can be understood. The interventions included: Gain individual's attention before beginning to converse. Initiated 06/14/2018. Speaks only Creole. Initiated 06/23/2021. Utilize French/Creole interpreter hotline as needed [Telephone number]. Initiated 11/03/2021. (This telephone number was for the previous, contracted provider service used prior to this facility being purchased in September 2022.) Utilize French/Creole interpreter hotline as needed [Telephone number] [Branch number]. Initiated 05/25/2021. Revised 08/05/2021. (This telephone number was for the previous, contracted provider service.) Utilize interpreter/Creole-speaking staff to translate as needed. Initiated on 06/14/2018. Last revised 05/25/2021 When talking to patient, use gestures and simple sentences while maintaining eye contact. Initiated 06/06/2018. Revised 05/25/2021. (Photographic evidence obtained) A review of the facility's policy and procedure entitled Translation and/or Interpretation of Facility Services (Version 1.2 (H5MAPL0897, revised March 2012) revealed: This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 11. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): a. A staff member who is trained and competent in the skill of interpreting, b. A staff interpreter who is trained and competent in the skill of interpreting, c. Contracted interpreter service, d. Voluntary community interpreters who are trained and competent in the skill of interpreting, and e. Telephone interpretation service. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 9 of 21 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 01/06/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that two (Residents #85 and #69) of a sample of 33 residents who were unable to carry out Activities of Daily Living (ADLs), received the necessary services to maintain grooming and personal hygiene for fingernail care and trimming. Residents Affected - Few The findings include: On 01/03/23 at 4:00 pm, Resident #85 was observed sitting up in bed, awake, with the company of two visitors. The visitors identified themselves as the resident's son and daughter-in-law. The family members verbally encouraged the resident to speak up if she had anything to say. Resident #85 presented extremely elongated fingernails on both hands. She stated she had asked staff to trim them several times, but no one had trimmed them. (Photographic evidence obtained) The resident's daughter-in-law proceeded to trim the resident's nails during visit, stating, If no one else is going to do it, then I will. On 01/03/23 at 4:05 pm, Resident #69 was observed lying in bed, awake. The resident showed her fingernails which were unusually elongated (right hand was observed to have thumb and index finger at normal length. The resident stated, Those two have just broke on their own. The middle, ring, and pinky fingernails were observed to be elongated and curled under. The left hand was observed to have all five fingers elongated and curled under. (Photographic evidence obtained) The resident was asked if she preferred her nails at that length. She replied, No, they hurt and dig into my hand. Both hands were observed to be contracted, with nails pressing against the palms. The resident was asked if she had asked staff to trim her nails. She stated, Yes, I've asked and asked, and they just ignore it. My mom and my daughter are both scared to cut them because they are so long. On 01/05/23 at 1:45 pm, Resident #69 was observed lying bed; her mother was visiting. Her mother voiced concerns regarding the resident's elongated fingernails. Resident #69's fingernails were observed to be as long as they were during the 1/3/23 observation. Her mother stated, I'm afraid to cut them, I don't want to hurt her. She's asked the staff many times to just cut them, but no one ever comes back to cut them. A medical record review for Resident #85 revealed diagnoses including cerebral arteritis, cerebral infarction, type two diabetes, muscle weakness, and the need for assistance with personal care. A review of the Minimum Data Set (MDS) assessment, Section G, conducted on 11/14/22, revealed that Resident #85 required extensive assistance and the assist of one person for personal hygiene. A review of the same MDS, Section E, revealed the resident had not had any instances of refusal of care. A review of the person-centered care plan for Resident #85, dated 5/23/22 and revised on 6/13/22, revealed a focus area which read: The resident has an ADL self care performance deficit. The related goal (revised 11/15/22) read: The resident will improve current level of function in at least one ADL by next review date. The interventionsincluded: Bathing: check nail length and trim on bath day and as needed. Report any changes to the nurse. Bathing: the resident requires staff participation with bathing. Assist with personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 10 of 21 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 01/06/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A medical record review for Resident #69 revealed diagnoses including spina bifida and functional quadriplegia. A review of the MDS assessment, Section G, conducted on 10/25/22, revealed that Resident #69 was totally dependent and required the assistance of two people for personal hygiene. A review of the same MDS, Section E, revealed that the resident had not had any instances of refusal of care. A review of the person-centered care plan for Resident #69, dated 4/28/21 and revised on 6/18/21, revealed a focus area which read: ADL self care deficit as evidenced by requiring assistance related to physical limitations, spina bifida, weakness, and other medical comorbidities. The related goal (revised 10/27/22) read: Will receive assistance necessary to meet ADL needs (last revision 10/27/22) The interventions included: Assist with daily hygiene, grooming, dressing, oral care, and eating as needed. On 01/05/23 at 4:33 pm, in an interview with Certified Nursing Assistant (CNA) A, he was asked if he was caring for Residents #85 and #69 today. He said yes. He was asked who trimmed and cleaned the residents' fingernails. He replied, That is not my job. I let the nurse know on shower day if a resident needs their nails trimmed. On 01/05/23 at 4:40 pm, in an interview with Licensed Practical Nurse (LPN) B, she was asked who cleaned and trimmed the residents' fingernails. She stated, The podiatrist will trim the toenails, and the CNAs will clean and trim the fingernails. She was asked if she ever checked residents' fingernails. She stated no. She was asked if she had seen Resident #69's fingernails. She stated, No, I haven't. She was asked if the assigned nurses looked at residents' fingernails. She stated, Yes, they would during the weekly skin assessment completed by nursing. On 01/06/23 at 10:02 am, in an interview with CNA C, she was asked who cleaned and trimmed the residents' fingernails. She stated, I don't cut them. I'll let the unit manager know if they need to be trimmed. I know the CNAs can't cut the diabetic fingernails, but I don't know if we can cut any fingernails, so I just let the unit manager know if anyone's fingernails need to be trimmed. On 01/06/23 at 10:10 am, in an interview with LPN D, she was asked who cleaned and trimmed the residents' fingernails. She stated, I'm not sure. I think the podiatrist does that. She was asked who cleaned and trimmed the diabetic residents' fingernails. She replied, I don't think we're allowed to. I think the podiatrist does that too. On 01/06/23 at 10:20 am, in an interview with the Director of Nursing (DON), she was asked who cleaned and trimmed the residents' fingernails. She stated, Generally, the CNAs will do that as part of the ADLs. If a resident is very contracted and they are uncomfortable with the task, they would let the nurse know so the nurse can clean and trim the fingernails. If it's a diabetic resident, then the nurse will trim the nails, not the CNA. She was asked how the nurse was made aware of whether a resident needed their nails trimmed by the nurse. She stated, The CNA would be observing the fingernails on their shower day and reporting to the nurse if they need to be trimmed, if they are diabetic or uncomfortable with contractures of the hands. A review of the facility's policy titled: Care of Fingernails/Toenails (revised 10/2010) revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 11 of 21 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 01/06/2023 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 0677 Purpose: The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. Level of Harm - Minimal harm or potential for actual harm General Guidelines: Residents Affected - Few 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. Reporting: 1. Notify the supervisor if the resident refuses the care. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 12 of 21 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 01/06/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on resident, family, and staff interviews, and medical record review, the facility failed to ensure that one (Resident #85) of a sample of 33 residents, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Residents Affected - Few The findings include: On 1/3/23 at 4:00 pm, Resident #85 was observed sitting up in her bed, awake. She stated she had asked to have appointments for a rheumatologist. She stated there had been no follow up and no appointments made that she was aware of. A medical record review revealed an order written on 8/24/22 which read: Schedule an appointment with rheumatology for consult. No evidence of this appointment being made or having taken place was found in the medical record. On 01/05/23 at 2:24 pm, Resident #85 was observed sitting up in her wheelchair with her son and daughter-in-law visiting. The resident was asked if she had a rheumatology consult since she was admitted to the facility in May 2022. She stated, No, no one has ever gotten back to me about that. I know I need the consult because of the Prednisone I take. I'm taking that for the vasculitis that caused my stroke. Further review of the resident's medical record revealed an admission date of 5/21/22 with diagnoses including cerebral arteritis and cerebral infarction. Further review of the physician's orders revealed: 5/22/22: Prednisone 20 mg (milligrams): three tablets by mouth daily for inflammation (d/c 9/26/22) (discontinued 9/26/22) 8/24/22: Schedule an appointment with rheumatology for consult 9/27/22: Prednisone 20 mg: two tablets by mouth daily for inflammation A review of Pharmacy Medication Review/Recommendations for Resident #85 and dated 8/15/22, revealed: Resident has an order for Prednisone 60 mg daily for inflammation with no stop date. Recommendation: Please provide a stop date for high-dose steroid treatment or describe why continued use is clinically indicated. Physician response: Other: Pt (patient) needs rheumatology consult (signed 8/24/22 by the physician). A review of the neurology consult visit, dated 9/20/22, revealed: Plan: Continue with current medication regimen, in particular continue Prednisone as stated in previous [hospital name] discharge, 60 mg daily, until rheum appt. established. Rheum appointment pending. On 01/05/23 at 4:20 pm, in an interview with LPN B, she was asked whether Resident #85 had any outside physicians appointments scheduled. She stated, I'm not sure. [Receptionist E] schedules those (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 13 of 21 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 01/06/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and then we get the appointment 1-2 days prior, so we know who is going out and when, so they can be gotten up and ready on time for transportation. [Receptionist E] also schedules the transportation. On 01/06/23 at 8:16 am, in an interview with Receptionist E, she was asked how appointments for outside physicians referrals she made. She stated, They come to me from the nurses and/or the social worker. Sometimes the appointments are already made by the family, or they are admitted with follow-up appointments, so I'll just schedule transportation for the appointments that are already made. She was asked if she had a doctor's appointment referral made/pending for a rheumatologist for Resident #85. She stated, No requests have been made for that. Let me double check that. No, I haven't received any requests for a rheumatology appointment to be made for her. On 01/06/23 at 9:05 am, in an interview with Social Services Worker G, she was asked how outside doctors' consults were arranged for residents. She stated, If they need to go out, they have appointments from the house doctor request, so we'll make the appointments after the nurse gives us the order, and we'll arrange transportation. Sometimes the new patients will come in with appointments. Sometimes when we check their insurance, we have to make new appointments with doctors who accept their insurance. She was asked if she could provide information about a rheumatology consult for Resident #85. She stated, I'll be scheduling that. I've called two doctors who were recommended by her neurologist. One doesn't take her insurance. I'm waiting to hear back from the second one; they are waiting for the referral from her neurologist. She needs the rheumatology appointment before she sees neurology again in March. I didn't know about that appointment until the son let me know yesterday, and that's when I started working on it. She was asked if she was aware of an order for a rheumatology consult which was ordered on 8/24/22. She replied, No, I wasn't aware of that consult request. I just heard about it yesterday from her son. On 01/06/23 at 9:31am, in an interview with Registered Nurse (RN) F, she was asked if she could confirm through medical record review, that Resident #85 had not had a rheumatology appointment scheduled since her admission to the facility. She stated, Yes, as far as I know, there has not been a rheumatology appointment scheduled. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 14 of 21 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 01/06/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one (Resident #50) of 16 residents receiving respiratory treatments, from a total sample of 33 residents, received the correct number of liters of oxygen as ordered by the physician. Residents Affected - Few The findings include: On 01/04/2023 at 10:53 am, Resident #50 was observed lying in bed with her eyes closed wearing a nasal cannula. Resident #50's oxygen concentrator, located at bedside, was set at 3.0 Liters per minute (L/min) with no date to identify a change of tubing. (Photographic evidence obtained) A review of Resident #50's physician's order, dated 01/03/2023, revealed she was to receive oxygen at 2 L/min via nasal cannula every shift for oxygen management to keep her oxygen level >93%. On 01/05/2023 at 10:46 am, a second observation of Resident #50's oxygen concentrator, revealed it was set at 3.0 L/min with no date to identify a change of tubing. (Photographic evidence obtained) A medical record review revealed the resident was admitted on [DATE]. Her diagnoses included acute respiratory failure, unspecified whether with hypoxia or hypercapnia; morbid (severe) obesity due to excess calories; cognitive/communication deficit; dementia in other diseases classified elsewhere, psychotic disturbance, mood disturbance, and anxiety. A review of the resident's January 2022 Medication Administration Record (MAR), revealed: Oxygen at 2 L/min via nasal cannula every shift for oxygen management to keep oxygen level >93% with nursing initials indicating the oxygen was provided per the order and oxygen saturation ranging 95-96%. A review of the quarterly minimum data set (MDS) assessment, dated 12/5/2022, revealed that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. The assessment also documented that she was receiving oxygen therapy. A review of Resident #50's care plan, dated 12/16/2022, revealed she had altered respiratory status/difficulty breathing relating to oxygen utilization usage of a continuous positive airway pressure (CPAP) and recent history of shortness of breath. Interventions included: Administer medications/puffers as ordered. Monitor for effectiveness and side effects, change tubing weekly. On 01/05/23 at 2:41pm, and in the presence of Licensed Practical Nurse (LPN) H, Resident #50's oxygen concentrator was set to administer oxygen at 3.0 L/min. (Photographic evidence obtained) LPN H confirmed that Resident #50's physician's order was for a flow rate of 2 L/min, and due to the undated oxygen tubing, the nurse could not verify that it had been changed weekly as ordered. The resident's oxygen saturation ranges between 95 and 96 percent and she has no distress. LPN H reported that nursing was responsible for on-going monitoring of oxygen therapy, ensuring the resident was provided the correct oxygen flow rate per physician's order, as well as weekly oxygen tube changes. The correct oxygen settings were communicated from one nurse to another during change of shift report. On 01/06/22 at 9:15am, the DON confirmed that the correct oxygen settings were identified in the MAR, nursing was responsible for providing on-going monitoring of oxygen therapy and tube changes. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 15 of 21 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 01/06/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA cannot change settings. It is the nurses' responsibility to ensure that oxygen therapy is provided as ordered. A review of the facility's policy and procedure entitled Oxygen Administration (dated October 2010), revealed that preparation included: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 16 of 21 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 01/06/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on the kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all the residents who consumed foods in the facility. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for food storage and proper sanitation practices in the kitchen. Specific instruction on food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted with Certified Dietary Manager (CDM) L on 01/03/2023 at 9:55 a.m. During the tour, the bread cart next to the food prep area had four open bundles of bread with no date marking identified. Opened Thick and Easy food and beverage thickener was observed in the dry storage room on the bottom. These observations were made again on 01/04/2023 at 11:22 a.m. and again at 1:24 p.m. (Photographic evidence obtained) On 1/6/2023 at 2:22 p.m., Dietary Aide J stated CDM L and the [NAME] were responsible for dry storage. CDM L updated and checked off at delivery. It was a team effort; all staff would help put food away. When asked what happened to open food packages, Dietary Aide J stated they were sealed and dated. When asked what happened when bread was used from the rack, she stated staff should open and use what was needed, then seal the package and date it. When ask again, so open bread has to be dated? Dietary Aide J stated, Yes, to inform staff the day the bread was opened. Open bread must be discarded in three days. She confirmed that she received dietary training when hired at the facility and also received monthly refresher trainings in areas of the drink station, dating food, sanitation, and cleanliness. On 1/6/2023 at 2:35 p.m., [NAME] K reported that Dietary Aides were usually responsible for receiving the dry storage. All staff help each other. When asked to explain what happened when bread was used from the rack, she stated it could be used for pureed meals, and left-over bread was wrapped and dated. When asked again, what happens to open food packages, she confirmed that bread must be sealed and dated. [NAME] K confirmed that she received dietary training. She stated CDM L verbally provided updates. In-service training was provided monthly, and sometimes weekly. On 1/6/2023 at 2:46 p.m., CDM L reported she received, reviewed, and checked off food deliverys to ensure the facility received what was ordered. All staff assisted with putting food away in dry storage. The CDM completes inventory and cooks ensue when food is pulled that dates are in order. Bread is delivered frozen. Bread is pulled 2-3 days at a time. Open bread is dated and discarded after three days. If found open, the CDM will discard. Open food is securely closed and dated. CDM L confirmed she received dietary training through culinary school and CDM training. During the second kitchen tour on 1/4/2023, CDM L confirmed dietary training was provided to staff monthly, upon hire, and when problems were identified. Training topics included sanitation, food preparation, substitutions, cleaning, and reading tickets. On 1/6/2023 at 3:30 p.m., the facility's Food Storage, Safety and Sanitation Policy was requested from administration. Administation provided the policy for Preventing Foodborne Illness - Food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 17 of 21 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 01/06/2023 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 0812 Handling Policy, staing the facility did not have a food storage policy. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 18 of 21 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 01/06/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to perform hand hygiene during medication administration for one (Resident #37) of three residents observed during medication administration. This practice has the potential to affect more than a limited number of residents. Facility census: 93 Residents Affected - Few The findings include: During an observation of medication administration on 01/05/23 at 9:30 AM, Licensed Practical Nurse (LPN) H was observed preparing and administering medication for Resident #37. LPN H failed to perform hand hygiene prior to preparing the medication, and failed to perform hand hygiene after administering the medications to the resident. On 01/05/23 at 9:45 AM, an interview was conducted with LPN H. He confirmed that hand hygiene was required prior to and after each resident medication administration. He confirmed that he failed to perform hand hygiene during medication administration. He stated he forgot. A review of the facility's policy titled, Handwashing/Hand Hygiene, with a revised date of 12/2009, revealed on page one, number two, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. A review of the facility's policy titled, Administering Medications, with a revised date of 12/2012, revealed on page two, number 22, Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 19 of 21 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 01/06/2023 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to maintain the kitchen freezer in a safe operating condition with the potential to place the health of all the residents who consumed foods in the facility at risk. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for maintaining essential equipment in the kitchen. Specific instruction on kitchen equipment is important in health care settings serving nursing home residents. Freezer units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. Residents Affected - Many The findings include: An initial tour of the kitchen was conducted with Certified Dietary Manager (CDM) L on 01/3/2022 at 9:55 a.m. During the tour, observations of the walk-in freezer identified condensation buildup on and around the door area, to include shelves on the right side of freezer door and plastic freezer shields. (Photographic evidence obtained) Internal temperatures ranged from -6°F to -8°F. A second observation of the walk-in freezer identified condensation buildup in the same area, on and around door area, to include shelves on the right side of freezer door and plastic freezer shields. (Photographic evidence obtained) CDM L stated she reported the condensation buildup in the freezer to the maintenance department last week. It needs a new seal on the door; staff have to ensure the door is closed tight. No maintenance log was found in the kitchen. CDM L stated, Maintenance will have a log. CDM L confirmed that when equipment was broken, it was immediately reported to maintenance. She had never reported in the TELS system that was used to track maintenance jobs. On 01/05/23 at 2:58 PM, an interview in the dining room with the Maintenance Director, revealed he arrived at the facility this week to fill in. The facility's maintenance director was currently out of the facility at the time of the survey. When asked how maintenance was informed of equipment failures within the facility, he stated verbal requests could be made and/or work orders were submitted in TELS (electronic system). When asked whether he was familiar with the condensation buildup in the Dietary freezer, he confirmed he was not familiar with any freezer issues or condensation buildup, and he did not have access to the TELS system at the facility. The Maintenance Director had not been notified of any equipment issues within the Dietary Department since arriving at the facility this week. When asked what the process was for addressing equipment failures, he stated, To try to repair or fix the issue. If maintenance cannot repair or fix the issue, contact [outside service] to submit a work request. Any staff can call maintenance directly or submit a work order in the TELS system. He stated he would inspect the edge of the freezer door and seal, and replace it if needed. If he could not replace it, a work request would be submitted for repair. On 1/6/2023 at 2:22 PM, Dietary Aide J confirmed that Dietary equipment failures were reported to the CDM. If the CDM was not available, equipment failures were reported to the cook. She stated she did not believe there was a maintenance logbook in Dietary; she had never filled out a request. Dietary Aide J confirmed that she received Dietary training when hired at the facility, as well as monthly refresher trainings in areas of the drink station, dating food, sanitation, and cleanliness. On 1/6/2023 at 2:35 PM, [NAME] K confirmed that Dietary equipment failures were reported to the CDM. She documented on paper or a report sheet, and gave it to the CDM. [NAME] K confirmed receiving dietary training. She stated the CDM verbally provided updates. In-service training was conducted monthly, and sometimes weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 20 of 21 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 01/06/2023 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 1/6/2023 at 2:46 PM, CDM L stated that staff reported equipment failures to her, and she would report them to Maintenance. She stated the Dietary Department did not have a maintenance logbook. I will report directly to maintenance. CDM L confirmed she received Dietary training through culinary school and CDM training. During the second kitchen tour on 1/4/2023, CDM L confirmed that Dietary training was provided to staff monthly, upon hire, and when problems were identified. Training topics included sanitation, food preparation, substitutions, cleaning, reading tickets. A review of the facility's Maintenance Request forms (dated 12/23/2022 to 1/5/2023), revealed no work order submitted from Dietary for freezer repair. (Copy obtained) A review of the facility's policy and procedure entitled Hazardous Areas, Devices and Equipment (dated July 2017), revealed: All hazardous area devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. (Copy obtained) Reference: United States Food and Drug Administration Food Code 2017. 4.501.11. Good Repair and Proper Adjustment. Page 504. https://www.fda.gov (Accessed 0n 01/09/2023): Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105692 If continuation sheet Page 21 of 21