Health inspection·February 4, 2021

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few degeneration of the brain, Aripiprazole 1 Milligram/ Milliliter (mg/ml), give 1 ml at bedtime (HS) for psychosis not due to substance abuse or known physiological condition, and Sertaline 12.5 mg every day (QD) for depression. A review of the quarterly minimum data set (MDS) assessment, dated 11/22/20, revealed that the resident had a brief interview for mental status (BIMS) score of 03 out of 15 possible points, indicating a severe cognitive impairment. The resident was assessed to require extensive assistance with transfers, bed mobility and toilet use, and supervision with eating. Resident #26 was careplanned for activities of daily living (ADL)/self care performance deficit related to dementia, unsteady balance, non-ambulatory status, limited mobility and joint pain. Interventions included TED hose as tolerated, observe/document/report to medical doctor any changes as needed (PRN) regarding any potential for improvement, reasons for self-care deficit, expected course and decline in function. A review of the Community Hospice nursing progress note, dated 12/9/2020, revealed that the resident was admitted to Community Hospice Palliative Care (CHPC) with senile degeneration of the brain. The resident required extensive assistance with ADLs and transfers to her wheelchair. She required assistance with meals, but was able to feed herself finger foods. She had a 2.6 pound weight gain from September to November 2020, but she now had bilateral ankle edema. [NAME] hose were ordered. A review of the Community Hospice refortification note, dated 12/17/20, revealed, Resident alert and oriented to person, poor appetite, assistance with all meals and care. Weight gain two pounds (lbs.) edema noted, so technically loss of weight - TEDs added, last Mid-Arm Circumference (MAC) 28 centimeters (cm), loss of 1 cm since March. She has had 6 lbs. loss since admission, she is weaker. Will recheck MAC and prealbumin. Further review of the progress notes for January 2021 and the Treatment Administration Record (TAR) for January 2021 revealed no documentation of TED hose. On 02/04/21 at 10:33 AM, the Director of Nursing (DON ) stated the CNAs were responsible for putting on the TED hose while getting the resident up in the morning. She added that the TED hose were to remain on as the resident could tolerate them or to be removed at bedtime. When asked if there was any documentation of the application and removal of TED hose, the DON stated there was no documentation, because the TED hose were supposed to be worn as tolerated. When asked how she ensured whether the resident tolerated the hose or refused them, she stated she was not sure as it was not documented. She added that the resident was on palliative care, so the compression stockings were for comfort only. There was no reason to document their application, removal or the resident's refusal to wear them. 2. During medication administration observation on 2/3/21 at 11:00 AM, Employee H, Licensed Practical Nurse (LPN), was observed alone as she prepared medications for Resident #3. Employee H pulled the following medications from the medication cart: Aspirin 81 milligram (mg) tablet, Magnesium 400 mg tablet, Vitamin D3 50 microgram (mcg) tablet, Potassium Chloride 20 milliequivalent (meq) tablet, Hydralazine 50 mg tablet, Amlodipine 10 mg tablet and Terazosin 2 mg tablet. She verified each medication label against the current Medication Administration Record (MAR) on the computer screen for accuracy of drug frequency, duration, dose and route. She stated she checked what was written on the Medication Administration Record (MAR) to ensure it matched what was written on the blister package of pills. Continued observation revealed that she poured the medications into a medication cup and gave the medications to be administered to Resident #3 to another Employee, LPN I. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 2 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 On 2/3/21 at 11:15 AM, Employee I, LPN, was observed administering the medications that were prepared by Employee H to Resident #3. Employee I was not present when Employee H prepared and verified the medications for Resident #3. Reconciliation of the observed medications administered with the resident's medical record did not reveal medication errors but Employee I, LPN, was not present during the medication preparation and she did not verify the medications with Employee H or the MAR prior to administering the medications. 3. During the medication administration observation on 2/3/21 at 11:40 AM, Employee H, LPN, was observed as she prepared medications for Resident #32. Employee H pulled the medication Simbrinza 1-02% (eye drops) from the medication cart. She verified the medication label against the current MAR on the computer screen for Resident #32. Employee I was observed behind the computer screen and did not participate when Employee H verified the medication for Resident#32. Employee H gave the eye-drops she prepared to be administered to Employee I, LPN. On 2/3/21 at 11:45 AM, Employee I, LPN, was observed administering the eye drops medication prepared by Employee H to Resident #32. During an interview with Employee I on 2/3/21 at 11:56 AM, she stated the internet went down earlier and Employee H was running behind on her medication administration. She further stated Employee H was new to the facility and she was trying to help her with her medication administration. Reconciliation of the observed eye-drops medication administered with the resident's medical record did not reveal medication errors but Employee I, LPN, did not verify the medication with Employee H or the MAR prior to administering the medication. An interview was conducted with Employee H, LPN, on 2/3/21 at 3:05 PM. She stated, I can see how this could be considered an error. I am not a new nurse. I am new to the facility and she (Employee I) was helping me catch up because the internet went down earlier. I should probably change the documentation because I did not give the medication for Resident #3 or Resident #32. During an interview with Employee I, LPN, on 2/4/21 at 4:45 PM, she stated she was still unsure what she did wrong. Employee I stated, I looked when [Employee H] was preparing the medications. During an interview with the Regional Director of Nursing on 2/4/21 at 4:50 PM, she stated her expectation was that during training periods, the nurse could allow trainees to document in the record while assisting with medication administration, but both nurses would verify the medications prior to administering them. 4. On 2/4/21 at 10:10 AM, an observation was made of the second-floor medication room refrigerator with the Director of Nursing (DON), revealing a medication card of Marinol 2.5 mg (with 22 capsules remaining) for Resident #17. On 2/4/21 at 10:15 AM, a review of the Narcotic Logbook with Employee G, LPN, revealed a discrepancy in the amount of a narcotic medication Marinol for Resident #17. The Narcotic Logbook, dated 2/3/21, showed the medication Marinol 2.5 mg and the amount remaining was recorded as 24 capsules for Resident #17. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 3 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 An immediate interview was conducted with Employee G on 2/4/2021 at 10:15 AM. Employee G stated during the morning medication administration, he administered one capsule of Marinol 2.5 mg for Resident #17 and forgot to sign it out of the Narcotic Logbook at 7:00 AM today. He was unable to account for the other capsule missing. He stated, I pulled the other Marinol early and that is wrong. I already put it in a pudding cup to melt because Resident #17 likes it that way, and I plan to give it at 4:00 PM. It's not the right procedure and I know that I am not supposed to do it this way. Employee G verified the amount remaining documented on the Narcotic logbook should always match what was in the locked refrigerator and locked cart for the resident. During an interview conducted on 2/4/2021 at 11:00 AM, the Regional DON stated an investigation was initiated immediately to determine the location of the missing capsule of Marinol 2.5 mg medication for Resident #17. She stated it was found that Employee G had pulled the dose early. The Regional DON stated, We found a pudding cup in his cart containing one round white tab and we compared it with the Marinol capsules and they did not match. He was relieved of his assignment and asked to give a written statement. His statement differed from his verbal account. He was escorted off the property pending investigation. We reported him to our human resources department and they will ask him to do a drug test. If he does not take the drug test, we will report him to the nursing board. The DON and myself inspected his cart and completed a narcotic count. We also spoke to the residents on his assignment and no other issues were found. He is on leave until the investigation is completed. On 02/04/21 at 11:30 AM, during an interview with Resident #17, she verified that she received her Marinol medication this morning and she did not have any concerns related to the administration of her medications. A medical record review revealed that Resident #17 was admitted to the facility on [DATE] with diagnoses of anemia and anorexia. A review of her physician's orders revealed an active order for the resident to have Marinol (controlled substance medication used to treat nausea and vomiting and as an appetite stimulant) 2.5 mg by mouth twice daily for anorexia (lack or loss of appetite for food). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 4 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 but one of the residents in the facility (65 residents from a census of 66 residents). The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene, disposable glove use, food storage, proper cooling methods and proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial kitchen tour on 02/01/2021 at 9:52 AM, the floor around the ice machine had food debris (rice) in the grooves between the tiles and rust marks on the floor. There was grease and built-up dirt and debris on floors under the storage tables, racks, dish machine and ware washing sinks. Large baking pans and insulated domes and plate holders were wet nesting. The fryer had stuck-on grease on the sides and front. A pipe and electrical outlet from the floor to the ceiling was observed to have built-up dirt and debris. (Photographic evidence obtained) These observations were made again on 02/03/2021 at 11:50 AM and on 02/04/2021 at 9:42 AM. During observations of the kitchen and lunch meal service on 02/03/2021 from 11:30 AM until 12:20 PM, the Dietary Staff was observed: At 11:36 AM, Employee A, Food Preparation Cook, was observed to change her gloves without washing her hands after taking the temperature of the fortified soup. At 11:43 AM, Employee B did not wash her hands upon re-entering the kitchen. She began to wipe down the preparation area with a sanitizing cloth. She left the kitchen again at 11:48 AM. Upon returning to the kitchen she did not wash her hands. She went to the clean side of the dish room and picked up a baking tray from a rack of recently cleaned dishes. Her cell phone rang in her pocket. She took the phone out of her pocket and looked at it. She then put it back in her pocket and took the clean baking tray to the preparation table, thereby contaminating the clean tray. At 11:45 AM, Employee D was observed to leave the kitchen with meal tickets in her hands. She returned to the kitchen and did not wash or sanitize her hands. She proceeded to assist with meal tray preparation. At 11:50 AM, Employee C came back to the kitchen after delivering a tray cart to one of the nursing units for meal service. She did not wash her hands or sanitize her hands. She began to assemble more meal trays for food service. At 12:02 PM, Employee E came into the kitchen and washed his hands at the hand sink. When he was done, he shut the faucet off with his bare hands, thereby re-contaminating his hands, and then took a paper towel and dried his hands. He then went to the dirty side of the dish room and moved several soiled pans and racks. He then went to the mop bucket and began mopping the floor. When he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 5 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 finished mopping the floor, without washing his hands, he donned a pair of latex gloves and proceeded to the clean side of the dish room. He moved clean pans out of the dish room to the preparation area. At 12:10 PM, Employee C was observed touching the soiled pans on the dirty side of the dish room. She then went to the clean side of the dish room and unloaded a rack without washing her hands in between the dirty side and the clean side, thereby contaminating the clean dishes. Her cell phone charging/head phone cord was hanging out of her pocket approximately 12 to 18 inches coming into contact with multiple surfaces in the kitchen. During an interview with Employee C at 12:15 PM, she stated she had not been trained to wash her hands with soap and water after working on the dirty side of the dish room before going to the clean side. She stated she was permitted to have her phone in her pocket at work. She did not know that she should wash her hands after touching her cell phone. During an interview with Employee D at 12:17 PM, she stated she had worked at this facility for two years. She thought she received training on handwashing and glove use about two weeks ago by the new Certified Dietary Manager (CDM). She stated she was trained to either wash her hands or sanitize her hands when she entered the kitchen. During observations of the kitchen on 02/04/2021 At 9:45 AM, Employee F washed his hands at the hand sink for 10 seconds and then shut the faucet off with his hands. He then took paper towels and dried his hands. At 9:50 AM, Employee F washed his hands at the hand sink for 10 seconds and then shut the faucet off with his hands. He then took paper towels and dried his hands. At 9:55 AM, he sanitized his hands with hand sanitizer and donned a pair of latex gloves. During an interview with Employee F on 02/04/2021 at 9:57 AM, he stated he had worked at the facility for a year and had received training on hand hygiene. During an interview with the CDM at 10:10 AM, she confirmed that dietary staff had to wash their hands with soap and water. Hand sanitizer was not enough. On 02/04/2021 at 10:20 AM, a large plastic container of chicken noodle soup was observed in the walk-in cooler. It appeared to be one gallon of soup. It was covered and date-marked 02/03/2021. During an interview with the CDM on 02/04/2021 at 10:25 AM, she stated the soup was homemade by her staff yesterday (02/03/2021). There was one resident in the facility who wanted soup for his dinner meal, so they made him soup every day. She stated the soup was placed in the container and then put in the walk-in cooler after dinner last night. When asked for the temperature log for the proper cooling of the soup, she stated she did not have one. She did not think the staff took the temperature of the soup as it cooled. She confirmed that the dietary staff closed the kitchen between 8:30 and 9:00 PM every night and returned the next day at approximately 5:30 AM. She confirmed no one was working last night to take the temperature of the cooling soup at two hours to make sure it reached 70 degrees Fahrenheit or below, and again at six hours to make sure it reached 41 degrees Fahrenheit or below, ensuring the soup had cooled quickly enough to prevent the growth of bacteria. Review of the dietary in-service training sheet dated 01/20/2021, revealed the subject of the training was sanitation and infection control. Proper sanitation and How to wash your hands was covered. The subject matter was presented by the CDM. Only dietary staff attended the training. (Copy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 6 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 obtained) Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure entitled Hand Hygiene, Reference #4008, effective 11/01/2017, revealed it read: All staff shall use the hand-hygiene techniques as set forth in the following: Always after removing gloves. Procedure: Wash hands thoroughly, using rigorous scrubbing action for at least 15 seconds. Rinse hands and wrists under running water. Dry hands with clean paper towel. Turn off faucets with used paper towel and discard. (Copy obtained) Residents Affected - Many Review of the facility policy and procedure entitled Handwashing/Hand Hygiene, revised August 2015, revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Rinse hands thoroughly under running water. Hold hands lower than wrists. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Perform hand hygiene before applying non-sterile gloves. (Copy obtained) Review of the dietary staff training form entitled Wash Your Hands to Stop COVID-19 revealed: When? Before, during and after preparing food. After touching surfaces in common areas that may be frequently touched by other people. Scrub hands for at least 20 seconds. (Copy obtained) Reference: United States Food and Drug Administration Food Code 2017. 3. PUBLIC HEALTH AND CONSUMER EXPECTATIONS. Clean environment. Page 10. https://www.fda.gov (Accessed 0n 2/4/2021): It is a shared responsibility of the food industry and the government to ensure that food provided to the consumer is safe and does not become a vehicle in a disease outbreak or in the transmission of communicable disease. This shared responsibility extends to ensuring that consumer expectations are met and that food is unadulterated, prepared in a clean environment, and honestly presented. Reference: United States Food and Drug Administration Food Code 2017. Section 3-501.14 Cooling (A). Page 124. https://www.fda.gov (Accessed on 2/4/2021): (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); P and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. Reference: United States Food and Drug Administration Food Code 2017. Sections. 2-301.13 Special Handwash Procedures. 2-301.14 When to Wash. (A-I). Page 79. https://www.fda.gov (Accessed on 2/4/2021): FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 7 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in ¶ 2-403.11(B); Level of Harm - Minimal harm or potential for actual harm (D) Except as specified in ¶ 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; Residents Affected - Many (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 8 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records that were accurately documented in accordance with accepted professional standards of practice, by failing to ensure that an account of all controlled drugs was maintained for one (Resident #17) of six sampled residents reviewed for medication storage from a total of 35 sampled residents. The findings include: On 2/4/21 at 10:10 AM, an observation was made of the second-floor medication room refrigerator with the Director of Nursing (DON), revealing a medication card of Marinol 2.5 mg (with 22 capsules remaining) for Resident #17. On 2/4/21 at 10:15 AM, a review of the Narcotic Logbook with Employee G, LPN, revealed a discrepancy in the amount of a narcotic medication Marinol for Resident #17. The Narcotic Logbook, dated 2/3/21, showed the medication Marinol 2.5 mg and the amount remaining was recorded as 24 capsules for Resident #17. An immediate interview was conducted with Employee G on 2/4/2021 at 10:15 AM. Employee G stated during the morning medication administration, he administered one capsule of Marinol 2.5 mg for Resident #17 and forgot to sign it out of the Narcotic Logbook at 7:00 AM today. He was unable to account for the other capsule missing. He stated, I pulled the other Marinol early and that is wrong. I already put it in a pudding cup to melt because Resident #17 likes it that way, and I plan to give it at 4:00 PM. It's not the right procedure and I know that I am not supposed to do it this way. Employee G verified the amount remaining documented on the Narcotic logbook should always match what was in the locked refrigerator and locked cart for the resident. During an interview conducted on 2/4/2021 at 11:00 AM, the Regional DON stated an investigation was initiated immediately to determine the location of the missing capsule of Marinol 2.5 mg medication for Resident #17. She stated it was found that Employee G had pulled the dose early. The Regional DON stated, We found a pudding cup in his cart containing one round white tab and we compared it with the Marinol capsules and they did not match. He was relieved of his assignment and asked to give a written statement. His statement differed from his verbal account. He was escorted off the property pending investigation. We reported him to our human resources department and they will ask him to do a drug test. If he does not take the drug test, we will report him to the nursing board. The DON and myself inspected his cart and completed a narcotic count. We also spoke to the residents on his assignment and no other issues were found. He is on leave until the investigation is completed. On 02/04/21 at 11:30 AM, during an interview with Resident #17, she verified that she received her Marinol medication this morning and she did not have any concerns related to the administration of her medications. A medical record review revealed that Resident #17 was admitted to the facility on [DATE] with diagnoses of anemia and anorexia. A review of her physician's orders revealed an active order for the resident to have Marinol (controlled substance medication used to treat nausea and vomiting and as an appetite stimulant) 2.5 mg by mouth twice daily for anorexia (lack or loss of appetite for food). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105813 If continuation sheet Page 9 of 10 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 105813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Nursing Center 730 College Street Jacksonville, FL 32204 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 0842 . 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: 105813 If continuation sheet Page 10 of 10