Inspection·December 16, 2021

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/16/21 at 11:06 AM, CNA A stated Resident #26 was bed bound and dependent with all activities of daily living (ADLs). She stated the resident was legally blind and was receiving hospice care. When asked about the oxygen setting, she stated, The nurses take care of that. In an interview on 12/16/21 at 11:19 AM, Registered Nurse (RN) B/Unit Manager, confirmed that the oxygen was set at 4 LPM. She adjusted the setting to 2 LPM and stated the resident sometimes manipulated the setting. She confirmed that the concentrator was not within the resident's reach. She added that the resident was rapidly declining, therefore, nurses should check the setting. In an interview on 12/16/21 at 11:30 AM, MDS Coordinator C stated hospice corroborated with the facility and any new orders were added to the resident's care plan. When asked about the oxygen orders for Resident #26, she stated the resident was receiving oxygen for comfort care. She confirmed the resident's oxygen therapy had not been added to her care plan. (Copy obtained) On 12/16/21 at 12:15 PM, the Director of Nursing (DON) stated she was made aware of Resident #26 receiving higher than the prescribed flow rate of oxygen. She mentioned that she would initiate in-service training with the nurses to include verification of physicians' orders three times before administering medication. She added that the oxygen orders should have been added to the care plan. 2. A review of the clinical record revealed that Resident #38 was admitted to the facility on [DATE], with a primary diagnosis of unspecified atrial fibrillation. Secondary diagnoses included chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, chronic kidney disease, major depressive disorder, and transient cerebral ischemic attack. The resident had a Do Not Resuscitate (DNR) order and was receiving hospice care. A review of the December 2021 Physician's Order Sheets revealed no active orders for the administration of oxygen. A review of the medication list included with the 11/30/2021 3008 (hospital to nursing facility transfer form), revealed no indication or order for oxygen. A review of the hospital History and Physical, dated 11/24/2021, revealed no indication or order for oxygen. A review of the hospital referral, dated 11/30/2021, revealed no indication or order for oxygen. On 12/14/2021 at 10:15 AM, Resident #38 was observed in her room receiving oxygen via a nasal cannula. The oxygen flow rate was set at 2.5 LPM. (Photographic evidence obtained) On 12/15/2021 at 1:40 PM, Resident #38 was observed in her room sitting on her bed and receiving oxygen via nasal cannula. The oxygen flow rate was set at 2.5 LPM. A review of the 5-day minimum data set (MDS) assessment, dated 12/7/2021, revealed that Resident #38 had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. Her hearing was highly impaired, she required limited to extensive assitance with activities of daily living (ADLs), and she was receiving oxygen. A review of the resident's current care plan, revealed a focus for Respiratory Complications related to Congestive Heart Failure (CHF). Interventions included oxygen as ordered or needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 2 of 8 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 105821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217 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 A review of the admission Assessment, dated 4/2/2021, revealed Resident #38 was to receive oxygen at 2 LPM via nasal cannula. A review of the resident's Vital Signs from 11/30/2021 through 12//15/2021, revealed that oxygen was being received on the following dates and times: Residents Affected - Few Date Value Method 12/15/2021 01:16 98.0 % Oxygen via Nasal Cannula 12/14/2021 17:34 98.0 % Oxygen via Nasal Cannula 12/14/2021 00:16 98.0 % Oxygen via Nasal Cannula 12/13/2021 17:26 98.0 % Oxygen via Nasal Cannula 12/11/2021 20:40 100.0 % Oxygen via Nasal Cannula 12/9/2021 18:40 98.0 % Oxygen via Nasal Cannula 12/8/2021 19:07 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 3 of 8 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 105821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217 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 98.0 % Level of Harm - Minimal harm or potential for actual harm Oxygen via Nasal Cannula 12/7/2021 22:03 Residents Affected - Few 98.0 % Oxygen via Nasal Cannula 12/7/2021 18:58 98.0 % Oxygen via Nasal Cannula 12/6/2021 21:13 100.0 % Oxygen via Nasal Cannula 12/6/2021 19:30 97.0 % Oxygen via Nasal Cannula 12/1/2021 01:30 94.0 % Oxygen via Nasal Cannula 11/30/2021 13:04 97.0 % Oxygen via Nasal Cannula On 12/16/2021 at 12:25 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about Resident #38 currently receiving oxygen without a physician's order. The DON stated she believed that the resident received the oxygen during her recent trip to the hospital. She would have to check the hospital orders. On 12/16/2021 at 12:40 PM, an interview was conducted with RN B/Unit Manager. RN B was asked about verification of oxygen orders/parameters for a resident. The Unit Manager stated she usually verified them with the physician. The Unit Manager was asked to access Resident #38's current medication administration record (MAR). She reviewed the recorded oxygen saturations on 12/14/2021 and was asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 4 of 8 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 105821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217 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 how the nurse who documented that data verified the correct oxygen orders/parameters. RN B stated the nurse could not have verified the orders/parameters, because no order was noted on the MAR. 3. A review of Resident #44's clinical record revealed she was admitted to the facility on [DATE]. Her primary diagnosis was senile degeneration of the brain. Secondary diagnoses included insomnia, hyperlipidemia, shortness of breath, atherosclerotic heart disease of native coronary artery without angina pectoris, and hypertension. A review of the 11/3/2021 minimum data set (MDS) assessment revealed that Resident #44 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 8 out of a possible 15 points. She was documented as receiving oxygen therapy while a resident at the facility. On 12/13/2021 at 1:15 p.m., the resident was observed resting in bed with an oxygen concentrator in use. The flow rate was set at 3 LPM (liters per minute). On 12/14/2021 at 11:05 a.m., the resident was observed resting in bed with an oxygen concentrator in use. The flow rate was set at 3 LPM. On 12/15/2021 at 9:15 a.m., the resident was observed resting in bed with an oxygen concentrator in use. The flow rate was set at 3 LPM. On 12/15/2021 at 1:10 p.m., the resident was observed sleeping in her bed with an oxygen concentrator in use. The flow rate was set at 3 LPM, but the nasal cannula was lying on the floor beside her bed. A review of the resident's physician's orders revealed a 2/7/2018 order to check the resident's oxygen saturation every shift. A 2/7/2018 physician's order, last revised on 7/17/2019, documented oxygen at 2 liters via nasal cannula continuously. Change tubing and clean filter one time weekly on Sunday. A review of the resident's electronic medication administration record (eMAR) for December 2021, revealed documentation indicating that the resident was receiving oxygen at 2 LPM every day, evening, and night shift. A care plan, initiated on 3/1/2018 and last revised on 5/28/2021, documented the resident was on oxygen therapy. Interventions included administration of medications as ordered by the physician, and to monitor/document side effects and effectiveness; uses oxygen concentrator when in bed; receives continuous oxygen; and provide extension tubing or portable oxygen apparatus. An interview with Certified Nursing Assistance (CNA) D was conducted on 12/15/2021 at 1:14 p.m. She stated the CNAs were not permitted to touch the residents' oxygen concentrators. If a resident needed more oxygen, or more water in the concentrator, they would tell the nurse. She said oxygen was a medication, so the nurse had to make any changes. She further stated if a resident needed oxygen services, she would take the resident to the nurse. She was not permitted to adjust the flow rate, add oxygen to an empty tank, or monitor oxygen saturations. An interview with Registered Nurse (RN) F was conducted on 12/15/2021 at 1:17 p.m. She observed that Resident #44 was in her bed, and the oxygen tubing and nasal cannula were on the floor. The RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 5 of 8 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 105821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217 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 picked up the tubing and said the CNAs needed to let her know if a resident resisted care or their oxygen. She would document all of that in the resident's record. The resident had sometimes taken off her nasal cannula, which the RN would then chart. The RN confirmed that the resident's oxygen concentrator was currently on and set at 3 LPM. She said she would get the resident clean oxygen tubing and put it back on the resident. She stated it was important for the resident to get her oxygen. The nurse was responsible for the oxygen, not the CNAs. She said she checked the oxygen each morning for her residents. An interview was conducted with RN F on 12/15/2021 at 1:25 p.m., after she had assisted Resident #44. She said the record showed that the resident had been on oxygen for a long time, and that her physician's order was for 2 LPM continuously, which meant she was always supposed to receive oxygen at that flow rate. An interview with RN E/Unit Manager was conducted on 2/15/2021 at 1:30 p.m. She said she was informed that Resident #44 was observed receiving oxygen at 3 LPM, when the order was for a flow rate of 2 LPM. She said sometimes oxygen orders were written with parameters, so the nurses had a little more leeway with the oxygen settings. She said the physician's order for Resident #44 was only for 2 LPM. The nurses did not document the liters per minute that the oxygen was on when they recorded on the eMAR, they only recorded oxygen saturation levels. She stated regardless of the reason the oxygen flow rate had been adjusted for this resident, they should have treated it like a medication before any adjustments were made to administration. An interview was conducted with the Director of Nursing (DON) on 12/16/2021 at 12:50 p.m. She stated the CNAs could refill oxygen canisters, but they would not adjust the oxygen flow rate. If the CNA had concerns, they were to get the nurse. Only the nurse should adjust the flow rate. If the resident was found to have a change in condition, the nurse should talk with the provider about oxygen needs but should not adjust the oxygen flow rate without a physician's order. A review of the facility's policy and procedure titled, Oxygen Administration (Revised October 2010), provided a guideline for safe oxygen administration. The policy further indicated that staff should verify that there was a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Adjust the oxygen delivery device so that it is comfortable for the resident. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 6 of 8 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 105821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that one (Resident #26) of 25 sampled residents, remained free of significant medication errors, by failing to administer blood pressure medication as ordered. Failure to administer blood pressure medication as ordered, following parameters set by the physician, could result in a risk of injury from falls and/or extreme hypotension/shock, which could be life-threatening. Residents Affected - Few The findings include: A review of the clinical record revealed that Resident #26 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina. A review of the Physician Order Sheets for November and December 2021 revealed current orders for losartan potassium 50 mg (milligrams) at bedtime for hypertension (HTN - high blood pressure), hold if blood pressure (BP) is less than 90/60, and Cardizem 120 mg one time a day for HTN, hold if blood pressure is less than 90/60. Hold BP medication if BP remains low every shift. A review of the resident's medication administration record (MAR) for November and December 2021 revealed that blood pressures were documented as follows: On 12/12/21, the resident's BP was documented as 100/58 mm Hg (millimeters of mercury) On 12/3/21, the resident's BP was documented as 100/54 mm Hg On 11/11/21, the resident's BP was documented as 116/56 mm Hg On 11/12/21, the resident's BP was documented as 150/56 mm HG, and On 11/28/21, the resident's BP was documented as 135/52 mm Hg. Each diastolic blood pressure was less than 60, however Cardizem 120 mg daily for HTN was checked off by nursing as having been administered on all of these days, despite the parameters that were in place. The care plan indicated the resident received psychotropic medication, which placed resident at risk for drug-related side effects, including hypotension. On 12/16/21 at 11:19 AM during an interview with Registered Nurse (RN) B/Unit Manager, and when asked about the resident's losartan potassium parameters, she stated the medication should not be administered outside of the parameters. On 12/16/21 at 12:15 PM, the Director of Nursing (DON) stated she was made aware of Resident #26 having received blood pressure medication outside of the documented parameters ordered by the physician. She added that she conducted random audits of the medication administration records (MARs) but she missed this resident. She stated she would initiate in-service training with the nurses for verification of physicians' orders three times before administering medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 7 of 8 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 105821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility policy and procedure titled, Administering Oral Medication (Revised October 2010), revealed the guideline for safe administration of oral medication included: Review the resident care plan to assess for any special needs of the resident. The procedure steps included to check the medication dosage. Re-check to confirm the proper dose. According to the Mayo Clinic at https://www.mayoclinic.org/diseases-conditions/low-blood-pressure/symptoms-causes/syc-20355465 (Accessed on 1/5/22 at 3:00 p.m.): Low blood pressure might seem desirable, and for some people, it causes no problems. However, for many people, abnormally low blood pressure (hypotension) can cause dizziness and fainting. In severe cases, low blood pressure can be life-threatening. A blood pressure reading lower than 90 millimeters of mercury (mmHg) for the top number (systolic) or 60 mmHg for the bottom number (diastolic) is generally considered low blood pressure. Shock - Extreme hypotension can result in this life-threatening condition. If you have signs or symptoms of shock, seek emergency medical help. Some heart conditions that can lead to low blood pressure include extremely low heart rate (bradycardia), heart valve problems, heart attack and heart failure. Risk factors - Age. Drops in blood pressure on standing or after eating occur primarily in adults older than 65. Neurally mediated hypotension primarily affects children and younger adults. Medications. People who take certain medications, for example, high blood pressure medications such as alpha blockers, have a greater risk of low blood pressure. Certain diseases. Parkinson's disease, diabetes and some heart conditions put you at a greater risk of developing low blood pressure. Even moderate forms of low blood pressure can cause dizziness, weakness, fainting and a risk of injury from falls. And severely low blood pressure can deprive your body of enough oxygen to carry out its functions, leading to damage to your heart and brain. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 8 of 8