Inspection·October 19, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bus, but there is no timeline for when this will take effect. She was then asked how the facility was accommodating residents who were alert and oriented and would like to go out. She stated, They would have to work something out with their family. As far as I know, the facility policy is that residents should have a chaperone when going out of the facility. She was asked if the facility provided chaperones for residents who would like to go out. She replied, No, only for medical appointments. If the resident wanted a leisure outing, they had to find their own chaperones regardless of their cognitive status. On 10/19/23 at 11:35 AM, Registered Nurse (RN) D stated she had worked with Resident #14 several times. The resident was alert and oriented and able to make his needs known. She added that the resident refused medication and dialysis at times and seemed to be depressed. When asked if the resident was receiving psychiatric services, she said she was not sure. She reviewed the documents in the resident's medical record and stated she did not see any psychiatric notes. During a 10/19/23 interview at 11:46 AM with the Director of Nursing (DON), she was asked about Resident #14's cognitive status. She stated, He is alert and oriented and able to make his needs known. He is not confused and he understands his choices. When she was asked if the resident had any changes in his condition, she said no. She was then asked if the resident could sign himself out of the facility. She said, Yes, but the facility policy is that the resident has to be escorted. When asked if Resident #14 used to go out by himself, she replied, Yes, however there was a change of Administration and we updated the policy to require someone to accompany the resident just in case they might need assistance while they were out. She was again asked if the facility was providing chaperones and she said only for medical appointments. For personal outings, the residents had to provide their own chaperone. She was again asked about residents who were alert, oriented, able to make their needs known, and were their own responsible party. If they could not find anyone to accompany them, how was that addressed? She replied, I feel like we are going in circles. We go by the policy and that is what we thought was right for the residents. She provided sign-out sheets which revealed that Resident #14 had been signing himself out from June 2023 through September 2023. (Copies obtained) A review of the facility's policy titled Signing Residents Out (revised August 2006) revealed that all residents leaving the premises must be signed out. The policy did not indicate that residents required chaperones. (Copy obtained) A review of the facility's policy titled Safety and Supervision of Residents (revised December 2007), revealed: The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy, under System Approach to Safety section, further indicated: Resident supervision is a core component of the facility system approach to safety. The type and frequency of resident supervision as determined by the individual resident's assessed needs and identified hazards in the environment. The time and frequency of resident supervision may vary among residents and over time for the same residents. For example, residents' supervision may need to be increased when there are temporary hazard in the environment or if there is a change in condition. ( Copy obtained) . 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 10/19/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview with Resident #44 on 10/16/2023 at 8:48 AM, she stated she wanted a copy of the posters in the front lobby that had the information regarding who to call when she needed help or wanted to file a complaint. She was not familiar with who the Ombudsman was and what role they played. She wanted the Ombudsman's information. She was concerned about saying too much. She stated she was afraid of retaliation by the staff. Things are not always done right around here. Care is not always the best. She did not elaborate and added, That's all I'll say right now. She asked her daughter, who was involved in her health care decisions and care) be contacted for more information. Residents Affected - Few During an interview with the Social Services Director (SSD) on 10/17/23 at 9:47 AM, she was asked for the grievance log and about obtaining copies of the posters in the lobby. She stated she could get them and thought she might know who the resident was that was requesting the posters. The identity of the resident was not provided to her. She mentioned three female residents who she described as manipulative. Resident #44 was one of those residents. A review of the grievance log revealed a grievance was filed on behalf of Resident #44 on 5/15/23 regarding resident care. The grievance form was requested. A review of the grievance form dated 5/15/23 regarding Resident #44, revealed that the grievance was initiated by Resident #44's daughter. It read: [Employee E] used a fork to press into my calf my leg. She had been very rough with me when cleaning me to change my briefs. She shoved me and when I told her it hurt she shoved harder and then pushed me up against the bars, which hurt. I told her to stop. She pressed me harder against the bars of my bed. I was frightened and started yelling for help. No one heard me. When she finished, I told her that hurt. She proceeded to jab me in the leg with my fork. It was as though she was threatening to stab me with it. This all happened because I asked her to clean me with baby wipes instead of a towel on another occasion. I am afraid of [Employee E] because she seems to have a grudge against me. She treats me in a bullying manner. The person investigating the grievance was the SSD. The grievance was given to the Director of Nursing (DON) and the Administrator for follow up and further investigation. On 5/15/23, an Agency for Health Care Administration (AHCA) immediate Abuse and Neglect report was completed. The grievance follow-up section read: 3. 5/22/23 5-day AHCA report completed. 4. Abuse, Neglect, Exploitation and Residents Rights was conducted on 5/16/23, 5/17/23 and 5/25/23. 5. AN&E (abuse, neglect and exploitation) was also addressed during the Town Hall meeting on 5/30/23. Overall, the staff and Administration followed AN&E protocol per facility policy. Both resident and family were notified and satisfied with investigation outcome and resolution. (Photographic evidence obtained) The 5-day report, dated 5/15/23, read: Administrator and Social Services Director interview on 5/15/23: Resident alleges that along with staff member providing care, staff member took resident's fork and pressed it against her leg. (Photographic evidence obtained) During an interview with the DON on 10/17/23 at 10:59 AM regarding Resident #44's investigation of an allegation of abuse, she read the grievance form and the 5-day AHCA report completed by the facility. She stated she could not remember exactly how the investigation was conducted or why they concluded that the allegation was unsubstantiated. She stated she would go look for the documents. The DON returned at 11:13 AM and stated there were no internal investigation documents that she could find. She stated CNA E was either terminated for excessive absences or she quit. She thought she was terminated. She did not have an explanation for the conclusion of the investigation. (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 10/19/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview with Resident #44's daughter on 10/18/23 at 12:03 PM, she confirmed the information in the grievance form and stated that her mother was pretty shaken up. Her mother told her that CNA E had been very rough with her when cleaning her and changing her brief. She shoved her, and when she told her it hurt, she shoved harder and then pushed her up against the bars. She told her to stop and that she was hurting her. Her mother told her that the CNA pressed her even harder against the bars of her bed. She told her she was frightened and started yelling for help. No one responded. When the CNA finished, she told her that it hurt and then the CNA took her fork and jabbed her in the leg with it. Her mother told her she felt it was as though CNA E was threatening to stab her with it. Resident #44 told her that she was afraid of CNA E because she seemed to have a grudge against her for past incidents. She told her that CNA E bullied her. During a second interview with the DON on 10/19/23 at 2:31 PM, she stated at the time of the alleged incident with CNA E and Resident #44 on 5/13/23, the current Administrator was not the Administrator. The former Administrator investigated the incident and she remembered that there was a red file with the investigation documents in it. When the former Administrator left, the file disappeared and she could not find it. She stated she was sure that a thorough investigation had been done. She could not remember if the police were called, and confirmed it was part of the facility's policy to call them if a crime was suspected. A review of the facility's policy and procedure titled Abuse, Neglect and Exploitation (implemented on 12/31/22 and revised on 12/31/22), revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. It includes verbal, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. V. Investigation of alleged Abuse, Neglect and Exploitation. B. Written procedures for investigations include: 6. Providing complete and through documentation of the investigation. Based on observations, interviews, and record review, the facility failed to 1) Provide evidence that alleged violations of abuse were thoroughly investigated, and 2) Prevent further potential abuse while the investigation was in progress for two (Residents #68 and #44 ) of two residents whose grievances were reviewed, from a total sample of 22 residents. The findings include: 1. On 10/16/23 at 10:34 AM, Resident #68 stated she was watching the Grammy's a while back. She stated she pushed the call light button and when the Certified Nursing Assistant (CNA) came to the room, Resident #68 had forgotten what she wanted. She pushed the call light button again after she remembered what she wanted. Per Resident #68, when the CNA returned, she placed a pillow over the resident's face and to tried suffocate her. (Resident #68 could not remember the name of the staff involved.) She stated she was afraid and anxious and she reported the incident to the nurse. She added that the same CNA worked with her the following day in the evening and when she placed the call light on, the CNA asked, What do you want? Resident #68 told the CNA that she wanted her tray table across her bed as she was getting ready for dinner. The CNA responded, It's not even time for dinner yet. Was (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 10/19/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few what I did last night not enough? Resident #68 told the CNA not to return to the room again. The following day, the Director of Nursing (DON) and the Administrator went to her room and stated they would start an investigation. She added that a few days later her sister was told that the facility notified her that she might have been dreaming. Resident #68 denied having hallucinations. She said, I was wide awake watching the Grammy's so there is no way I was dreaming, and I still find it odd that they might think that I was dreaming while the CNA worked with me for two days in a row. A review of the medical record revealed that Resident #68 was admitted to the facility on [DATE] with a re-entry on 2/27/22. Her diagnoses included hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting her left non-dominant side; epilepsy, unspecified dementia, insomnia, anxiety disorder, and major depressive disorder. A review of the quarterly minimum data set (MDS) assessment, dated 8/16/23, indicated that the resident had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating she was cognitively intact. She required extensive assistance with activities of daily living (ADLs). There were no hallucinations or delusional behaviors noted in the assessment. A review of the psychiatric notes dated 2/17 /23, revealed that Resident #68 stated a staff member put a pillow over her face on the 3-11 shift a few weeks ago. A review of the facility's Abuse Report revealed that on 2/7/23 at 4:30 PM, the resident reported that CNA E attempted to suffocate her with a pillow during care. The facility's immediate action included the suspension of CNA E during the investigation of the incident. The resident was assessed for injuries, and adult protective services, the physician and the resident's family were notified of the incident. The facility initiated abuse and neglect training. The findings of the investigation were reported as unsubstantiated. In an interview with the DON on 10/17/23 at 11:45 AM, she confirmed the allegations reported by Resident #68. When asked for the findings of the facility's investigation and the facility's corrective actions, the DON stated the previous Administrator conducted the investigation and she could not find any documentation of it. A review of the personnel file for CNA E revealed that she was hired on 9/19/16. The file included several instances of disciplinary action related to attendance. There was no indication that she was suspended pending investigation when Resident #68 made the aforementioned allegation. There was documented evidence that CNA E was suspended from 5/31/23 through 6/1/23, but that was related to a violation of the facility's attendance policy. 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 10/19/2023 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that two (Resident #7 and #68) of three residents who were reviewed for inability to carry out activities of daily living, from a total sample of 22 residents, received necessary assistance to maintain good grooming and personal hygiene. Residents Affected - Few The findings include: 1. On 10/16/23 at 9:44 AM, Resident #7 stated he had not received a shower or bed bath in the last month. He added that the facility was operating with Agency staff who don't care. He further stated he was having diarrhea and it was important for him to get a bath/shower, as it was the only way he would feel clean. A review of the medical record revealed that Resident #7 was admitted to the facility on [DATE] with a re-entry on 5/2/23. His diagnoses included dementia, anxiety, depression, and lactose intolerance. A review of the physician's orders dated 5/3/23, revealed a schedule for weekly bathing on Tuesdays and Fridays during the 7 am to 3 pm shift. Further review of the physician's orders, revealed an order dated 10/18/23, indicating current diarrhea and a history of recurrent C-Diff (Clostridium Difficile - bacteria causing diarrhea and inflammation of the colon). A review of the Care Plan, last revised on 7/26/23, revealed that there was no ADL care plan. (Copy obtained) A review of the Certified Nursing Assistant (CNA) Task List for October 2023, revealed that the resident was to be showered/bathed on the following days: Tuesday, 10/3, Friday, 10/6, Tuesday, 10/10, Friday, 10/13, and Tuesday10/17. Documentation indicated the resident received a bed bath on 10/3/23, refused on 10/6/23, and received another bed bath on 10/10/23. There was no indication of bathing/showering or refusal of care on 10/13 or 10/17. A review of the quarterly Minimum Data Set (MDS) assessment, dated 8/7/23, revealed that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. He required extensive assistance for bed mobility, transfers, and toilet use, supervision for eating, and he was totally dependent upon staff for bathing. During a 10/19/23 interview with CNA A at 10:01 AM, she stated Resident #7 required total assistance from staff with ADL care. Resident #7 was alert and able to make his needs known. When asked if she worked with this resident on Sunday (10/15), she said she was not the assigned CNA, but the resident had his call light on and she answered it. The resident reported that he asked the assigned CNA to clean him and she had an attitude. CNA A went ahead and cleaned the resident and reported the resident's complaint to the nurse. 2. On 10/16/23 at 10:34 AM, Resident #68 was observed with long fingernails on both hands. She also had a dry, scaly scalp and was scratching her head. When asked if she received her showers/baths as scheduled/desired, she replied, I am lucky if get it at least once a week. She added that she had a prescription shampoo for psoriasis and therefore needed to have a shower. When she was asked about (continued on next page) 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 10/19/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm the length of her fingernails she said, As a nurse, I never liked long nails. I also used to have them done, but I have not had that here. I was told that staff were supposed to clip and clean them on shower days and as needed, but as you can see, they don't do it. The last time they were done, the Unit Manager was the one who clipped them. She added that the facility had a lot of Agency staff and they didn't seem to care about the residents. Residents Affected - Few On 10/17/23 at 11:51 AM, Resident #68 was again observed with long fingernails. She was seated in her wheelchair. She stated she had asked the staff to give her a shower and shampoo her hair with the prescription shampoo, and the CNA told her that the nurse should do that. Another observation was made on 10/18/23 at 10:15 AM. The resident was observed in bed. Her fingernails remained long, approximately two inches long, and both thumb nails were observed with debris underneath. A review of the medical record revealed that Resident #68 was admitted to the facility on [DATE] with a re-entry on 2/27/22. Her diagnoses included hemiparesis and hemiplegia following a cerebral infarction (stroke) affecting her left non-dominant side; epilepsy, unspecified dementia, insomnia, anxiety disorder, and major depressive disorder. A review of the quarterly Minimum Data Set (MDS) assessment, dated 8/16/23, revealed that the resident had a brief interview for mental status (BIMS) of 14 out of 15 possible points, indicating that she was cognitively intact. She required extensive assistance with activities of daily living (ADL). No hallucinations or delusional behaviors were documented in the assessment. A physician's order, dated 9/13/23, was noted for Clobetasol propionate shampoo, 0.05%, apply to scalp topically every day shift every Tuesday and Thursday for skin health to be done on shower days. A review of the care plan (last revised on 8/21/23), revealed that the resident had a focus area for ADL/Self-Care Performance Deficit related to impaired mobility. Interventions included that the staff assist the resident with bathing/showering. They were to check her nail length and trim and clean on bath/shower days and as needed. A review of the CNA Task List for October 2023, revealed that the resident was to be showered/bathed on the following days: Tuesday, 10/3, Thursday, 10/5, Tuesday, 10/10, Thursday, 10/12, Tuesday,10/17, and Thursday, 10/19. Documentation indicated that the resident received a shower on 10/6 and a bath on 10/10/23. There was no indication of bathing/showering or refusal of care on 10/3, 10/5, 10/12, or 10/17. In an interview on 10/19/23 at 10:01 AM, CNA A stated Residents #7 and #68 required total assistance from staff for all ADLs. She further stated there was a shower schedule on each unit and the residents received showers two times a week and as needed. Nail care should be provided during showers and as needed. She mentioned that showers were documented in the computerized charting system. When a resident refused care, the nurse should be notified and if the resident still refused, staff documented the task as having been refused. During an interview on 10/19/23 at 10:45 AM with Licensed Practical Nurse (LPN) C/Unit Manager, she stated residents should receive a shower two times a week unless they refused. She said the staff were expected to document in the electronic medical record when a shower was provided, and when a (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 10/19/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shower was refused, there was an alert that went to the nurses' dashboard for follow up. When she was asked when nail care was provided, she produced a form indicating that nail care should be provided on Wednesdays by the CNAs and as needed. She stated Activities staff also filed and polished residents' nails. When asked what days Residents #7 and #68 received their showers, she replied, Tuesdays and Fridays. She confirmed that Residents #7 and #68 had only three baths/showers documented for the month of October 2023. She also confirmed that Resident #7 did not have an ADL care plan. She was accompanied to Resident #68's room and she confirmed that the resident's nails were long. Resident #68 stated at that time that she would like to have them clipped. A review of the facility's policy and procedure titled Activities of Daily Living (ADLs) (implemented on 6/1/23), revealed: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure that a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care services will be provided for the the following activities of daily living: Bathing, dressing, grooming and oral care; transfer and ambulation; toileting and eating. The policy further explained that a resident who was unable to carry out activities of daily living would receive the necessary services to maintain a good nutrition, grooming and personal and oral hygiene. The facility would maintain individual objectives of the care plan and periodic review and evaluation. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 8 of 8