Inspection·October 2, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm 2/25/2025 - O2 at 2L/min NC (via nasal cannula) every night at bedtime (QHS) for chronic obstructive pulmonary disease (COPD). 2/24/2025 - O2 at 2L/min via nasal cannula as needed to maintain O2 saturation % >92%. Check O2 saturation % every shift to keep O2 saturation levels > 92%. Residents Affected - Few Further review of Resident #73's medical record revealed that she was admitted to the facility on [DATE] with an admitting diagnosis of acute on chronic diastolic (congestive) heart failure. Additional diagnoses included, but were not limited to, atherosclerotic heart disease, atrial fibrillation, anxiety disorder and non-rheumatic aortic (valve) stenosis. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 8/29/2025, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. She was documented as receiving hospice care and had a DNR (Do Not Resuscitate) status. A review of the resident's active care plan, initiated on 8/29/2025, revealed a target completion date of 9/2/2025, and a completed date of 9/26/2025. The resident was noted as at risk for breathing problems related to her diagnosis of COPD and was at risk for respiratory complications. Goals and interventions included but were not limited to: Maintain respiratory baseline as evidenced by no occurrence of dyspnea or SOB (shortness of breath) through the review period. Administer medications as ordered by the physician. Administer oxygen at night as ordered. Encourage to clear secretions. Head of bed with 2-3 pillows while in bed/chair as tolerated per patient. Monitor O2 saturation as ordered. Observe and report signs and symptoms of respiratory infections and report to MD. Observe and report signs of dyspnea and SOB. Observe respiratory status for rate, depth and ease, essence of tachypnea, dyspnea in relation to disease process or decreased energy level. Assess for shortness of breath and cyanosis as needed. Monitor vital signs as ordered. Notify MD (physician) of significant abnormalities. The Medical Director's report dated 9/9/2025 and electronically signed on 9/23/2025 revealed: COPD/SOB - Continue Long-Acting Beta-Antagonist (a type of bronchodilator medication) every 12 hours, as needed O2, and nocturnal O2. Patient has orders for O2 as needed and she does okay with this during the day but reports she needs O2 all throughout the night - order nocturnal O2 via Nasal Cannula @ 2L. Patient assessed and well compensated on Room Air, lungs diminished but clear; 9/9/25 patient seen and assessed, she is alert and doing well - patient wearing O2 today and sats 95%, continue O2 throughout day PRN (as needed) and continuous QHS as well as pulmonary toilet - lungs clear – monitor. On 10/02/2025 at 12:08 PM, Nurse A stated she had worked at the facility for about two years. She further stated she reviewed doctors' orders in the electronic medical record to verify the oxygen flow rate a resident should be receiving. She stated she checked the oxygen concentrator and oxygen delivery tubing about once per shift but would check more often if the resident seemed to be experiencing distress. She checked the oxygen saturation levels per the physicians' orders using the monitor that was kept in the nursing cart. She stated the facility conducted different in-service training throughout the year and had staff sign an attendance log when training was provided. When asked what Resident #73's oxygen flow rate should be, Nurse A stated 2 L/min. Earlier on this date at 9:10 AM, Resident #73's O2 flow rate was adjusted from 4 L/min to 2 L/min by Nurse A after she was asked what the resident's flow rate should be. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 2 of 3 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 10/02/2025 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 On 10/02/2025 at 1:00 PM, Nurse B/Unit Manager stated she had worked at the facility for 20 years. She stated she would review the orders in the EMR to verify at what flow rate Resident #73's oxygen should be set. She stated residents' oxygen saturation levels were obtained by using the pulse oximeter kept in the nursing cart. Oxygen delivery tubing was usually ordered to be changed weekly, and oxygen humidifier bottles were changed monthly. She further stated if a resident was receiving oxygen, they should be checked on a regular basis, like, every nurse should check every shift. When she was asked to check the oxygen flow rate order in Resident #73's EMR, she did and replied that the resident should be receiving 2 L/min. A review of the facility's policy titled Oxygen Administration Level III (revised October 2010), revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the preparation section, the policy directed the reader to verify that there was a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. The policy listed a humidifier bottle under equipment and supplies. The policy stated the humidifying jar was to be checked to be sure it was in good working order, securely fastened, and that the water level was high enough that the water bubbled as oxygen flowed through. (Photographic evidence obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105821 If continuation sheet Page 3 of 3