Inspection·May 2, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm diagnoses included unspecified dementia, major depressive disorder, epilepsy, and schizoaffective disorder. Further review of the record revealed that the admission PASARR for Resident #33 did not reflect the diagnosis of schizoaffective disorder. Residents Affected - Few A review of the resident's 11/8/2023 Quarterly MDS, revealed the following diagnoses: dementia, Parkinson's disease, seizure disorder/epilepsy, anxiety, depression, and manic depression (bipolar disease). Schizoaffective disorder was not noted. A review of the 3/20/24 Annual MDS, revealed the following diagnoses: dementia, Parkinson's disease, seizure disorder/epilepsy, anxiety, depression, and manic depression (bipolar disease). Schizoaffective disorder was not noted. Section B (Hearing, Speech, and Vision) indicated the resident had clear speech, was sometimes understood, and was sometimes able to understand others. Under Section C (Cognitive Patterns), the resident was documented as unable to participate in a brief interview for mental status (BIMS) because he was rarely/never understood. Under Section C (Cognitive Patterns), the resident was documented as unable to participate in a brief interview for mental status (BIMS) because he was rarely/never understood. Staff documented this section of the assessment as follows for Resident #33: Long and short-term memory problems, and severely impaired cognitive skills for daily decision-making. He was noted with an acute change in mental status from his baseline as follows: Inattention - behavior continuously present. Disorganized thinking - behavior continuously present. The resident was not interviewed for Mood (Section D) because he was rarely/never understood. Staff documented the following: Appearing down, depressed or hopeless nearly every day. Trouble concentrating on things nearly every day. Social isolation: Sometimes. On 5/2/2024 at 1:55 p.m. during an interview with the Social Services Director, she stated she had been employed with the facility since December 2023. She stated she was aware of the issues with the facility's PASARRs. She was shown the PASARRs for Residents #25 and #33. She agreed a Level II review should have been done for both residents. She confirmed that Resident #25's bipolar diagnosis was present upon admission in the facility. She stated the schizoaffective diagnosis for Resident #33 was added after his admission and the facility failed to perform an updated screening with the new diagnosis. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105826 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 105826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Jacksonville, The 1771 Edgewood Ave W Jacksonville, FL 32218 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, by failing to employ a qualified food service manager who met state requirements for food service managers and who did not frequently receive consultations from a qualified dietitian or other clinically qualified nutrition professional. The findings include: During the initial kitchen tour, conducted on 4/29/24 at 10:20 a.m., Employee D stated she was responsible for the Dietary Department and the kitchen staff; the Registered Dietitian (RD) would not be at the facility until Thursday, 5/2/24. A follow-up tour of the kitchen was conducted on 5/1/24 at 11:50 a.m. Employee D confirmed that no recipes were used for the lunch meal. When she was asked how staff would know how to prepare the cabbage, she replied, It's just basic steaming of the cabbage. I talk staff through it. You use a little butter in the bottom of the pan, water and steam. I go back to working with my granny on how she would cook and not measure. She stated she had been cooking by sight since 2001. A review of facility documentation titled Employee Status Change Form, dated: 9/21/23, revealed that Employee D's job title was changed to Dietary Manager at that time. (Photographic evidence obtained) A review of facility documentation titled Dietary Manager - Job Description, revealed that minimum requirements for the position included one of the following: Certification as a dietary manager; certification as a food service manager; has similar national certification for food service management and safety from a national certifying body; has an associate's or higher degree in food service management or in hospitality if the course of study includes food service or restaurant management from an accredited institution of higher learning; has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting, and has completed a course of study in food safety and management by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. Must also meet State requirements for food service managers or dietary managers. Two years' experience in food service management. Prior experience in healthcare food service preferred. (Photographic evidence obtained) On 5/2/24 at 11:53 a.m., an interview was conducted with Employee D, which revealed that the Dietary Department did not get the correct food items to serve the menu because some ordered items were not delivered. She stated she called the RD to ensure the appropriate nutrients were included for the meal served. She stated the kitchen did not run out of food, but if a food item was needed, the Administrator would purchase it from the local store. Employee D stated substitutions were used on the menu maybe two times per month. There had not been any changes to the food budget. There were no issues with food theft. Employee D stated she was responsible for overseeing the food budget. If she was over budget, corporate would notify her regarding the overage. She was responsible for purchasing food and supplies for the kitchen. When asked what was the status of her CDM application, she reported that she had not taken CDM classes or applied for the exam. I'm working on it, it is a long (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105826 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 105826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Jacksonville, The 1771 Edgewood Ave W Jacksonville, FL 32218 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few process. I should have it before the end of this year. She reported completing the SafeServ course and exam in January 2024. When asked what were some of the complaints received from the resident council meeting, she stated, Cold food, food is spicy, request for double portions, or not enough food. She discussed corrective actions with the RD to ensure temperatures were warmer and likes/dislikes were documented on the meal ticket. She stated spices were not used; seasoned salt and table salt were used to season food when preparing meal items. In an interview on 5/2/24 at 12:34 p.m. with the RD, she stated she was contracted and worked about 16 hours per month. When she was asked what her role was in the facility, she replied, Mostly a clinical dietitian and to be of any assistance to [Employee D]. The facility previously had a Certified Dietary Manager (CDM) and she would assist the CDM with menu changes and kitchen inspections in the past. Since the Dietary Manager role had been filled, the RD stated she was still assessing what kind of assistance was needed. The CDM had more training than [Employee D], so I might need to assist more. She has been working in a lead role for a long time, so I don't want to offend or overstep, or question skills and knowledge. We're working through that and trying to discover that. Her title is Dietary Manager; she is not a CDM. She can't complete clinical duties, so I have taken on more clinical responsibilities. The RD was asked whether she knew if the facility is getting the correct food items required to serve the menus. She replied, For the most part. Most of the time yes, but she has had difficulty getting some things for one reason or another. When asked whether the kitchen had ever run out of food, the RD replied, No, they do not run out of food. When asked what was the frequency of substitutions being used, the RD stated she was not notified every time a substitution was offered. We're working on that, for her to contact me. She was not aware of any changes in the food budget. Corporate, the Administrator and Employee D were responsible for overseeing the food budget. Employee D was responsible for the purchasing of food and supplies. When asked whether she was aware of some of the complaints received from the resident council meeting, the RD replied, From time to time, it's been a while. The RD and Employee D discussed resident preferences, likes, and dislikes during the RD visit. An interview on 5/2/24 at 2:25 p.m. with the Administrator, revealed he was not aware of the status of Employee D's CDM application. He had been at the facility since February 2024 and was not aware of the process. He stated corporate oversaw the food budget. Employee D purchased food and supplies for the kitchen. The RD was contracted and was responsible for the clinical aspect of the department to include assessments and diets. Employee D was responsible for food service operations. An interview was conducted with the Administrator on 5/2/24 at 2:30 p.m. He stated the RD did not attend QAPI meetings because they fell on Fridays. The RD worked at the facility on Thursday's. He stated going forward he would have the RD work on Fridays during QAPI so she could be involved. A review of the facility's policy and procedure titled Dietary Services - Staffing (revised 1/13/2023), revealed: The facility employs sufficient staff with the appropriate competencies and skills sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Policy Explanation and Compliance Guidelines for staffing: . 3. If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility will designate a person to serve as the director of food and nutrition services who: a. For designations prior to November 28, 2016, meets these requirements not later than 5 years after November 28, 2016 or no later than one year after November 28, 2016 for designations after November 28, 2016 is: i. A certified dietary manager; ii. A certified food service manager; iii. Has similar national certification for food service management and safety from a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105826 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 105826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Jacksonville, The 1771 Edgewood Ave W Jacksonville, FL 32218 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few national certifying body; or iv. Has an associate's or higher degree in food service management or in hospitality if the course study includes food service or restaurant management, from an accredited institution of higher learning; and b. In states that have established standards for food service managers or dietary managers; meets State requirements for food service managers or dietary managers. c. Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105826 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 105826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Jacksonville, The 1771 Edgewood Ave W Jacksonville, FL 32218 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and policy and procedure review, the facility failed to ensure food served was prepared by methods that conserved nutritive value and flavor, by failing to follow standardized recipes to provide palatable and appetizing food in accordance with professional standards for food service. This practice can result in decreased food consumption by residents who consume foods from the facility's kitchen. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. Residents Affected - Many The findings include: During a follow-up tour of the kitchen on 5/1/24 at 11:50 a.m., Employee D was asked to provide the recipes used for today's menu. Employee D confirmed that no recipes were used today. When she was asked how staff would know how to prepare the cabbage, she replied, It's just basic steaming of the cabbage. I talk staff through it. You use a little butter in the bottom of the pan, water and steam. I go back to working with my granny on how she would cook and not measure. I've been cooking by sight since 2001. During the same follow up tour of the kitchen on 5/1/24 at 11:50 a.m., a regular diet test tray was ordered. The test tray left the kitchen at 12:53 p.m. and arrived on the west hallways at 12:56 p.m. The regular diet test tray food items included fried chicken leg, steamed rice, cabbage, and peach cobbler. The test tray was received at 1:11 p.m. Results of the test tray concluded that the cabbage flavor was unpalatable. It tasted highly of pepper. On 5/2/24 at 11:05 a.m., an interview was conducted with [NAME] A. When asked what was used to follow and prepare menu items, such as pureed meat or cabbage, she stated the shredded cabbage was received from the food distributor precooked. She used the shredded carrots of the cabbage but not the purple cabbage. Seasoned salt was added to the cabbage. We don't have a recipe. [Employee D] would have already printed a menu of what was to be prepared and provided all of the food components to cook the meal (meat, starch, vegetable, and dessert). If she prepared hamburger, the hamburger was cooked or blended fine. A thickener was added, bread, or mashed potatoes for pureed menu items. When asked again how she followed meal recipes as she was preparing each meal item, [NAME] A replied, No, if you know how to cook, you know how to cook. If you don't know, you ask somebody. On 5/2/24 at 11:17 a.m., an interview was conducted with Employee B, Cook. She reported she had been a cook at the facility for one year. When asked what was used or followed to prepare menu items such as pureed meat or cabbage, she replied, The manager provides a menu, cooks the meat and separates some for puree. Hot water or bread was added for pureed items if the kitchen was out of thickener. When asked whether meal recipes were used to prepare meal items, she replied, I don't think we have any. [Employee D] shows the cooks how to prepare almost all menu items. She stated she really did not know how much seasoning to add. I know not to put too much. When asked whether the kitchen had the correct food items to serve the menu, she replied, Some, but a lot don't come in. When asked if they ever ran out of food, she replied, Yes, maybe one to two days per week. If they run out of a food item, a substitute is used; a vegetable is substituted with another vegetable or the entire meal is changed. On 05/02/24 at 11:38 a.m., an interview was conducted with Employee C, Cook. When asked what was used or what menu was followed to prepare menu items such as pureed meat or cabbage, she replied, A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105826 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 105826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Jacksonville, The 1771 Edgewood Ave W Jacksonville, FL 32218 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many menu is printed and placed on the table. The recipe book is in the Manager's office. I've cooked cabbage a lot so I already know. If something is new, I look at the recipe. When asked if she followed meal recipes as she was preparing the meal item, she replied, Yes, because I've already cooked the item before. She stated, The kitchen may be short of food or does not have the correct food items to serve the menu a day before food delivery. She also stated the kitchen did not run out of food and they did not have to make a lot of substitutions. On 5/2/24 at 11:53 a.m., an interview was conducted with Employee D, which revealed that the Dietary Department did not get the correct food items to serve the menu because some ordered items were not delivered. She stated she called the RD to ensure the appropriate nutrients were included for the meal served. She stated the kitchen did not run out of food, but if a food item was needed, the Administrator would purchase it from the local store. Employee D stated substitutions were used on the menu maybe two times per month. There had not been any changes to the food budget. There were no issues with food theft. Employee D stated she was responsible for overseeing the food budget. If she was over budget, corporate would notify her regarding the overage. She was responsible for purchasing food and supplies for the kitchen. When asked what was the status of her CDM application, she reported that she had not taken CDM classes or applied for the exam. I'm working on it, it is a long process. I should have it before the end of this year. She reported completing the SafeServ course and exam in January 2024. When asked what were some of the complaints received from the resident council meeting, she stated, Cold food, food is spicy, request for double portions, or not enough food. She discussed corrective actions with the RD to ensure temperatures were warmer and likes/dislikes were documented on the meal ticket. She stated spices were not used; seasoned salt and table salt were used to season food when preparing meal items. In an interview on 5/2/24 at 12:34 p.m. with the RD, she stated she was contracted and worked about 16 hours per month. When she was asked what her role was in the facility, she replied, Mostly a clinical dietitian and to be of any assistance to [Employee D]. The facility previously had a Certified Dietary Manager (CDM) and she would assist the CDM with menu changes and kitchen inspections in the past. Since the Dietary Manager role had been filled, the RD stated she was still assessing what kind of assistance was needed. The CDM had more training than [Employee D], so I might need to assist more. She has been working in a lead role for a long time, so I don't want to offend or overstep, or question skills and knowledge. We're working through that and trying to discover that. Her title is Dietary Manager; she is not a CDM. She can't complete clinical duties, so I have taken on more clinical responsibilities. The RD was asked whether she knew if the facility is getting the correct food items required to serve the menus. She replied, For the most part. Most of the time yes, but she has had difficulty getting some things for one reason or another. When asked whether the kitchen had ever run out of food, the RD replied, No, they do not run out of food. When asked what was the frequency of substitutions being used, the RD stated she was not notified every time a substitution was offered. We're working on that, for her to contact me. She was not aware of any changes in the food budget. Corporate, the Administrator and Employee D were responsible for overseeing the food budget. Employee D was responsible for the purchasing of food and supplies. When asked whether she was aware of some of the complaints received from the resident council meeting, the RD replied, From time to time, it's been a while. The RD and Employee D discussed resident preferences, likes, and dislikes during the RD visit. An interview on 5/2/24 at 2:25 p.m. with the Administrator revealed he was not aware of the status of Employee D's CDM application. He had been at the facility since February 2024 and was not aware of the process. He stated corporate oversaw the food budget. Employee D purchased food and supplies for the kitchen. The RD was contracted and was responsible for the clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105826 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 105826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Jacksonville, The 1771 Edgewood Ave W Jacksonville, FL 32218 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many aspect of the department to include assessments and diets. Employee D was responsible for food service operations. A review of the facility's policy and procedure title Food Preparation Guidelines, revealed, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. 2. Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. This includes but is not limited to: . b. preparing foods as directed. 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: . b. using spices or herbs to season food in accordance with recipes. c. serving hot food/drinks hot and cold foods/drinks cold. d. addressing resident complaints about foods/drinks. (Copy obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105826 If continuation sheet Page 8 of 8