Inspection·July 29, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some splatter was on the pump, wall, floor, bed frame, mattress and IV pole. A plastic cap and debris were also observed next to the wall and under the bed. (Photographic evidence obtained) On 7/29/2021 at 10:18 AM, Resident #18's room was observed for a third time. The enteral food product splatter previously observed on 07/26/2021 and 07/27/2021, remained on the pump, the pole, and the wall. (Photographic evidence obtained) On 7/29/2021 at 10:22 AM, Resident #33's room was observed for a second time. The enteral food product splatter previously observed on 07/28/2021, remained on the pump, wall, floor, bed frame, and IV pole. On 7/29/2021 at 10:26 AM, Resident #91's room was observed for a second time. The enteral food product splatter previously observed on 07/28/2021, remained on the pump, wall, floor, bed frame, mattress and IV pole. A plastic cap and debris were once again observed next to the wall and under the bed. (Photographic evidence obtained) On 7/29/2021 at 10:39 AM, Resident #5's room was observed for a second time. The enteral food product splatter previously observed on 07/28/2021, remained on the IV pole, wall, and floor. (Photographic evidence obtained) On 7/29/2021 at 10:41 AM, Resident #14's room was observed for a second time. The enteral food product splatter previously observed on 07/28/2021, remained on the IV pole, wall, and floor. (Photographic evidence obtained) A review of Resident #42's clinical record revealed a physician's order, which read: Enteral Feed Order every shift Jevity 1.5 at 50 ml/hour x 20 hours via pump. A review of Resident #18's clinical record revealed a physician's order, which read: Enteral Feed Order every shift for to allow for by mouth intake Jevity 1.5 @ 40 ml/hour x 12 hours (on at 6p off at 6a). A review of Resident #5' clinical record revealed a physician's order, which read: Enteral Feed Order every shift Isosource 1.5 cal. at 60 ml/hour x 20 hours via pump, on at 2 PM, off at 10 AM. A review of Resident #14's clinical record revealed a physician's order, which read: Enteral Feed Order every shift Jevity 1.5 at 55 ml/hour x 20 hours via pump. A review of Resident #33's clinical record revealed a physician's order, which read: Enteral Feed Order every shift Jevity 1.5 at 55 ml/hour x 20 hours via pump. A review of Resident #91's clinical record revealed a physician's order, which read: Enteral Feed Order every shift Jevity 1.5 at 75 ml/hour via pump to be turned off. One time a day Jevity 1.5 @75 ml/hour to be turned back on @1700. During an interview with the Housekeeping Supervisor on 07/29/2021 at 1:20 PM, he was shown the food splatter in the six residents' rooms. While observing the rooms, he stated he was not aware the enteral food product had been splattered on the various surfaces in each room. When he was asked who was responsible for cleaning the food splatters in the rooms he replied, Housekeeping is. He stated he would immediately clean the rooms and replace the IV poles so they could be cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 2 of 9 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the Regional Nurse Consultant on 07/29/2021 at 5:00 PM, she stated that if the nurse makes the mess with the enteral food product, they should clean it up right away and not leave it to dry. Review of the facility policy and procedure entitled Daily Cleaning Schedule revealed: Resident Rooms. Clean bathrooms, vents, paper & soap, high & low dust, trash, baseboards, beds, furniture, blinds, sills, tables, chairs, light fixtures, closets, windows, doors & handles. Detail Clean 3-4 rooms or check outs each day. Report any floor problems immediately. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 3 of 9 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interview, the facility failed to revise the physicain's orders for continuous oxzygen therapy in the care plan for one (Resident #162) out of 38 residents receiving respiratory treatment, from a total of 36 sampled residents. Failing to revise care plans places the resident at risk of not receiving appropriate care. The findings include: On 07/26/2021 at 2:32 PM, Resident #162 was observed in her room lying in bed with her eyes closed with a nasal cannula on her face. Her oxygen (O2) concentrator was turned on its side and pushed in between the nightstand and the wall with a chair stacked on top of it. The concentrator was running. The reading on the concentrator was not able to be seen and the tubing was not dated. On 07/27/20 at 1:32 PM, Resident #162 was observed in her room, lying in bed with her eyes open. She did not respond to questions. Once again, her oxygen (O2) concentrator was turned on its side and pushed in between the nightstand and the wall with a chair stacked on top of it. When the oxygen concentrator was pulled out from its position, the oxygen level setting was at 3 liters per minute. (Photographic evidence obtained) On 07/29/2021 at 11:38 AM, Resident #162's oxygen concentrator was observed running and set at 2.5 liters per minute. (Photographic evidence obtained) A review of Resident #162's clinical record revealed she was admitted to the facility on [DATE] and then readmitted on [DATE]. Her diagnoses included transient cerebral ischemic attack, cerebral infarction, chronic systolic, heart failure, peripheral vascular disease, atrial fibrillation (A-Fib), congestive heart failure (CHF), edema, coronary artery disease (CAD), embolism, and thrombosis of arteries of the lower extremities, gastroesophageal reflux disease without esophagitis, hypokalemia, pain in right lower limb, muscle weakness, need for assistance with personal care. A review of Resident #162's Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Oxygen therapy was marked yes. (Photographic evidence obtained) A review of Resident #162's physician's orders revealed continuous oxygen at 2L/minute with a start date 07/19/2021. (Photographic evidence obtained) A review of Resident #162's care plan dated 07/14/2021 read: The resident is at risk for altered respiratory status/difficulty breathing related to a history of coronary artery disease and chronic heart failure. The interventions included: Encourage resident to cover mouth when coughing. Encourage resident to wash their hands frequently. Observe and notify physician if the resident experiences increased respiratory distress such as shortness of breath or low O2 saturation. Observe changes in vital signs. Observe for cough. The resident has altered cardiovascular/circulatory status relate to A-Fib/CAD with pacemaker, CHF, hypertension, deep vein thrombosis. The interventions included: Administer oxygen as needed. (Photographic evidence obtained) A review of Resident #162's Medication Administration Record (MAR) read: Change O2 tubing and nebulizer circuit every day shift every Wednesday. Start date: 06/18/2020. Oxygen saturation rates every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 4 of 9 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift for hypoxemia. Start date 06/14/2021. Administer Oxygen at 2 liters via nasal cannula if O2 sat drops below 90%. May titrate O2 to keep saturation >90%. Ask resident to take several breathes prior to administration of oxygen. Notify family if oxygen is administered. Start 11/12/2019. Discontinued on 07/19/2021. No other orders for oxygen therapy were listed on the MAR. (Photographic evidence obtained) During an interview with Employee D, Unit Manager (UM) on 07/29/2021 at 11:45 AM, he stated Resident #162 was a hospice recipient. He confirmed the oxygen concentrator was not set at 2L/minute. He stated that the resident's sister was just visiting with her and sometimes she changes the setting on the concentrator. He was not sure what her O2 level should be set at and left the interview to go look for the order and the date the tubing was changed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 5 of 9 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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 provide activities of daily living (ADLs) necessary to maintain grooming and personal hygiene for one (Resident #61) out of a total of 36 sampled residents. The resident's fingernails were not clean or trimmed. Residents Affected - Few The findings include: On 07/26/2021 at 2:13 PM, Resident #61 was observed sitting on her bed with her hands on the bedside table. Her fingernails on both hands were untrimmed and approximately two inches long with a black substance under some of the nails. An interview was conducted with Resident #61 at the time of the observation. When she was asked if she liked her nails long, she said, No, I can't find scissors to clip them. On 07/27/2021 at 1:07 PM, Resident # 61 was observed lying on her bed completing a puzzle. Her fingernails were still long and unclean. During the observation, she once again stated that she wanted her nails clipped, but no one brought her scissors. Record review for Resident #61 revealed she was admitted to the facility on [DATE] and then readmitted on [DATE]. Her diagnoses included senile degeneration of the brain, major depressive disorder, muscle weakness, constipation, protein calorie malnutrition, and anxiety disorder. Record review of the 05/26/2021 quarterly minimum data set (MDS) for Resident #61's revealed she had a brief interview of mental status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. A review of her functional status revealed she needed extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. Record review of Resident #61's care plan found she was care planned for activities of daily living (ADL) self-care performance deficit related to advanced age with generalized weakness, cognitive impairment, poor safety awareness and impaired balance. Review of the interventions revealed the resident required extensive assistance from staff with personal hygiene and oral care. On 07/29/2021 at 3:20 PM, Resident #61 was observed lying in bed. Her fingernails on both hands remained long and untrimmed with a brown substance under some of her nails. On 07/29/2021 at 3:25 PM, an interview was conducted with Employee A, certified nursing assistant (CNA) assigned to care for Resident #61. When she was asked if she provided nail care to Resident #61, she said, No. When she was asked who did, she said, I'm not sure. She then stated that some residents get their nails done in the beauty shop. An interview was conducted with Employee B, Registered Nurse (RN)/Unit Manager on 07/29/2021 at 3:28 PM. After reviewing Resident #61's fingernails, she confirmed they were long and unclean and needed to be clipped. She stated the CNAs were supposed to provide nail care on shower days and clean them daily as needed. While at the bedside, Resident #61 stated that she would like to have her nails clipped, but no one provided her with scissors. She then asked Employee B for scissors. Employee B commented that Resident #61 refused care most of the time. When asked if the refusal of care was documented, Employee B answered, No. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 6 of 9 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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 A review of the facility's policy and procedure for Activities of Daily Living (ADLs), review date 05/05/2020, revealed the following procedure will be followed for fingernail care: Level of Harm - Minimal harm or potential for actual harm 1. Ensure fingernails are clean and trimmed to avoid injury and infection. Residents Affected - Few 2. Explain the importance of fingernail care to the resident. 3. Assemble all necessary equipment which may include fingernail clipper, nail file or emery board, orange sticks, wash basin, towel, and any other necessary equipment. 4. Provide privacy and perform nail care, taking care not to trim the nail below the skin line and not to cut the skin. 5. Report any abnormalities to the nurse. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 7 of 9 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility policy and procedure review, the facility failed to provide urinary catheter care for one (Resident #162) of five sampled residents with indwelling catheters, from a total of 36 sampled residents. Resident #162 had recently been treated for a urinary tract infection (UTI). Failure to provide catheter care could potentially exacerbate the urinary tract infection. The findings include: On 07/26/2021 at 2:32 PM, Resident #162 was observed in her room lying in bed with her eyes closed. Her catheter bag was sitting directly on the floor. The catheter tubing had dark brown sediment in it. (Photographic evidence obtained) On 07/27/2021 at 12:05 PM, Resident #162's catheter bag was observed hanging on the bed rail at the level of her bladder. The catheter tubing had dark brown sediment in it. (Photographic evidence obtained) On 07/27/2021 at 1:32 PM, Resident #162's catheter bag was observed to be hanging at the level of her bladder. The catheter tubing had dark brown sediment in it. (Photographic evidence obtained) On 07/29/2021 at 11:38 AM, Resident #162's catheter bag was observed sitting directly on the floor. The catheter tubing had dark brown sediment in it. (Photographic evidence obtained) Record review for Resident #162 revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included transient cerebral ischemic attack, cerebral infarction, chronic systolic heart failure, peripheral vascular disease, atrial fibrillation, heart failure, edema, coronary artery disease, embolism, and thrombosis of arteries of the lower extremities, end stage renal failure, gastroesophageal reflux disease without esophagitis, hypokalemia, pain in right lower limb, muscle weakness, need for assistance with personal care. (Photographic evidence obtained) Record review of the 07/07/2021 comprehensive minimum data set (MDS) for Resident #162 revealed she had an indwelling catheter in use. (Photographic evidence obtained) Review of the physician's orders for Resident #162 read catheter care: every shift, keep catheter bag placed below the level of the bladder. No other orders were found for catheter care. (Photographic evidence obtained) Review of the discontinued physician's orders for Resident #162 revealed an order dated 06/29/2021 for Bactrim DS tablet 800-160 milligrams. Give 1 tablet by mouth one time a day for urinary tract infection (UTI) for 5 days. Review of the care plan for Resident #162 dated 07/14/2021 revealed the resident has an indwelling Foley catheter inserted related to end stage renal disease. Catheter care every shift. Observe for and document for pain/discomfort due to catheter. Observe for and report to physician for signs or symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp. Urinary frequency. Foul smelling urine, fever, chills, altered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 8 of 9 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mental status, change in behavior, change in eating patterns. Observe for signs and symptoms of discomfort on urination and frequency. Resident's Foley catheter inserted on 06/23/2021 for one week. Inserted on 06/28/2021 for urinary retention. Removed on 06/28/2021. Inserted on 07/02/2021. No other interventions were found. (Photographic evidence obtained) During an interview with Employee D, Unit Manager (UM) on 07/29/2021 at 11:45 AM, he stated that they keep the catheter bag low, so it drains. He agreed there was a lot of sediment in the tubing. He stated he was not sure when it was changed last, and the resident is dehydrated. She does not drink enough water. She is a hospice recipient. He confirmed the resident's urine was very dark brown when he moved the dignity bag out of the way and exposed the catheter bag with dark brown colored urine collecting in it. He confirmed it was on the floor. He stated she had recently been treated for a UTI. He left the interview to go look for the orders for catheter care and the date the tubing was changed. He did not return to the interview. Review of the facility policy and procedure entitled Indwelling Urinary Catheter (Foley) Care and Management revealed the following: 2. Monitor the catheter daily and assess for complications resulting from the use of an indwelling catheter such as symptoms of blockage with associated bypassing of urine, catheter-associated urinary tract infection (CAUTI), expulsion of the catheter, pain, discomfort, and bleeding. Also assess the potential for catheter removal. 3. Develop and individualized care plan based on assessment findings and revised as needed. For the resident with an indwelling urinary catheter, include a component to inform the resident and representative about the risks and benefits of catheter us and identify approaches to minimize the risk of infection by addressing personal hygiene measure, catheter/tubing /bag care and educating the resident and representative regarding signs and symptoms of urinary tract infection. Clinical alert: Monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color. Notify the practitioner of abnormal findings. Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder which increases the risk of CAUTI. However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI. Review of the facility's policy and procedure entitled Urinary Incontinence and Indwelling Urinary Catheter (Foley) Management revealed the following: Regulatory Requirements. 483.25 Quality of Care Based on comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. A resident who is incontinent of bladder receives appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible. This facility uses the Lippincott procedures. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105928 If continuation sheet Page 9 of 9