Inspection·September 28, 2023

F 0602 (Photographic evidence obtained) Level of Harm - Minimal harm or potential for actual harm Review of a physician's order for Resident #50 dated 6/26/23, read: Urine 14 panel drug screen one time only for 2 days. Residents Affected - Some On 9/27/23 at 3:09 pm, an interview was conducted with Employee F, Licensed Practical Nurse (LPN) who was familiar with Resident #50. She referred to him as max assist and stated he was incontinent of bladder and bowel. She stated the resident complains of right hip pain and that he doesn't have feeling in his fingers. She stated he does not refuse care or treatment. She stated Resident #50 gets out of bed but will request to go lay back down as a result of the right hip pain. She stated he doesn't like to take the pain medication because he doesn't want to get hooked on narcotics adding that the resident will ask for his muscle spasm medication. During an interview with the Administrator and Director of Nursing (DON) on 9/27/23 at 3:50 pm, she was asked about Resident #50's pain medication regimen. The DON stated the resident would complain of pain to the nurse so the nurse on duty would medicate him. She stated the resident didn't want to get addicted to anything. The DON was asked to provide Resident #50's narcotic medication records for May and June. On 9/28/23 at 11:02 am, the Administrator and DON provided narcotic medication records dated 5/30/2023 for Resident #50. Based on the information provided the medication was signed out as being administered three times daily on 5/31/23, 6/1, 6/4/-6/5/, 6/8-6/10 and 6/14/23. The signature of the nurse administering the medication was the same for all dates. When shown the MAR for this time period and asked about the discrepancy between the two records for the same medication, the Administrator could not provide an explanation. Instead, he provided a written statement from the facility's Unit Manager regarding the negative results of the urinalysis on 6/26/23 for Resident #50. (Photographic evidence obtained) When asked why a urinalysis had been ordered, the DON stated the wife had concerns the resident was not receiving the medications. She stated the facility had the urinalysis done to prove that he was receiving the medications. However, based on the information provided the resident was not receiving the medication. She stated they contacted the lab regarding this and was advised the request needed to be more specific to include the narcotic they were testing for in order for the proper test to be performed. When asked why this information wasn't provided and the resident re-tested, she replied that two days had passed since the resident had taken the medication and she didn't think it would still be in his system and show up on the test. On 9/28/23 at 11:36 am, the Administrator and DON provided a copy Resident #50's narcotic medication record dated 6/11/23 along with the lab results for the urinalysis. Based on the information provided the medication was signed out as being administered three times daily on 6/15-6/16, and 6/18-6/21. It was signed out as being administered twice daily on 6/24-6/26/23. Again, the signature for the nurse administering the medications was the same for each date. The same signature was also on the narcotic medication record dated 5/31/23. The DON explained that the nurse who signed both narcotic medication records was written up for not updating the MAR. She added that the information was sent to corporate and during that time the nurse quit. During a subsequent interview on 9/28/23 at 11:54 am, the Administrator and DON explained the nurse was also written up for not documenting appropriately. The DON stated when she spoke with the nurse during that time, he stated he was giving the resident pain medication as ordered because he was in chronic pain. She stated they called the lab regarding the results and was told the medication wouldn't show in those results. She stated the lab advised they would need to ask for a specific opiate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 2 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some drug screen. When asked why a second test wasn't performed, she stated, They said they couldn't get another screening. They said we had to request an opiate panel and it couldn't be done. The DON admitted she didn't tell the lab the amount of medication the resident had received, nor did she confirm her assumption that the medication would not show up on the test if it had not be administered in two days. The Administrator acknowledged the facility did not further investigate the issue nor was it reported to the agency. He stated at the time the nurse did not display any behaviors of drug use, so he was not questioned and there was no further investigation. Further review was conducted for the medication administration record revealed the following: 2. Resident #89 had physician's order with a revision date of 9/17/23 for tramadol 50 mg for times a day as needed for 30 days (for pain). In the month of June 2023, resident was assessed to have pain level of 0 on a pain scale of 0-10 (0 being the least pain and 10 being the most pain). June MAR indicated that tramadol was administered on 6/9/23, 6/14/23 and 6/17/23 (pain level of 5, 5 and 3 respectively). Controlled medication utilization record revealed that tramadol was signed of a given from 6/8/23 - 6/29/23 (these days were not indicated in the MAR) (Copies obtained) 3. Resident #13 had physician's order with a revision date of 5/16/23 for tramadol 50 mg every 6 hours as needed for 30 days (for non -acute pain). Per June 2023 MAR resident had no pain reported and medication was not administered. However, the controlled medication utilization record revealed that tramadol was signed of a given on 6/103, 6/14-6/15, 6/17-6/22, 6/24-26/23. (Copies obtained) 4. Resident #20 had physician's order dated 6/12/23 for oxycodone 5 mg every 6 hours as needed for breakthrough pain. June 2023 MAR indicated that resident had no pain. Medication was signed off as given on 6/12/23, 6/19/23, 6/21/23, 6/22/23 and 6/26/23. The controlled medication utilization record revealed the medication was administered two to three times a day from 6/21/23 - 6/26/23. (Copies obtained) A review of the facility's current employee roster provided upon entry to the facility on 9/25/23 revealed that some of employees who signed off the medication inappropriately were still working at the facility. A review of the facility's policy: Abuse- Identification of Types (issued 10/4/22, reviewed 7/18/23) under Misappropriation of Property and Exploitation read: Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. Misappropriation of Property and Exploitation 3. Examples of misappropriation of resident property include, but are not limited to: i. missing prescription medications or diversion of a resident's medication(s), including but not limited to, controlled substances for staff use or personal gain. A review of the facility's policy: Abuse-Conducting an Investigation (issued 10/4/22; reviewed 7/18/23) read: It is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 3 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary (if any) for the protection of residents. Depending on the type of allegation received, it is expected that the investigation would include, but is not limited to: c. Conducting record review for pertinent information related to the alleged violation as appropriate, such as progress notes (nurse, social services, physician, therapist, consultants as appropriate, etc.), financial record, incident reports (if used), reports from hospital/emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports from other investigatory agencies. 9. If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited. (Copy obtained) A review of the facility's policy: Investigating an Allegation of Suspected Drug Diversion (issued 7/31/18, reviewed 8/30/23) read: Background Suspicion of drug diversion may arise from a variety of circumstances, including but not limited to the following: 5. Notification of suspected drug diversion from an external source, such as local law enforcement or a family member of a suspected drug diverter Policy The facility will investigate all allegations of drug diversion in accordance with current state and federal guidance. The facility will utilize the following procedure in conjunction with pharmacy policy and guidance related to loss or theft of medications. Procedure 1. c. Drug diversion by an associate will be reported to all appropriate government, licensing, regulatory, and law enforcement agencies as required by law. 2. Internal reporting a. Upon notification of an allegation or suspicion of a drug diversion, the Executive Director or Director of Nursing will notify the following as soon as practical after becoming aware of the allegation: 3. External Reporting a. The Executive Director or Director of Nursing will be responsible for reporting to external agencies as required by law Investigation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 4 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0602 1. The Executive Director or Director of Nursing will be responsible for directing the investigation. Level of Harm - Minimal harm or potential for actual harm 3. All suspected incidents/allegations of drug diversion will be thoroughly investigated. (Copy obtained) Residents Affected - Some . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 5 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to report allegations of misappropriation of resident property (controlled medications) in accordance with State law, including reporting to State Survey Agency for 1 (Resident #50) of 31 residents sampled. The findings include: During a tour of the facility on 9/25/23 at 3:25 pm, Resident #50 was observed resting in bed. There were no signs or symptoms of pain or distress. When asked about his medication regimen, he said there was some hanky panky going on with his medications. However, he was not able to provide full details of what he meant by this and requested his wife be contacted for additional information on the matter. On 9/25/23 at 3:36 pm, a phone interview was conducted with the wife of Resident #50. She stated that after reviewing their insurance statements she noticed they were being charged for narcotic pain medication which she knew he was not taking. She stated she contacted the facility regarding her concerns. She stated the facility responded and a urinalysis was requested. She stated the test confirmed the resident had not been taking the narcotic pain medication. She stated the facility provided conflicting information as to what happened to the medication. She stated she was advised the nurse whom she referred to as XXX was terminated. She did not know his last name, but he had been the nurse for Resident #50 since admission. She stated after the incident with the medication she became fearful of retaliation and therefore had not addressed any of her concerns with the facility. She felt Resident #50 was being intentionally neglected and would eventually be evicted if she voiced her concerns. A clinical record review for Resident #50 revealed he was admitted to the facility on [DATE], with diagnoses that included unspecified atrial fibrillation, type 2 diabetes mellitus, respiratory failure, heart failure, hypertensive heart disease with heart failure, chronic kidney disease Stage 3b, end stage renal disease, long term use of anticoagulants and generalized anxiety disorder. The significant change minimum data set (MDS) assessment dated [DATE] indicated the resident had a brief interview for mental status (BIMS) score of 14 out of 15, indicating cognitively intact. Review of the Medication Administration Record (MAR) for Resident #50 revealed an order on 8/16/22 for Norco Tablet 5-325 milligrams (mg) (hydrocodone-acetaminophen) one tablet by mouth every six hours as needed for severe pain. On 6/21/23 the orders was updated to include: SECOND NURSE MUST WITNESS ADMINISTRATION OF CONTROLLED MEDS. Review of the May and June 2023 MAR revealed the resident received the medication on 5/21/23, level 3 pain was documented. Review of the MAR for June 23 revealed the resident received the medication on 6/21/23 and 6/24/23, level 4 pain was documented. (Photographic evidence obtained) Review of a physician's order for Resident #50 dated 6/26/23, read: Urine 14 panel drug screen one time only for 2 days. On 9/27/23 at 3:09 pm, an interview was conducted with Employee F, Licensed Practical Nurse (LPN) who was familiar with Resident #50. She referred to him as max assist and stated he was incontinent of bladder and bowel. She stated the resident complains of right hip pain and that he doesn't have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 6 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feeling in his fingers. She stated he does not refuse care or treatment. She stated Resident #50 gets out of bed but will request to go lay back down as a result of the right hip pain. She stated he doesn't like to take the pain medication because he doesn't want to get hooked on narcotics adding that the resident will ask for his muscle spasm medication. During an interview with the Administrator and Director of Nursing (DON) on 9/27/23 at 3:50 pm, she was asked about Resident #50's pain medication regimen. The DON stated the resident would complain of pain to the nurse so the nurse on duty would medicate him. She stated the resident didn't want to get addicted to anything. The DON was asked to provide Resident #50's narcotic medication records for May and June. On 9/28/23 at 11:02 am, the Administrator and DON provided narcotic medication records dated 5/30/23 for Resident #50. Based on the information provided the medication was signed out as being administered three times daily on 5/31/23, 6/1, 6/4/-6/5/, 6/8-6/10 and 6/14/23. The signature of the nurse administering the medication was the same for all dates. When shown the MAR for this time period and asked about the discrepancy between the two records for the same medication, the Administrator could not provide an explanation. Instead, he provided a written statement from the facility's Unit Manager regarding the negative results of the urinalysis on 6/26/23 for Resident #50. (Photographic evidence obtained) When asked why a urinalysis had been ordered, the DON stated the wife had concerns the resident was not receiving the medications. She stated the facility had the urinalysis done to prove that he was receiving the medications. However, based on the information provided the resident was not receiving the medication. She stated they contacted the lab regarding this and was advised the request needed to be more specific to include the narcotic they were testing for in order for the proper test to be performed. When asked why this information wasn't provided and the resident re-tested, she replied that two days had passed since the resident had taken the medication and she didn't think it would still be in his system and show up on the test. On 9/28/23 at 11:36 am, the Administrator and DON provided a copy Resident #50's narcotic medication record dated 6/11/23 along with the lab results for the urinalysis. Based on the information provided the medication was signed out as being administered three times daily on 6/15-6/16 and 6/18-6/21. It was signed out as being administered twice daily on 6/24-6/26/23. Again, the signature for the nurse administering the medications was the same for each date. The same signature was also on the narcotic medication record dated 5/31/23. The DON explained that the nurse who signed both narcotic medication records was written up for not updating the MAR. She added that the information was sent to corporate and during that time the nurse quit. During a subsequent interview on 9/28/23 at 11:54 am, the Administrator and DON explained the nurse was also written up for not documenting appropriately. The DON stated when she spoke with the nurse during that time, he stated he was giving the resident pain medication as ordered because he was in chronic pain. She stated they called the lab regarding the results and was told the medication wouldn't show in those results. She stated the lab advised they would need to ask for a specific opiate drug screen. When asked why a second test wasn't performed, she stated, They said they couldn't get another screening. They said we had to request an opiate panel and it couldn't be done. The DON admitted she didn't tell the lab the amount of medication the resident had received, nor did she confirm her assumption that the medication would not show up on the test if it had not be administered in two days. The Administrator acknowledged the facility did not further investigate the issue nor was it reported to the agency. He stated at the time the nurse did not display any behaviors of drug use, so he was not questioned and there was no further investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 7 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's current employee roster provided upon entry to the facility on 9/25/23 revealed that some of employees who signed off the medication inappropriately were still working at the facility. A review of the facility's policy: Abuse- Identification of Types (issued 10/4/22, reviewed 7/18/23) under Misappropriation of Property and Exploitation read: Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. Misappropriation of Property and Exploitation 3. Examples of misappropriation of resident property include, but are not limited to: i. missing prescription medications or diversion of a resident's medication(s), including but not limited to, controlled substances for staff use or personal gain. A review of the facility's policy: Investigating an Allegation of Suspected Drug Diversion (issued 7/31/18, reviewed 8/30/23) read: Background Suspicion of drug diversion may arise from a variety of circumstances, including but not limited to the following: 5. Notification of suspected drug diversion from an external source, such as local law enforcement or a family member of a suspected drug diverter Policy The facility will investigate all allegations of drug diversion in accordance with current state and federal guidance. The facility will utilize the following procedure in conjunction with pharmacy policy and guidance related to loss or theft of medications. Procedure 1. c. Drug diversion by an associate will be reported to all appropriate government, licensing, regulatory, and law enforcement agencies as required by law. 2. Internal reporting a. Upon notification of an allegation or suspicion of a drug diversion, the Executive Director or Director of Nursing will notify the following as soon as practical after becoming aware of the allegation: 3. External Reporting a. The Executive Director or Director of Nursing will be responsible for reporting to external agencies as required by law (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 8 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0609 Investigation Level of Harm - Minimal harm or potential for actual harm 1. The Executive Director or Director of Nursing will be responsible for directing the investigation. 3. All suspected incidents/allegations of drug diversion will be thoroughly investigated. Residents Affected - Few (Copy obtained) A review of the facility's policy: Incident and Reportable Event Management (issued 8/15/23; reviewed 9/14/23) revealed: Definitions Event Management Medication discrepancy Immediately means as soon as possible, in the absence of a shorter state time frame requirement but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. External Notifications 4. The facility should be aware that external reporting may include: a. state licensing and certification agencies b. Ombudsman c. Law Enforcement d. Adult Protective Services e. State Practice Boards . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 9 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 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** Based on observations, interviews, record review, and facility policy review, the facility failed to investigate an allegation of misappropriation of resident property (controlled medication) for 1 (Resident #50) of 4 residents reviewed for misappropriation, from a total of 31 residents in the sample. Residents Affected - Few The findings include: During a tour of the facility on 9/25/23 at 3:25 pm, Resident #50 was observed resting in bed. There were no signs or symptoms of pain or distress. When asked about his medication regimen, he said there was some hanky panky going on with his medications. However, he was not able to provide full details of what he meant by this and requested his wife be contacted for additional information on the matter. On 9/25/23 at 3:36 pm, a phone interview was conducted with the wife of Resident #50. She stated that after reviewing their insurance statements she noticed they were being charged for narcotic pain medication which she knew he was not taking. She stated she contacted the facility regarding her concerns. She stated the facility responded and a urinalysis was requested. She stated the test confirmed the resident had not been taking the narcotic pain medication. She stated the facility provided conflicting information as to what happened to the medication. She stated she was advised the nurse whom she referred to as XXX was terminated. She did not know his last name, but he had been the nurse for Resident #50 since admission. She stated after the incident with the medication she became fearful of retaliation and therefore had not addressed any of her concerns with the facility. She felt Resident #50 was being intentionally neglected and would eventually be evicted if she voiced her concerns. A clinical record review for Resident #50 revealed he was admitted to the facility on [DATE], with diagnoses that included unspecified atrial fibrillation, type 2 diabetes mellitus, respiratory failure, heart failure, hypertensive heart disease with heart failure, chronic kidney disease Stage 3b, end stage renal disease, long term use of anticoagulants and generalized anxiety disorder. The significant change minimum data set (MDS) assessment dated [DATE] indicated the resident had a brief interview for mental status (BIMS) score of 14 out of 15, indicating cognitively intact. Review of the Medication Administration Record (MAR) for Resident #50 revealed an order on 8/16/22 for Norco Tablet 5-325 milligrams (mg) (hydrocodone-acetaminophen) one tablet by mouth every six hours as needed for severe pain. On 6/21/23 the orders was updated to include: SECOND NURSE MUST WITNESS ADMINISTRATION OF CONTROLLED MEDS. Review of the May and June 2023 MAR revealed the resident received the medication on 5/21/23, level 3 pain was documented. Review of the MAR for June 23 revealed the resident received the medication on 6/21/23 and 6/24/23, level 4 pain was documented. (Photographic evidence obtained) Review of a physician's order for Resident #50 dated 6/26/23, read: Urine 14 panel drug screen one time only for 2 days. On 9/27/23 at 3:09 pm, an interview was conducted with Employee F, Licensed Practical Nurse (LPN) who was familiar with Resident #50. She referred to him as max assist and stated he was incontinent of bladder and bowel. She stated the resident complains of right hip pain and that he doesn't have feeling in his fingers. She stated he does not refuse care or treatment. She stated Resident #50 gets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 10 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out of bed but will request to go lay back down as a result of the right hip pain. She stated he doesn't like to take the pain medication because he doesn't want to get hooked on narcotics adding that the resident will ask for his muscle spasm medication. During an interview with the Administrator and Director of Nursing (DON) on 9/27/23 at 3:50 pm, she was asked about Resident #50's pain medication regimen. The DON stated the resident would complain of pain to the nurse so the nurse on duty would medicate him. She stated the resident didn't want to get addicted to anything. The DON was asked to provide Resident #50's narcotic medication records for May and June. On 9/28/23 at 11:02 am, the Administrator and DON provided narcotic medication records dated 5/30/2023 for Resident #50. Based on the information provided the medication was signed out as being administered three times daily on 5/31/23, 6/1, 6/4/-6/5/, 6/8-6/10 and 6/14/23. The signature of the nurse administering the medication was the same for all dates. When shown the MAR for this time period and asked about the discrepancy between the two records for the same medication, the Administrator could not provide an explanation. Instead, he provided a written statement from the facility's Unit Manager regarding the negative results of the urinalysis on 6/26/23 for Resident #50. (Photographic evidence obtained) When asked why a urinalysis had been ordered, the DON stated the wife had concerns the resident was not receiving the medications. She stated the facility had the urinalysis done to prove that he was receiving the medications. However, based on the information provided the resident was not receiving the medication. She stated they contacted the lab regarding this and was advised the request needed to be more specific to include the narcotic they were testing for in order for the proper test to be performed. When asked why this information wasn't provided and the resident re-tested, she replied that two days had passed since the resident had taken the medication and she didn't think it would still be in his system and show up on the test. On 9/28/23 at 11:36 am, the Administrator and DON provided a copy Resident #50's narcotic medication record dated 6/11/23 along with the lab results for the urinalysis. Based on the information provided the medication was signed out as being administered three times daily on 6/15-6/16 and 6/18-6/21. It was signed out as being administered twice daily on 6/24-6/26/23. Again, the signature for the nurse administering the medications was the same for each date. The same signature was also on the narcotic medication record dated 5/31/23. The DON explained that the nurse who signed both narcotic medication records was written up for not updating the MAR. She added that the information was sent to corporate and during that time the nurse quit. During a subsequent interview on 9/28/23 at 11:54 am, the Administrator and DON explained the nurse was also written up for not documenting appropriately. The DON stated when she spoke with the nurse during that time, he stated he was giving the resident pain medication as ordered because he was in chronic pain. She stated they called the lab regarding the results and was told the medication wouldn't show in those results. She stated the lab advised they would need to ask for a specific opiate drug screen. When asked why a second test wasn't performed, she stated, They said they couldn't get another screening. They said we had to request an opiate panel and it couldn't be done. The DON admitted she didn't tell the lab the amount of medication the resident had received, nor did she confirm her assumption that the medication would not show up on the test if it had not be administered in two days. The Administrator acknowledged the facility did not further investigate the issue nor was it reported to the agency. He stated at the time the nurse did not display any behaviors of drug use, so he was not questioned and there was no further investigation. A review of the facility's policy: Abuse- Identification of Types (issued 10/4/22, reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 11 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0610 Level of Harm - Minimal harm or potential for actual harm 7/18/23) under Misappropriation of Property and Exploitation read: Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. Misappropriation of Property and Exploitation Residents Affected - Few Misappropriation of Property and Exploitation 3. Examples of misappropriation of resident property include, but are not limited to: i. missing prescription medications or diversion of a resident's medication(s), including but not limited to, controlled substances for staff use or personal gain. Per the facility's policy: Abuse-Conducting an Investigation issued 10/4/2022; reviewed 7/18/2023. Per the policy It is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated .Residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported. 4. The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary (if any) for the protection of residents. Dependening on the type of allegation received, it is expected that the investigation would include, but is not limited to: C. conducting record review for pertinent information related to the alleged violation as appropriate, such as progress notes (nurse, social services, physician, therapist, consultants as appropriate, etc.), financial record, incident reports (if used), reports from hospital/emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports from other investigatory agencies. 9, If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited. Per the facility's policy: Investigating an Allegation of Suspected Drug Diversion issued 7/31/2028, reviewed 8/30/2023 Background Suspicion of drug diversion may arise from a variety of circumstances, including but not limited to the following: 5. Notification of suspected drug diversion from an external source, such as local law enforcement or a family member of a suspected drug diverter Policy The facility will investigate all allegations of drug diversion in accordance with current state and federal guidance. The facility will utilize the following procedure in conjunction with pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 12 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0610 policy and guidance related to loss or theft of medications. Level of Harm - Minimal harm or potential for actual harm Procedure Residents Affected - Few 1. c. Drug diversion by an associate will be reported to all appropriate government, licensing, regulatory, and law enforcement agencies as required by law. 2. Internal reporting a. Upon notification of an allegation or suspicion of a drug diversion, the Executive Director or Director of Nursing will notify the following as soon as practical after becoming aware of the allegation: 3. External Reporting a. The Executive Director or Director of Nursing will be responsible for reporting to external agencies as required by law Investigation 1. The Executive Director or Director of Nursing will be responsible for directing the investigation. 3. All suspected incidents/allegations of drug diversion will be thoroughly investigated. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 13 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices by failing to provide adequate foot care/skin care, medication administration and bathing for 1 (Resident #50) of 31 residents in the sample. Residents Affected - Few The findings include: On 9/25/23 at 3:25 pm, Resident #50 was observed resting in bed. There were no signs or symptoms of pain or distress. He was asked about the care and treatment he had received while residing in the facility and he replied that he had not been receiving showers. He stated he received bed baths but would like to have showers. He advised that he was diabetic and was experiencing numbness in his feet and fingertips. He stated he no longer required glucose checks, but the numbness in his fingertips remained. When asked about his medication regimen, he said there was some hanky panky going on with his medications. However, he was not able to provide full details about what he meant by this and requested his wife be contacted for additional information on the matter. A clinical record review for Resident #50 revealed he was admitted to the facility on [DATE], with diagnoses that included unspecified atrial fibrillation, type 2 diabetes mellitus, respiratory failure, heart failure, hypertensive heart disease with heart failure, chronic kidney disease Stage 3b, end stage renal disease, long term use of anticoagulants and generalized anxiety disorder. A review of the significant change minimum data set (MDS) assessment dated [DATE] indicated the resident had a brief interview for mental status (BIMS) score of 14 out of 15, indicating cognitively intact. Resident required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene. The resident's preferences section indicated it was very important for him to choose between a tub bath, bed bath, or sponge bath. This preference was also captured during the admission MDS assessment dated [DATE]. On 9/25/23 at 3:36 pm, a phone interview was conducted with the wife of Resident #50. She stated that after reviewing their insurance statements she noticed they were being charged for narcotic pain medication which she knew he was not taking. She stated she contacted the facility regarding her concerns. She stated the facility responded and a urinalysis was requested. She stated the test confirmed the resident had not been taking the narcotic pain medication. She stated the facility provided conflicting information as to what happened to the medication. She stated she was advised the nurse whom she referred to as XXX was terminated. She did not know his last name, but he had been the nurse for Resident #50 since admission. She stated the resident was diabetic and she was concerned about a wound on his foot. The bandage wasn't being changed as it should, and staff were not taking care of the resident's feet as they should. She stated she had been keeping photographic evidence and encouraged observations of the resident's feet. She stated after the incident with the medication she became fearful of retaliation and therefore had not addressed any of her concerns with the facility. She felt Resident #50 was being intentionally neglected and would eventually be evicted if she voiced her concerns. On 9/25/23 at 4:31 pm, Resident #50 was observed in his room. He was asked for permission to look at his feet. He replied, Sure, they aren't being taken care of. The resident's right great toe was observed with a thick, overgrown, dark gold-colored nail along with a dark brown spot on the corner of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 14 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the toenail. The other nails on the remaining toes were also overgrown and a dark gold color. The skin along the toes up to the ankle was dry and scaly. The resident could not confirm the last time the podiatrist had been in to provide care. He stated when his family member came to visit him, she took care of his feet and applied lotion. The resident's right ankle also had a pink bandage affixed to it. On the bandage 9/9/23 RH was written in blue. The resident denied any pain or discomfort in the area. He stated the bandage was applied for preventative measures. Observation of the resident's left foot revealed thick, overgrown toenails which were also dark gold in color. The skin on the left foot was also dry and scaly. (Photographic evidence obtained) On 9/27/23 at 10:20 am, Resident #50 was observed lying in bed. There were no signs of pain or distress. The resident stated he had still not received any foot care and had poor circulation in his feet. He could wiggle his toes a little, but stated again that his family member was the only person providing him with any foot care. The bandage, dated 9/9/23, remained in place. (Photographic evidence obtained) The resident along with his family member, who was present telephonically at the time of the observation, again voiced fear of retaliation. A review of Resident #50's September 2023 Physician's Order Sheets, revealed and active order for Tradjenta 5 mg (milligrams) by mouth daily for diabetes; Furosemide 40 mg by mouth daily for edema; potassium chloride 10 meq extended release by mouth daily for congestive heart failure; ammonium lactate external cream 12%, apply to both legs and feet topically every day shift for dryness; Eliquis 2.5 mg by mouth twice a day for atrial fibrillation; and apply protective dressing to right outer ankle every day shift, every other day for prophylactic measures and PRN (as needed). An order sated 6/26/23 instructed staff to obtain a Urine 14 panel drug screen one time only for 2days. Review of the Medication Administration Record (MAR) for Resident #50 revealed an order on 8/16/22 for Norco Tablet 5-325 milligrams (mg) (hydrocodone-acetaminophen) one tablet by mouth every six hours as needed for severe pain. On 6/21/23 the orders was updated to include: SECOND NURSE MUST WITNESS ADMINISTRATION OF CONTROLLED MEDS. Review of the May and June 2023 MAR revealed the resident received the medication on 5/21/23, level 3 pain was documented. Review of the MAR for June 23 revealed the resident received the medication on 6/21/23 and 6/24/23, level 4 pain was documented. (Photographic evidence obtained) A review of the most recent Care Plan included the following Focus Area: At risk for break in skin integrity hx (history) of resolved pressure areas, Goal: Maintain intact skin w/no skin breaks through next review and Intervention: treatment as ordered 12/2/22, weekly skin checks 8/13/22. The resident was also care planned for ADL self-care performance deficit related to COPD. A review of skin assessments for Resident #50 dated 9/24/23, 9/17/23, 9/16/23, No skin concerns were documented on the assessments. Review of a skin assessment dated [DATE] revealed resident with some redness to buttocks, barrier cream applied. No additional information provided. Review of shower sheets/skin evaluations confirmed the resident had been receiving bed baths as he stated. The information reflected: 7/1/2023- red buttocks scratching on left leg scratches does resident need toenails cut no; 7/4/2023 no skin conditions identified does resident need toenails cut no; 7/8/2023 no skin conditions identified does resident need toenails cut no; 7/1/2023 redness on buttocks does resident need toenails cut no; 7/20/2023 no skin conditions identified does resident need toenails cut no; 8/3/2023 redness on feet& coccyx does resident need toenails cut no; 8/8/2023 no skin conditions identified does resident need toenails cut no; 8/17/2023 redness coccyx does resident need toenails cut no; 8/22/2023 no skin condition identified does resident need toenails cut no; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 15 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/26/2023 no skin condition identified does resident need toenails cut no; 9/12/2023 no skin conditions does resident need toenails cut no. During an interview conducted with Employee F, Licensed Practical Nurse (LPN), Unit Manager, he stated the nurses were responsible for doing skin checks. He stated every resident has a skin check assigned and the nurses perform it sometimes with the help of a Certified Nursing Assistant (CNA). He stated the CNAs also have shower sheets that they have to complete. They check the skin, the nurses sign it, and ultimately it is turned in to him. He then reviews them. He again stated the nurses perform a weekly skin check on all resident. Adding, it's head to toe. He stated residents are offered showers at least three times a week. He stated if the resident declines a shower or if there is a medical condition i.e., they are on isolation then a resident may not receive a shower. He stated a resident's size wouldn't prevent them from receiving a shower. He stated, We have the equipment to accommodate residents of all sizes. We have the staff to accommodate residents of all sizes. He stated the nurse, and the CNA are responsible for making sure a resident who can't meet their ADLs needs are getting them met. He stated they would find that information in the [NAME] in Point Click Care and they would both have access to that. During an interview with Employee G, LPN on 9/27/23 at 3:09 pm, who was familiar with Resident #50, she stated that he was a max assist and incontinent of bladder and bowel. She stated the resident complains of right hip pain and that he doesn't have feeling in his fingers. She explained that he does not refuse care or treatment and if he did, she would make other attempts to provide car. If by chance, he still refused then she would document it. She stated Resident #50 gets out of bed but will request to go lay back down as a result of the right hip pain. She stated he didn't like to take the pain medication because he didn't want to get hooked on narcotics instead he will ask for his muscle spasm medication. When asked about footcare for the residents she stated the podiatrist comes in to clip the toenails. She stated she was not sure when or how often they came to the facility to perform these services. Employee G was asked to go to Resident #50's room. After greeting and introductions were made, Employee G advised the resident she would be looking at his feet. She removed his right sock exposing the bandage dated 9/9/23 affixed to his ankle. She immediately removed the bandage and crumpled it up and discarded it into a glove she was wearing. She was asked the date on the bandage, she responded it was 9/9/23. She advised the resident she would be changing the bandage. She was asked about the observation of swelling to the resident's feet. Employee G confirmed the resident's feet were swollen. The resident was asked if he had been seen by the podiatrist. He stated no one had clipped his toenails in a long time. When asked if he received showers, he stated he got bed baths. When Employee G asked him what his preference was, he stated he would prefer a shower but couldn't get it because of the Hoyer. He told her he had received 2 showers in the year he had been in the facility. He really wanted a shower but didn't think it was possible because he required a Hoyer lift. He went on to say that his head would appreciate it because his hair wasn't being shampooed with the bed baths. Employee G was asked if there was a shower bed to accommodate the resident. She said, Yes and confirmed there was no reason the resident could not receive showers as he preferred. During an interview with the Administrator and Director of Nursing (DON) on 9/27/23 at 3:50 pm, they were asked about the availability of equipment for baths and showers for residents requiring special accommodations. They confirmed there was equipment available for all residents to receive showers. They were advised of the concerns with Resident #50 regarding him receiving bed baths versus the showers he preferred. The Administrator stated that the staff were telling them that the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 16 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been refusing care. They were that according to Employee G, LPN the resident did not refuse care. The DON responded they weren't sure of the validity of the statements, but it was what they had been told. During an interview with Employee H, LPN on 9/28/23 at 3:54 pm, she stated that resident's preferences are listed in their care plan. She stated all staff have access to that information through the [NAME] and the certified nursing assistants (CNAs) can also come to the nurses for the information. She stated if an alert and oriented resident refuses baths and showers the resident completes the shower form. The CNA then brings the form to the nurse who re-approached the resident to offer the service. If they still refuse the nurse can then offer the bed bath. She stated the CNA should not initially offer the bed bath unless they are care planned for the bed bath. She stated resident skin checks are a part of the point click care system and there is an alert that tells the nurses there is a skin check to be performed. She stated even if a bandage was clean and in place if there was an order for it to be changed every other day the order was to be followed and the treatment record updated. During an interview with Employee I, CNA on 9/28/23 at 4:54 pm, she stated the resident's preferences are found in the [NAME] along with their functional level. She stated any refusal are to be reported to the nurse. She stated observation of wounds or skin conditions are documented on the shower sheets and reported to the nurse. She stated if there is an old wound or bandage it would be reported to the nurse. She stated there weren't any reasons why a resident wouldn't be given a shower if they wanted one. She confirmed the facility had he equipment and team work to accommodate residents regardless of their size. A review of the facility's policy: Activities of Daily Living (ADLs) (issued 12/11/18; 8/23/23) read: Policy: The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 17 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed food from the facility, by failing to complete temperature logs for dish machine, maintain thermometers and temperature logs in walk in fridge and freezer, remove outdated food, and properly store food. Food handling is important in health care settings serving nursing home residents. The findings include: An initial tour of the kitchen was conducted on 9/25/23 at 10:38 am. Employee A introduced herself as the Assistant Dietary Manager and stated the Certified Dietary Manager (CDM) was out on extended leave. When asked who the acting manager was, she stated herself and the Administrator. She explained that the walk-in refrigerator and freezer were being replaced and this had been going on for approximately two weeks. Therefore, the food was being stored in a temporary refrigerator and freezer located outside of the facility at the rear of the kitchen. During the tour of the kitchen on 9/25/23 the following items were observed: At 10:50 am, the low temperature dish machine was observed with a Low temperature Dish Machine Log for [DATE] hung on the wall near the machine. The instructions included; Check and record temperature results before washing dishes. There were several days where no temperatures were recorded on the log. (Photographic evidence obtained). At this time, Employee C was asked to perform a test the temperature of the wash and rinse of the dish machine as well as the sanitizer concentration level. There were no concerns. At 11:13 am, a small deep freezer containing ice cream and sherbet had no thermometer. Employee A was asked about the thermometer. She looked around inside of the deep freezer and confirmed there was no thermometer present. She stated someone must have taken it out, but acknowledged there should have been a thermometer present. A barrel of corn meal dated 3/9/23 with a use by date of 9/9/23 was observed in the dry storage area. (Photographic evidence obtained) At 11:16 am, a stand-alone refrigerator in the kitchen had no temperature log present. A sign taped to the outside of door read juice poured 09/23/23 and sandwiches made 09/24/23. During an interview with Employee B, Cook, she stated the stand-alone refrigerator is only used for items that will be used immediately. At 11:29 am, there were four bags of opened bread on a shelf and an undated unsealed bag of bread located on a rack. At 11:38 am, the portable walk-in refrigerator and freezer located outside of the facility at the rear of the kitchen did not have temperature logs. During an interview on 9/26/23 at 2:41 pm with Employee D, Registered Dietitian (RD), she stated she had worked in the facility for approximately four months and works in the facility three days a week. When asked about the walk-in refrigerator and freezer. She stated, We are getting new walk-in fridge and freezers. We're tearing what we have out. We have rented an outside fridge and freezer so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 18 of 19 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 105962 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center at Wells Crossing 355 Crossing Blvd 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many we can keep everything in code and safe. When asked about the temperature logs for both and who's responsible for ensuring they are up to date. She responded, The staff are monitoring the logs as well as the management. I go into the kitchen each time that I'm here to make sure since there's not a CDM. It's been like that about a month. It's the same kind of form as if it were inside. The staff handle it. A follow up tour of the kitchen was conducted on 9/26/23 at 3:07 pm with the RD. The temperature log for the low temperature machine was still not being updated. During an interview with Employee E, Dietary Aide, she was asked who is responsible for ensuring the temperature log is completed. She looked at the log and confirmed it had not be updated as it should. She stated the fourth person to do the dishes should be updating the log. When asked for clarity she stated it should be done after each meal when the dishes are done. On 9/26/23 at 3:24 pm, a follow up tour of the temporary refrigerator outside of the facility was conducted. A bag of green peppers, three opened cabbages, a bag of green vegetables, and a bag of unidentifiable items on a silver tray were observed. In addition, a dark brown liquid was present on the tray along with the food items. (Photographic evidence obtained. The RD was made aware of the observation. Upon seeing this, the RD consulted with Employee A regarding the observation and said, There were some cucumbers there but they're going the get rid of it. On 9/26/23 at 3:29 pm, the RD provided a temperature log for the portable refrigerator and freezer given to her by Employee A. A review of the documentation revealed the temperature had only been recorded during the survey dates of 9/25/23 and 9/26/23 for both pieces of equipment. Employee A confirmed this was accurate and there was no other information available. (Photographic evidence obtained) On 9/26/23 at 3:37 pm, the barrel of outdated corn meal remained in the dry storage room. On 9/27/23 at 9:48 am, the Administrator provided written documentation stating the portable cooler and freezer were delivered on 9/14/2023. They were hooked up to electricity on 9/18/2023 and food was put inside on 9/19/2023. The notice stated the facility cooler and freezer were taken offline on 9/21/23 to prepare for the replacement. On 9/27/23 at 11:27 am, the barrel of outdated corn meal remained in the dry storage room. An interview was conducted with Employee A on 9/27/23 at 11:40 am. She was asked about the observation of the outdated corn meal. She confirmed it was out of date, adding it was her responsibility to ensure the contents were discarded. She stated: I just didn't look at that, I usually take it out and dump it. She stated: We have more up top. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105962 If continuation sheet Page 19 of 19