Health inspection·February 25, 2021

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. Based on medical record reviews and staff interviews, the facility failed to revise resident care plans following the completion of a signed Do Not Resuscitate (DNR) order for three (Residents #80, #22 and #1) residents sampled for a review of their care plans, from a total sample of 25 residents. The findings include: 1. A review of the medical record for Resident #80, revealed a DNR order dated 10/1/2018. A review of Resident #80's hard chart revealed an admission care plan that stated the resident was a Full Code (the resident desired resuscitation in the event of respiratory/cardiac arrest). The hard copy admission care plan was dated 9/28/2018. A review of Resident #80's current comprehensive care plan, revealed the care plan was not revised to include the current DNR order. 2. A medical record review for Residents #22 and #1 revealed that both residents had signed, active Do Not Resuscitate orders. The signed declarations were located in the hard charts, and the DNRs were also acknowledged in their files located in the electronic medical records. During a review of the two residents' current comprehensive care plans, the advanced directives were not addressed. During an interview with the Nursing Supervisor on 02/23/21 at 10:14 a.m., she confirmed the care plan had not been revised to include the active DNR order for Residents #80, #22 or #1. She stated, DNR orders are care planned by the social worker and they should be listed on the care plan, because that is how we communicate with the interdisciplinary team. During an interview with the Director of Social Services on 2/23/21 at 10:20 a.m., she confirmed that the care plans had not been revised to include the active DNR orders for Residents #80, #22 or #1. She stated, I will revise the care plan to include the DNR orders. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106077 If continuation sheet Page 2 of 6 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 106077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moosehaven 1701 Park Avenue 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to 1) Ensure as needed (PRN) psychotropic medications ordered for greater than fourteen days included justification for extended use for one (Resident #9) of five residents reviewed, and 2) Ensure the provision of adverse consequence monitoring for two (Residents #14 and #11) of five residents reviewed for psychotropic medications, from a total of 25 residents in the sample. The findings include: 1. A review of the medical record for Resident #9 revealed he was admitted on [DATE]. He had a diagnosis of anxiety and was prescribed 0.5 mg (milligram) of Ativan every 6 hours PRN on 06/09/2020, with an end date of 08/03/2020. On 09/03/2020, a new order was written for 0.5 mg of Ativan every 6 hours PRN for 90 days. On 01/02/2021, a new order for 1.0 mg of Ativan every 6 hours PRN was written. The Order Summary Report revealed an end date of 04/02/2021, but no language was added to the order to justify the length of use. (Photographic evidence obtained) A History and Physical dated 06/12/2020, electronically signed by the physician who prescribed the Ativan, revealed no rationale statement for the extended use of the medication. The next physician's assessment, dated 09/03/2020, was also lacking the rationale statement. Resident #9's nurse, Employee C, was interviewed on 02/25/2021 at 11:58 a.m. He confirmed that Resident #9 had been prescribed antianxiety medication since his admission. There was no additional documentation with the rationale for the 90-day supply presented. The Director of Nursing (DON) was asked to present the thinned chart (materials removed from the resident's immediate record and maintained in a medical records file) for review. No documentation with the rationale for extended use was discovered. At 1:55 p.m. on 02/25/2021, the DON confirmed knowledge of the requirement for the PRN order justification. The facility's policy titled Antipsychotic Medication Use, dated December 2016, stated: (14) The need to continue PRN orders for psychotropic medication beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. (Photographic evidence obtained) 2. A review of Resident #14's medical record revealed she was ordered Zoloft 125 mg and Wellbutrin XL (extended release) 150 mg for depression. She was also ordered Buspirone 75 mg for anxiety on 10/16/2020. On 2/23/2021 at 11:11 a.m., her nurse explained that behavior monitoring was completed each shift and documented in the hard chart (physical paper medical record) at the nurses' station. Resident #14's current care plan addressed her depression (initiated on 07/06/2020), which included a goal that she would experience fewer signs and symptoms of depression. An intervention included monitoring and documenting side effects of her medication. (Photographic evidence obtained) Resident #14's hard chart contained a behavior monitoring form for Bupropion (Wellbutrin). The behavior listed was tremors and the form showed no instances of tremors for the current month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106077 If continuation sheet Page 3 of 6 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 106077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moosehaven 1701 Park Avenue 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Sertraline (Zoloft) 100 mg and 25 mg each, had a different sheet which listed a behavior of depression. No instances were documented. Buspirone 10 mg had a form which listed the behavior of anxiety. This form listed no behaviors for the current month. These forms all had a section titled side effects with three lines to indicate which side effects staff were to look for. Nothing was specified on any of the forms. The back of the forms listed potential side effects and included 26 potential side effects depending on the drug class. (Photographic evidence obtained) There was no documentation in the electronic record of adverse consequence monitoring for Resident #14. 3. A review of Resident #11's medical record revealed she was admitted on [DATE]. She was diagnosed with anxiety for which she was ordered Lorazepam (Ativan)1 mg once a day, as well as Lorazepam 1 mg every other day. She also had a PRN order written on 02/18/2021, to be taken every 8 hours as needed. The electronic Medication Administration Record (MAR) showed Resident #11 took the scheduled medications as ordered, and used the PRN anxiety medication twice in February 2021 (02/03/2021 and 2/04/2021). The hard chart included behavior monitoring sheets for Lorazepam 1 mg, with the behavior anxiety written in. A second form for Lorazepam 1 mg was also in this section, also for the behavior anxiety. There was a behavior monitoring sheet for Duloxetine (Cymbalta), with the behavior depression written in. None of the behavior sheets had any side effects written in the box to specify which behaviors one was monitoring for. (Photographic evidence obtained) A review of the nursing documentation for the previous three months, located in the electronic record, did not indicate nurses were documenting their efforts to monitor for adverse consequences. Resident #11's depression care plan (initiated 06/17/2020) addressed her anxiety and the first intervention listed was to Administer medications as ordered. Monitor/document for side effects and effectiveness. (Photographic evidence obtained) During an interview on 02/24/2021at 9:15 a.m. with Employee A, Resident #11's nurse, he was asked how he monitored for side effects of Resident #11's medications. Employee A explained that Resident #11 received antianxiety and antidepressant medication. When asked what side effects he was monitoring for with the antidepressant, he stated he didn't know. When asked about PRN medication monitoring, he explained that the nurses documented in the nursing notes when they administered the medications. He further stated the nurses could also use the behavior monitoring sheets. He opened Resident #11's and explained that if she were to have any side effects they'd be able to document those there. A review of the policy titled Behavioral Assessment, Intervention, and Monitoring, dated March 2019, mandated the following in the Management section: (10) When medications are prescribed for behavioral symptoms, documentation will include: (h.) Monitoring for efficacy and adverse consequences. (Photographic evidence obtained) On 02/25/2021 at 10:05 AM, the DON was asked how nurses were monitoring for adverse consequences of medications, and the explain the details of the facility's policy that required documentation. She explained that the nurses were documenting by exception, which was not her expectation. She acknowledged corrective action was needed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106077 If continuation sheet Page 4 of 6 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 106077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moosehaven 1701 Park Avenue 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure dental appointments were coordinated and scheduled according to physicians' orders for one (Resident #14) of two sampled residents. Residents Affected - Few The findings include: During an interview with Resident #14 on 02/22/2021 at 11:07 a.m., she was asked about her dental needs. She explained she was having issues, and was waiting for the facility to follow up on an order written by her dentist for more dental work to be completed. A review of the electronic medical record did not reveal any visits to a dentist, or orders for dental work to be completed. The Director of Nursing (DON) was interviewed on 2/23/2021 at 1:44 p.m. She was asked to provide any information related to dental appointments for Resident #14. The DON called the facility's clinic and was told Resident #14 went to the dentist on 11/11/2020; information would be located in the hard chart (physical paper record) located at the nurses' station. A review of the hard chart conducted directly after the interview showed no notes about Resident #14's dental visit on 11/11/2020. At 2:57 p.m. on 2/23/2021, the DON confirmed she also found no documentation, and agreed to check the thinned materials (materials removed from the resident's immediate record and maintained in a medical records file). She later presented paperwork from Resident #14's dental visits in 2019 and 2020. A review of these records showed that in 2019, she visited the dentist on 3/26/2019 and he ordered work done to smooth out a fractured molar and a filling in a different tooth. This carbon paper had a notation in different handwritten/ink which read,3/27/2019 Committee approval and was signed by an RN (Registered Nurse). A second carbon paper note, dated 4/2/2019, showed the work ordered on 3/26/2019 had been completed. (Photographic evidence obtained) The next dental visit record was dated 11/11/2020, and was on the same yellow carbon paper. This form noted Resident #14 had a lot of decay. At least four teeth should be extracted. And multiple cavities. The bottom of this form indicated the resident was to return on 11/17/2020 at 12:00 p.m. This, as well as the next cleaning date of 11/10/2021, was initialed in different ink. (Photographic evidence obtained) There were no other dental visit records presented from the thinned chart. A second review of the hard chart and electronic medical record found no evidence indicating the resident went back to the dentist on 11/17/2020. This was confirmed by the DON on 2/24/2021 at 4:15 p.m., who stated the clinic may have more records, and she would investigate further. At 11:15 a.m. on 2/25/2021, the DON confirmed there was no follow-up visit on 11/17/2020. She explained the documentation was lacking as to why she didn't go back to the dentisit, but during this time they were reviewing every appointment to see if it was necessary to send people out because of the cases in the community. The DON stated the resident now had an appointment scheduled for 3/2/2021 for a follow-up to the 11/11/2020 orders. She was asked when the appointment for 3/2/20201 was scheduled for Resident #14, and she confirmed it was not until today, 2/25/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106077 If continuation sheet Page 5 of 6 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 106077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moosehaven 1701 Park Avenue 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 0791 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106077 If continuation sheet Page 6 of 6