Health inspection·March 24, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cardiac problems through the next review. Interventions included, but were not limited to, medications as ordered and monitor for/document any edema (swelling). (Copies obtained) Resident #121 had a physician's order dated 03/01/22 that instructed clinical staff to apply ace wrap knee highs (ace bandages applied to the lower legs up to knee level in order to provide gently pressure and reduce swelling); On in the AM (morning), remove in the PM (evening). She also had a physician's order for Ipratropium Bromide Solution 0.3% (a medication used to open up the airways in the lungs), two sprays in both nostrils twice a day for rhinorrhea (excessive drainage from the nose/nasal passages). The order was written on 3/14/22 (8 days ago), but said it was still Pending Confirmation instead of Active. (Copies obtained) A review of the electronic medication administration record (eMAR) found the Ipratropium nasal spray was scheduled to be administered daily at 9:00 AM and 6:00 PM, however, between 03/14/22 (the day the order was written) and 03/21/22, the signature boxes used to indicate the medication was administered were all marked with Xs. There was no explanation of what X meant. On 03/22/22, both signature boxes had nurses' initials in them, indicating the spray was administered at 9:00 AM and 6:00 PM. A review of the electronic treatment administration record (eTAR) found Resident #121's ace wraps had been signed off as applied on 3/22/22, despite multiple observations and an interview with the resident verifying that they had not been put on. (Copies obtained) An interview was conducted with Agency CNA N on 03/23/22 at 10:12 AM. She explained that Resident #121's legs swelled a lot if not wrapped. An interview was conducted with Licensed Practical Nurse (LPN) O on 03/23/22 at 3:09 PM. She confirmed that Resident #121 had edema and received ace wraps to her legs each morning. The wraps were removed at night, and this was to be done every day. LPN O reported staff encouraged Resident #121 to keep her feet elevated, but the resident stayed out of her bed all day and late into the night. LPN O was asked why Resident #121's nasal spray was still pending confirmation a week after it was ordered. She explained that Sometimes the physicians write an order, but the electronic medication ordering system does not allow the facility nurses to confirm the order. She speculated that perhaps that was why the order was pending for that long. LPN N said Resident #121's nasal spray just came in, but she had not received it yet. Photographic evidence of the Ipratropium spray was obtained on 03/23/22. The medication label said it was filled by the pharmacy on 03/22/22, eight days after it was ordered. A handwritten note indicated the spray was not opened until 03/23/22. The Director of Nursing (DON) was interviewed on 03/24/22 at 2:41 PM and was advised that Resident #121's ace wraps were being signed off by nursing as having been applied when they had not been applied. She had no explanation and acknowledged the findings. She said she would speak with the nurses. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 2 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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. Based on observations, interviews, and record reviews, the facility failed to ensure that psychotropic medications were used to treat a specific, diagnosed condition and failed to ensure as-needed (PRN) anti-anxiety medications were limited to a use of 14 days for one (Resident #57) of five residents reviewed for unnecessary medications. The findings include: A review of Resident #57's medical record revealed an admission date of 1/14/22. She received hospice services for end-of-life care related to her primary medical diagnosis of Alzheimer's disease. Secondary diagnoses included dementia, major depressive disorder, and anxiety. A review of the resident's physician's orders revealed the following medication orders: An order dated 2/18/22 for Seroquel (antipsychotic medication) 25 milligrams(mg) to be given twice daily for behavior management. An order dated 2/18/22 for Seroquel 50 mg to be given by mouth at bedtime for behavior management. An order dated 1/25/22 for Depakote (anticonvulsant medication)125 mg to be given two times a day for a diagnosis of anxiety. An order dated 1/16/22 for Ativan (sedative medication) 0.5 mg to be given by mouth every 12 hours as needed (PRN) for a diagnosis of agitation. On 3/21/22 at 12:27 p.m., Resident #57 was observed walking out of her room into the hallway. She was wearing pajamas and was barefoot. A staff member in the hallway approached the resident and hurriedly redirected the resident back into her room while stating, Where are you going? When Resident#57 attempted to reply, the staff member interrupted the resident and stated, You have to put some shoes on. Let's go. Resident #57 did not display any other behaviors. On 3/21/22 at 12:35 p.m., an interview was conducted with Resident #57's assigned Licensed Practical Nurse. The nurse identified Resident #57 as having dementia and wandering behaviors. The nurse stated she was not aware of any other behaviors aside from wandering. She added that the resident had been relocated to the top floor of the facility due to her wandering. On 3/21/22 at approximately 12:47 p.m., Resident #57 was observed sitting in a chair in her room. Her lunch tray was positioned in front of her on the over-bed table. The room lights were off and the window blinds were closed. The room was dark and Resident #57 was not eating. A review of the nursing progress notes revealed an entry dated 1/16/22 at 1:25 p.m. which indicated the resident was wandering in the hallway barefoot with only a brief and a shirt on. The resident stated she was looking for the restroom. She removed her brief and threw it on the floor. The hospice nurse visited and gave new orders for Haldol (antipsychotic medication) 1 mg to be given every twelve hours and Ativan 0.5 mg to be given every twelve hours as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 3 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 A review of the hospice provider's documentation revealed a handwritten order dated 1/16/22 for Ativan 0.5 mg to be given by mouth every 12 hours as needed for agitation. A pharmacy recommendation for Resident #57, dated 2/27/22, indicated, This resident has an order to receive Seroquel for behavior management. Per FDA (Food and Drug Administration) guidelines, the only approved indications for this agent are the treatment of manifestations of psychotic disorders, the short-term treatment of schizophrenia, the treatment of acute manic episodes associated with bipolar disorder, and the treatment of bipolar depression. Seroquel is not approved for aggression, Alzheimer's disease, anger management, anxiety, attention-deficit/hyperactivity disorder, bipolar maintenance, dementia, depression, mood disorder, post-traumatic stress disorder, or sleeplessness. A second pharmacy recommendation dated 2/27/22 indicated, Previous recommendation to discontinue PRN [as needed] use of Ativan was not completely addressed by MD [physician], and thus no duration for treatment was given . A psychiatric provider note dated 2/4/2022 was reviewed. The note indicated Resident #57 was receiving Depakote for management of mood and behavior. A review of Resident #57's Medication Administration Record (MAR) for March 2022, revealed documented administration of PRN Ativan on 3/11/2022, 3/12/2022, 3/17/2022 and 3/23/2022. A review of Resident #57's Behavior Monitoring Records for March 2022, revealed one instance of a documented behavior identified as continuous crying/vocalizations. The documented attempted interventions were redirection, providing a rest period, and administration of medication. A review of Resident #57's care flow records for March 2022, revealed one documented episode of difficulty sleeping. There were no documented behaviors for the remainder of the month. According to the Mayo Clinic (Accessed 3/24/2022 at 4:15 p.m.) at https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/description/drg-20066912), Seroquel is an antipsychotic medication that works in the brain to treat bipolar disorder and schizophrenia. This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer's disease. According to the Mayo Clinic (Accessed 3/24/2022 at 4:20 p.m.) at https://www.mayoclinic.org/drugs-supplements/valproic-acid-oral-route/description/drg-20072931), Depakote is used to treat the manic phase of bipolar disorder and certain types of seizures. According to the Mayo Clinic (Accessed 3/24/2022 at 4:24 p.m.) at https://www.mayoclinic.org/drugs-supplements/lorazepam-oral-route/description/drg-20072296), Ativan is a medication used to treat anxiety disorders and is used for short-term relief of the symptoms of anxiety. According to the Alzheimer's Foundation (Accessed 3/24/2022 at 5:15 p.m.) at https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior), individuals with dementia should use antipsychotic medications only if behavioral symptoms are due to mania or psychosis, the symptoms present a danger to the person or others, or the person is experiencing inconsolable or persistent distress, a significant decline in function, or substantial difficult receiving needed care. Antipsychotic medications should not be used to sedate or restrain persons with dementia. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 4 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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. Based on observation, dietary staff interview, facility document review, and facility policy and procedure review, the facility failed to store, prepare, and serve food under sanitary conditions when the dietary staff failed to wash hands between glove changes and change gloves when contaminated, as required. Food was stored in the walk-in cooler and walk-in freezer uncovered and not date marked. Food was kept beyond the allowed use by date. Baking sheets were wet nesting. Cutting boards were deeply grooved and in need of replacement. Handwashing sinks had no signage posted to indicate the sink was for handwashing only. The handwashing sink in the dish room was blocked by a mop bucket, broom, and dustpan. Food was observed on the floor of the freezer. Paper products to be used by residents were stored on the floor in the nutrition room. Hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a food safety hazard and a potential source of pathogen exposure for residents. The findings include: On 03/21/22 at 9:54 AM, Dish Room Aide D was observed putting insulated domes that had been washed and were still wet on a rack to air dry. He then went back to the dirty side of the dish room and started rinsing the dirty dishes and loading them into the dish machine. He then went to the clean side of the dish room and stacked the clean glasses on a pan. He did not change his gloves or wash his hands. He continued to go back and forth between the dirty and clean side without changing his gloves or washing his hands. At 10:14 AM, he changed his gloves but did not wash his hands. On 03/21/22 during the 9:54 AM kitchen observation, large stainless steel baking pans were observed to be wet and stacked on top of each other, not able to air dry on a rack near the dish room. Four large cutting boards were worn and deeply grooved. The handwashing sinks had no signage posted to indicate the sink was for handwashing only, and that staff must wash their hands. The milk cooler had no internal thermometer. Inside one milk crate was observed one quart-size carton of whipping cream that had not been opened and was dated 03/19/22. (Photographic evidence obtained) The Certified Dietary Manager (CDM) stated, I don't know why he left that in here. He was just here. Speaking in reference to the milk delivery man. On 03/21/22 at 10:20 AM, the walk-in cooler was observed with a large ham that was on a tray with plastic wrap covering it. There was no date mark. The CDM stated she thought a dietary aide had opened the package and sliced off a piece last Friday (03/18/2022). (Photographic evidence obtained) Cheese sandwiches were observed prepared and stacked in a large stainless steel pan with plastic wrap covering part of the pan. The sandwiches were not date marked. (Photographic evidence obtained) Eleven quarts of scrambled egg mix were on a tray on a bottom shelf. The date mark on the cartons was 03/07/22. (Photographic evidence obtained) The CDM confirmed they were out of date and needed to be discarded. Sliced cheese wrapped in plastic wrap was observed stacked on a large pan. The opened packages were not date marked. (Photographic evidence obtained) A cardboard box with cucumbers had one cucumber wrapped in plastic wrap with no date mark. (Photographic evidence obtained) A plastic re-sealable bag with sliced corned beef was dated 03/11/22. (Photographic evidence obtained) A pan of baked fish sitting on a shelf was observed to be uncovered. (Photographic evidence obtained) Two pans were observed covered with aluminum foil with no date marks. (Photographic evidence obtained) A plastic container was observed with lettuce in it. It was not covered or date marked. (Photographic evidence obtained) The CDM stated the expectation was that the dietary staff would cover the food and date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 5 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 mark it in the cooling units. Level of Harm - Minimal harm or potential for actual harm On 03/21/22 at 10:42 AM, the walk-in freezer was observed with frozen beef patties uncovered in a box. (Photographic evidence obtained) Frozen plant-based chicken strips were observed uncovered in the freezer.(Photographic evidence obtained) There were two packages of unidentified frozen food observed on the floor of the freezer. (Photographic evidence obtained) Residents Affected - Many During a second tour of the kitchen on 03/23/22 at 11:16 AM, observed in the walk-in cooler was the same plastic re-sealable bag with sliced corned beef that was dated 03/11/22. (Photographic evidence obtained) Observed in the walk-in freezer was the box of frozen beef patties still open and uncovered. An open box of frozen zucchini sticks was observed. (Photographic evidence obtained) The handwashing sink was still blocked by the mop bucket, broom and dust pan. There was still no signage at the sink. (Photographic evidence obtained) Observed wet nesting of baking sheets and pans. (Photographic evidence obtained) Dietary Staff C was observed preparing the lunch meal in the main kitchen on 03/23/22 from 11:50 AM until 12:25 PM. At 12:04 PM, he was observed wearing a pair of disposable gloves and was cooking the vegetables and meat patties. He touched the handle on the walk-in cooler, returned to the preparation area and continued to prepare the meal. He did not change his gloves. At 12:15 PM he changed gloves but did not wash his hands in between. He touched the handles of the oven and utensils used for the preparation of the meal. He moved food pans from the preparation area to the steam table, using a pair of oven mitts, touching the surfaces of the steam table. He doffed the oven mitts and donned new disposable gloves without washing his hands. On 03/23/22 at 12:35 PM, the Bistro kitchen and nutrition room on the second floor of the facility were toured. Paper products were stored on the floor in the nutrition room. (Photographic evidence obtained) On 03/23/22 from 12:35 PM until 12:50 PM, Housekeeping Staff Q and Social Services Staff R were working in the Bistro kitchen during the lunch food service and were observed donning and doffing disposable gloves without washing their hands in between. Social Services Staff R was preparing sandwiches on a panini press. She touched the utensils to make the sandwiches and kitchen equipment with her gloved hands and then touched the ready to eat sandwiches with her contaminated gloves. The hand sink for employees to wash their hands was located in the nutrition room next to the Bistro kitchen. During an interview with Dietary Staff C on 03/24/22 at 8:25 AM, he was asked if he was supposed to change his gloves when they became contaminated and wash his hands prior to donning new gloves. He replied Yes. Did I not do that? When he was informed that he was observed on 03/23/22 during the lunch meal service not changing gloves as needed and not washing his hands prior to donning new gloves, he stated, Oh, I'm sorry. I was a little nervous. During a 03/24/22 interview with the CDM at 8:35 AM, she stated she was not aware that her staff were changing gloves without washing their hands. She agreed that the food in the cooler and freezer was not covered. She stated the staff were running in there in a hurry, grabbing what they needed and then not covering it again. She confirmed that she did not have enough room in the kitchen to air dry the dishes. A review of the Food Storage Chart For Safety and Quality, used by the facility for date marking and shelf time, revealed prepared meat products should be kept only three days wrapped in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 6 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 refrigerator. (Copy obtained) Level of Harm - Minimal harm or potential for actual harm A review of the staff training dated 03/09/22, entitled Food Handling and Food Safety, Glove Usage, revealed Dietary Staff Q and Social Services Staff R received the training. Residents Affected - Many A review of the staff training dated 02/17/22, entitled Storage of Foods Food Safety and Leftovers, revealed Dietary Staff C received the training. A review of the facility policy and procedure for Food Storage Overview revealed: Purpose: Food is stored by methods designed to prevent contamination. 3. Food items should be stored on shelves. 4. Containers are to be labeled. 11. Food is stored a minimum of 6 inches above the floor. 12. Leftover food is stored in covered containers or wrapped securely. Each item is securely labeled and dated before being refrigerated. Leftover food is used within 2 days or discarded. 14. e. Foods are to be covered, labeled, and dated including month, day, and year. A review of the facility policy and procedure for Glove Use revealed: Wash hands thoroughly before and after wearing or changing gloves. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 7 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on a review of the Facility Assessment, CMS (Centers for Medicare and Medicaid Services) form 672 (Census and Condition of Residents), and interviews with staff, the facility failed to update the Facility Assessment on an annual basis in order to assess the population's acuity level and determine what resources were needed to provide care for its residents during not only day-to-day operations, but during an emergency. The facility also failed to employ the input of facility staff members including the Medical Director, Director of Nursing, any member of the governing body, residents or their representatives. This had the potential to affect all 124 residents in the facility. Without a comprehensive assessment of the residents' diagnoses, conditions and needs, the facility was not able to determine staff competencies required to provide appropriate care, nor the environment or equipment needed to perform such care. The findings include: A review of CMS form 672, Census and Condition of Residents, found there were 124 residents in the building at the time of the survey. Some of the current population's special care needs included, but were not limited to: 7 indwelling catheters, 3 bedfast residents, 10 residents with contractures, 14 residents with pressure ulcers, 6 residents with depression, 7 residents with dementia, 9 residents receiving hospice services, 4 residents on dialysis, 3 residents requiring ostomy care, 55 residents receiving psychotropic medications, 34 residents requiring injections, 6 residents receiving tube feedings, 65 residents requiring rehabilitative services, and 4 residents with significant weight loss. The Director of Nursing (DON) signed the CMS 672 on 3/21/22. (Copy obtained) A review of the Facility Assessment (FA), dated 2022, found there were two people involved in completing the assessment; the Administrator and the Compliance Officer. The FA was updated in 3/2020, 10/2020, 1/15/2021 and 1/2022, and the Quality Assurance and Performance Improvement (QAPI) committee reviewed the FA on those same dates. The Resident Profile section reported there were 146 licensed beds. It also asked for the following information: -Average daily census. -Average weekday admissions in 2021. -Average weekend admissions in 2021. -Average weekday discharges in 2021. -Average weekend discharges in 2021. Each section's response noted, Fluctuations due to Covid-19. The section titled Common Diagnoses/Conditions, provided general examples falling under each condition, however, the Acuity section of the FA asked for the following data based on resident needs: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 8 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 0838 -Rehabilitation Plus Extensive Services. Level of Harm - Minimal harm or potential for actual harm -Rehabilitation. -Extensive Services. Residents Affected - Many -Special Care High. -Special Care Low -Clinically Complex. -Behavioral Symptoms and Cognitive Performance. -Reduced Physical Function. All fields asking for the number/average range of residents was left blank. The Special Treatments and Conditions section asked for data on the following resident needs: -Cancer treatments (chemotherapy and radiation), respiratory treatments (oxygen therapy, suctioning, trachesostomy care, ventilator/respirator or BIPAP/CPAP machines). -Mental health services (behavioral health needs, substance abuse disorders). -Other services (Intravenous medications, injections, dialysis, ostomy care, hospice, respite care, isolation or quarantine for active infection diseases and advanced wound care needs). All of the corresponding fields asking for the typical number of residents with these needs were blank. The Assistance with Activities of Daily Living - Currently In-house section asked how many in-house residents required assistance with dressing, bathing, transfers, eating, toileting, mobility or other care needs. All fields were left blank. Section 3, Facility Resources Needed, revealed the facility staffing patterns were based on an average of 125 residents, however, this pattern was considered without first identifying the above resident-specific information. The final Risk Assessment section of the FA, the SWOT (Strengths, Weaknesses, Opportunities and Threats) Analysis was left blank for all 4 sections. (Copy obtained) An interview was conducted with the Administrator on 03/24/22 at 5:43 PM. He was asked where the updates to the 2022 FA were, since there was no assessment of the acuity levels of his resident population. He stated the facility's needs changed last year. After serving all COVID-19-positive residents, the census went to zero then built back up. He had no other explanation as to why residents' needs had not been assessed since initial licensure. He was asked if he had considered that initially, because there were primarily COVID-19-positive residents in the building, and each of those residents had conditions and special treatment needs other than COVID-19. He admitted he had not included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 9 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that information in the assessment. The Administrator acknowledged after the facility zeroed out on the census, then rebuilt, the new residents' needs were also never assessed in order to determine proper staffing and other resources required to meet those needs. The Administrator was reminded that the FA was driven by census and acuity levels of the residents and without that information, it was not possible to accurately assess facility resources required. He acknowledged the requirement. The Administrator also confirmed that only he and the Compliance Officer were involved in the FA completion. He was not aware additional team members should be involved in its development in order to comprehensively assess needs and plan for meeting those needs. The Administrator stated he would review the FA requirements again. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 10 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of resident records and facility policies, the facility failed to accurately document resident medication and treatment records for one (Resident #121) of one resident who reported problems with receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample. The findings include: An observation of and an interview with Resident #121 was conducted on 03/22/22 at 10:24 AM. During the interview, she commented that by this time of day, her legs should already be wrapped. They were still not wrapped. She explained that staff were supposed to wrap her legs daily with ace bandages, however, some days it was after 4:00 PM or 5:00 PM by the time they finally applied the wraps. Some days, the staff did not apply them at all. Resident #121 added that her doctor recently prescribed her some nasal spray, but she still had not received it. It was intended for her wheezing and coughing. An observation at this time found no ace bandage wraps on either of Resident #121's lower legs, which were both edematous (swollen due to a buildup of fluid). Resident #121 was observed on 03/22/22 at 1:43 PM and again at 4:21 PM, and the ace wraps had still not been applied. During an observation and interview with Resident #121 on 03/23/22 at 10:08 AM, she had ace bandage wraps to both of her legs below the knees. She reported that Agency Certified Nursing Assistant (CNA) N wrapped her legs this morning before she got out of bed. She had gone to therapy this morning and the bandages were now loose. When asked if the wraps had been applied yesterday (3/23/22) after the 4:21 PM observation, she said, No. A record review for Resident #121 found she was readmitted to the facility on [DATE]. The 5-day minimum data set (MDS) assessment, dated 02/27/22, indicated Resident #121 had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact. Resident #121 had a physician's order dated 03/01/22 that instructed clinical staff to apply ace wrap knee highs (ace bandages applied to the lower legs up to knee level in order to provide gently pressure and reduce swelling); On in the AM (morning), remove in the PM (evening). She also had a physician's order for Ipratropium Bromide Solution 0.3% (a medication used to open up the airways in the lungs), two sprays in both nostrils twice a day for rhinorrhea (excessive drainage from the nose/nasal passages). The order was written on 3/14/22 (8 days ago), but said it was still Pending Confirmation instead of Active. (Copies obtained) A review of the electronic medication administration record (eMAR) found the Ipratropium nasal spray was scheduled to be administered daily at 9:00 AM and 6:00 PM, however, between 03/14/22 (the day the order was written) and 03/21/22, the signature boxes used to indicate the medication was administered were all marked with Xs. There was no explanation of what X meant. On 03/22/22, both signature boxes had nurses' initials in them, indicating the spray was administered at 9:00 AM and 6:00 PM. A review of the electronic treatment administration record (eTAR) found Resident #121's ace wraps had been signed off as applied on 3/22/22, despite multiple observations and an interview with the resident verifying that they had not been put on. (Copies obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 11 of 12 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 106135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dolphin Pointe Health Care Center 5355 Dolphin Point Blvd Jacksonville, FL 32211 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Licensed Practical Nurse (LPN) O on 03/23/22 at 3:09 PM. She confirmed that Resident #121 had edema and received ace wraps to her legs each morning. The wraps were removed at night, and this was to be done every day. LPN O was asked why Resident #121's nasal spray was still pending confirmation a week after it was ordered. She explained that Sometimes the physicians write an order, but the electronic medication ordering system does not allow the facility nurses to confirm the order. She speculated that perhaps that was why the order was pending for that long. LPN N said Resident #121's nasal spray just came in, but she had not received it yet. Photographic evidence of the Ipratropium spray was obtained on 03/23/22. The medication label said it was filled by the pharmacy on 03/22/22, eight days after it was ordered. A handwritten note indicated the spray was not opened until 03/23/22. LPN P was interviewed on 03/24/22 at 9:29 AM. She stated if a medication was not available at the time of administration, she would go to the electronic medication dispenser to see whether the medication was available. If not, she would call the physician and mark the eMAR (electronic medication administration record) Other and note the medication was not available. The Director of Nursing (DON) was interviewed on 03/24/22 at 2:41 PM and was advised that Resident #121's ace wraps were being signed off by nursing as having been applied when they had not been applied. She was also told of the two doses of nasal spray that were signed as having been administered before the medication had been delivered to the facility. The DON explained there was a code on the eMAR and eTAR (electronic treatment administration record) for nurses to document Other if a medication was not available for administration. The nurses just received training on that. She had no explanation for why nurses were documenting that medication and treatments were being provided when they were not. She said she would speak with the nurses. A review of the Clinical Guidelines Manual Medication Pass Guidelines, CCHC 0115 Copyright 2008, revealed: Purpose: To safely and accurately prepare and administer medication according to physicians' orders and patient needs. Document: -Medication administered -Resident refusal of medication and reason, contact physician for guidance. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106135 If continuation sheet Page 12 of 12