Inspection·September 30, 2021

F 0726 received any competencies since I have been here. Level of Harm - Minimal harm or potential for actual harm 2. A record review for Resident #5 revealed an admissions date of 6/11/21, with diagnoses including respiratory failure, tracheostomy (trach), and paraplegia. Residents Affected - Many A review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating cognitively intact. The resident required suctioning and trach care. During an interview with Resident #5 on 9/27/21 at 11:00 AM, he stated, he provided his own tracheostomy suction. He added, he learned to suction himself at another facility. When asked if he was assessed for self-care at the facility, he stated, no, he was not. When asked if staff assisted him with his tracheostomy care, he stated, No. During an interview with Employee D, Certified Nursing Assistant (CNA) on 9/29/21 at 10:12 AM, she stated, she has been a CNA for a while and knew how to provide care to the residents. When asked if she had completed any competency skills check, she replied, No. On 9/29/21 at 10:15 AM, an interview was conducted with Employee E, CNA. She stated, she received her training by working with another CNA during orientation. When asked if she had completed any competency skills check, she replied, No. On 9/29/21 at 10:26 AM, an interview was conducted with Employee F, Assistant Director of Nursing (ADON)/Registered Nurse (RN). She stated, she was responsible for staff education. When asked if she had conducted any competencies for employees, she stated, the Director of Nursing (DON) and her had talked about having a skill fair, but it had not happened at the time of survey. She confirmed that none of the licensed nursing employees had received competency skills check during the year of 2021. On 9/30/21 at 2:14 PM, an interview was conducted with Employee A, Administrator and Employee B, Regional Administrator regarding employees' competencies. They confirmed competency skills checks were not conducted in 2021. The also confirmed that Resident #5 was not assessed to provide his own tracheostomy care. They added, the regional nurse consultant would initiate the training as soon as possible. During an interview with Employee G, Patient Care Attendant (PCA) on 9/30/21 at 2:46 PM, she stated, she has been at the facility for about two months. When asked if she received training, she stated that she received online training upon hire and then shadowed another CNA. When asked how to identify resident's requirement with transfer, she stated she would ask the residents or get someone to help. When asked about documentation regarding resident's transfer requirements, she stated that she was not aware of it. On 9/30/21 at 2:05 PM, an interview was conducted with Employee C, LPN, who was the nurse assigned to care for Resident #5. He confirmed, Resident #5 suctioned himself and completed his own tracheostomy care. When asked about tracheostomy ties, he stated, they are changed by the nursing staff as needed. He confirmed that he had not had any tracheostomy care or suctioning competencies since he worked at the facility. He stated his last tracheostomy care and suctioning training was at his last place of employment two years ago. A review of the staff education calendar for 2021 revealed the facility had a different competency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105531 If continuation sheet Page 2 of 7 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 105531 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at San Jose 9355 San Jose Blvd Jacksonville, FL 32257 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many skill set scheduled each month, such as: dressing change in February, use of lifts in June, Tracheostomy care and tracheostomy suctioning in August, etc. (Copy obtained) A review of the facility assessment updated dated 1/4/2021 revealed the following: III. Facility Resources needed to provide competent support and care for our Resident population every day and during emergencies. Facility resources (staff, equipment, physical plant) are evaluated during annual budget review, monthly during financial operations review or whenever changes in resident population and/or their needs requires resource evaluation. B. Staff training and competencies: Staff training and qualifications are evaluated during the hiring process by reviewing their education and experience. Once hired, staff goes through classroom and floor orientation depending on their discipline. Classroom orientation include the following modules provided to all staff on hire, annual, as needed (PRN) and on Demand: Abuse neglect and exploitation, infection control, cultural change ( that is person- centered and person- directed care), cultural competency, person centered care, disaster planning, medication administration, measurements (vitals, intake and output), caring for people with dementia, Alzheimer's and cognitive impairments, non- pharmacological management of Responsive behaviors and resident assessment. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105531 If continuation sheet Page 3 of 7 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 105531 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at San Jose 9355 San Jose Blvd Jacksonville, FL 32257 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 - Some 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 record reviews, interviews, and policy and procedure review, the facility failed to ensure the medical records for three (Resident #38, #15 and #24) of five residents sampled for unnecessary medication use were complete and accurate, from a total sample of 33 residents. The findings include: 1. A record review for Resident #38 revealed an admission date of 8/4/17, with diagnoses including but not limited to type 2 Diabetes Mellitus (DM) without complications, pain in unspecified shoulder, major depressive disorder, schizoaffective disorder, bipolar type, unspecified psychosis not due to a substance or known physiological condition, insomnia, and generalized anxiety disorder. A review of Resident #38's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. The assessment also indicated that the resident had trouble falling or staying asleep, sleeping too much, feeling down, or depressed, or hopeless 12-14 days. A review of Resident #38's care plan revealed, she has insulin dependent diabetes melilotus; uses antidepressant medication related to depression and insomnia, has COPD, uses antipsychotic therapy related to psychosis, has acute and chronic pain related to bipolar psychosis, depression, and on antibiotic therapy related to elevated blood ammonia levels. Interventions included to administer medications as ordered. During an interview with Resident #38 on 9/27/21 at 11:31 AM, she stated she was receiving her medications late on the 3-11 shift. A review of Resident #38's current physician's orders revealed orders for: Depakote Tablet Delayed Release 250 milligram (mg) twice a day (BID) for seizures, Depakote ER Tablet Extended Release 24-hour 500 mg once a day in the evenings for seizures, tramadol HCI tablet 50 mg give 2 tablets every 8 hours for nonacute pain, Latuda tablet 20 mg, give 3 tablets in the evening for schizoaffective with dinner, Levemir Solution 100 unit/ml inject 26 units subcutaneously in the morning for Diabetes Mellitus, Trazodone HCI tablet 300 mg one at bedtime for major depressive disorder, Metformin HCI tablet give 500 mg BID for Diabetes Mellitus, and Gabapentin tablet give 1200 mg three times a day (TID) for neuropathy. Behavior monitoring every shift. Assess resident for pain every shift. Monitor side effects every shift. (Copy obtained) A record review of Resident #38's Medication administration Record (MAR) for September 2021 revealed multiple omissions: Latuda 20 mg tablet, give 3 tablets by mouth in the evening was not documented on 9/3, 9/8, 9/14, 9/15, 9/16, 9/17 and 9/21. Tramadol HCI 50 mg, give 2 tablets every 8 hours for nonacute pain was not documented on 9/3, 9/8, 9/10, 9/14, 9/15, 9/16, 9/17 and 9/21. Metformin HCI 500 mg tab, two times a day for DM was not documented on 9/3 (1700), 9/8 (1700), 9/14 (1700), 9/15 (1700), 9/16 (1700), 9/17 (1700), 9/21 (1700) and 9/23 (0900). NovoLog Solution 100 unit/ml inject as per sliding scale subcutaneously BID for edema was not documented on 9/3 (1630), 9/8 (1630), 9/14 (1630), 9/15 (1630), 9/16 (1630), 9/17 (1630) and 9/21 (1630). Lorazepam 0.5 mg tablet every 12 hours for anxiety was not documented on 9/10 (2100), 9/14 (2100), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105531 If continuation sheet Page 4 of 7 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 105531 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at San Jose 9355 San Jose Blvd Jacksonville, FL 32257 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 - Some 9/15 (2100), 9/16 (2100), 9/17 (2100) and 9/21 (2100). Depakote Delayed Release 250 mg tab, give 1 tab BID for seizures was not documented on 9/3 (1700), 9/8 (1700), 9/14 - 9/17 (1700) and 9/21 (1700). Depakote ER Extended Release 24-hour 500 mg tab, give 1 tab in the evening for seizures was not documented on 9/3 (1700), 9/8 (1700), 9/14 -9/17 (1700) and 9/21 (1700). Gabapentin 1200 mg tablet, 1-tab TID for neuropathy was not documented on 9/3 (2200), 9/8 (1400 and 2200), 9/10 (2200), 9/14 - 9/17 (2200) and 9/21 (2200). Trazodone HCL 300 mg tab, give 1 at bedtime for major depressive disorder was not documented on 9/3, 9/8, 9/10 and 9/14 - 9/17. Behavior monitoring, pain assessment and side effects monitoring was not documented on 9/3, 9/8, 9/14 - 9/17 and 9/21. (Copies Obtained) During an interview with Employee C, Licensed Practical Nurse (LPN), on 9/30/21 at 2:54 PM, he was asked the process for documenting medication administration. He stated, You document when you give it in the computer on the MAR. Medications should be given then documented, You have to click in the computer that you have given the medication. When he was shown the MAR for Resident #38, he confirmed that the medication was not documented. He could not explain the blanks on the residents' MAR. 2. A record review for Resident #15 revealed an admission date of 8/8/20, with diagnoses that included bipolar disorder, major depressive disorder, chronic pain, and type 2 diabetes. A review of Resident #15's annual MDS assessment dated [DATE] revealed a BIMS score of 15, indicating cognitively intact. The resident requires extensive mobility for bed mobility, limited assistance for transfer and toilet use and is on antidepressants. Care plan for Resident #15 indicated, he uses antidepressant medication related to depression with insomnia and sedative/hypnotic therapy related insomnia. Interventions included administer medication as ordered by the physician and monitor/document side effects and effectiveness every shift. A review of Resident #15's current physician's orders included: oxycodone-acetaminophen tablet 10-235 mg, 1 tab every 6 hours as needed (PRN), Metformin 500 mg BID, and Fluoxetine HCI 20 mg, 1 capsule daily for major depressive disorder. Assess resident for pain every shift. Behavior monitoring every shift. Side effects every shift for monitoring put in corresponding code. A record review of Resident #15's MAR for September 2021 revealed multiple omissions: Fluoxetine 20 mg was not documented on 9/6, 9/9, 9/15 and 9/23-9/24. Assess resident for pain was not documented on 9/2, 9/6-9/8, 9/13, 9/15-9/17 and 9/23. Behavior monitoring was not documented on 9/2, 9/6-9/9, 9/13, 9/15-9/17 and 9/23. Side effects was not documented on 9/2, 9/6-9/8, 9/13, 9/15-9/17 and 9/23-9/24 (Copies obtained) 3. A record review for Resident #24 revealed an admission date of 5/17/14, with diagnoses that included cardiovascular disease, diabetes mellitus Type 2, dysphasia, embolism and thrombosis, atrial fibrillation, hypertension, neuropathy, anxiety disorder, schizoaffective disorder, bipolar disorder, seizures, gastrostomy, major depressive disorder, hyperlipidemia, history of malignant neoplasm of breast. A review of Resident #24's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, indicating moderate cognitive impairment. The assessment also indicated that the resident receives antipsychotic, antianxiety, antidepressant, and anticoagulant medications. A review of Resident #24's care plan revealed the following: behaviors related to schizoaffective disorder, impaired cognitive function processes related to depression, psychotropic drug use, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105531 If continuation sheet Page 5 of 7 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 105531 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at San Jose 9355 San Jose Blvd Jacksonville, FL 32257 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 - Some seizures, insulin dependent due to diabetes and a risk for falls. Interventions included medication administration. A review of Resident #24's current physician's orders revealed orders for: Atorvastatin Calcium tablet 80 mg, 1 tab at bedtime related to hyperlipidemia, Sertraline HCI 100 mg tablet, 1 tab daily related to major depressive disorder, Tradjenta 5 mg tablet, give 1 tablet daily related to type 2 DM, Buspirone HCI 10 mg tablet, 1 tab BID for anxiety, Eliquis 5 mg tablet, 1 tab BID related to cerebrovascular disease, Hydralazine HCI 100 mg tablet, 1 tab every 12 hours for HTN, Levetiracetam 100 mg tablet, 1 tab BID related to convulsions, Metoprolol tartrate 25 mg tablet, 1 tab BID HTN, Olanzapine 5 mg tablet, 1 tab BID for schizoaffective disorder bipolar type, Baclofen 10 mg tablet, 1 tab TID for pain, Gabapentin 100 mg capsule, 1 capsule every 8 hours for neuropathy pain, Behavior monitoring every shift, Side effects every shift for monitoring put in corresponding code. (Copy obtained) A record review of Resident #24's MAR for September 2021 revealed multiple omissions that included: Atorvastatin Calcium tablet 80 mg, 1 tab at bedtime related to hyperlipidemia was not documented on 9/3, 9/10, 9/14-9/17 and 9/21. Sertraline HCI tablet 100 mg, 1 tab daily related to major depressive disorder was not documented on 9/8. Tradjenta 5 mg tablet was not documented on 9/8 and 9/22. Buspirone HCI 10 mg tablet was not documented on 9/3, 9/8, 9/10, 9/14-9/17 and 9/21. Eliquis 5 mg tablet was not documented on 9/3, 9/8, 9/10, 9/14-9/17 and 9/21-9/22. Hydralazine HCI 100 mg tablet was not documented on 9/3, 9/8, 9/10, 9/14-9/17 and 9/21-9/22. Levetiracetam 100 mg tablet was not documented on 9/3, 9/8, 9/10, 9/14-9/17. Metoprolol tartrate 25 mg tablet was not documented on 9/3, 9/8, 9/10, 9/14-9/17. Olanzapine 5 mg tablet was not documented on 9/3, 9/10, 9/14-9/17 and 9/21-9/22. Baclofen 10 mg tablet was not documented on 9/3, 9/8, 9/10, 9/14-9/17 and 9/21-9/22. Gabapentin 100 mg capsule was not documented on 9/3, 9/8, 9/10, 9/14-9/17 and 9/21-9/22. Behavior monitoring was not documented on 9/3, 9/10, 9/14-9/17 and 9/21. Side effects was not documented on 9/3, 9/8, 9/10, 9/14-9/17 and 9/21-9/22. (Copy obtained) A review of the policy titled Medication Management- Psychotropic Medications Document Name: N-1255 Revised on 3/28/2018 Procedures: 4. Monitoring behavior and side effects every shift utilizing the Behavior Monitoring Flow Record (BMFR) or electronic equivalent (copy obtained). 5. Resident centered non- pharmacological interventions should be initiated as indicated. 12. Monitor resident's response to medication and progress towards goals. 13. Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches. A review of the General Dose Preparation and Medication Administration policy Effective 12/01/21 and last revised on 01/01/2013 Page 2 4. Prior to administration of medication. Facility staff should take all measures required by facility policy and applicable law including but not limited to the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105531 If continuation sheet Page 6 of 7 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 105531 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at San Jose 9355 San Jose Blvd Jacksonville, FL 32257 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 4.1 Facility staff should: Level of Harm - Minimal harm or potential for actual harm 4.1.1 Verify each time a medication is administered that it is the correct medication at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident as set forth in Appendix 17: Facility Medication Administration Times Schedule: Residents Affected - Some 4.1.2 Confirm that the MAR reflect the most recent medication order. 6 After medication administration, facility staff should take all measures required by facility policy and applicable Law, including but not limited to the following: 6.1 Document necessary medication administration/ treatment information (e.g., when medications are opened, when medications are given, injection site of the medication, if medications are refused, PRN medication, application sites) on appropriate forms. (Copy obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105531 If continuation sheet Page 7 of 7