Health inspection·February 5, 2026

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 reviews, and review of the facility's Oral Administration of Medication policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of four residents reviewed for medication management, by failing to follow physician's orders related to heart failure medication.The findings include:Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included unspecified systolic (congestive) heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, cardiac arrhythmia, unspecified, other cardiomyopathies; and presence of automatic (implantable) cardiac defibrillator. Review of Resident #1's Medicare/5-day MDS (minimum data set) dated 1/26/26 revealed a BIMS (brief interview for mental status) score of 14 out of 15, indicating she was cognitively intact. She required substantial assistance with toileting/transfers and required dialysis and IV access. Review of the care plan for Resident #1 noted the following: FOCUS: I have altered cardiovascular status r/t Hypertension, CAD, HF, h/o PE Date Initiated: 1/21/26, Revision on: 1/21/26. Goals: I will be free from complications of cardiac problems through the review date. Date Initiated: 1/21/26. Intervention: Monitor VITAL SIGNS as ordered. Notify MD of significant abnormalities. Date Initiated: 1/21/26, Revision on: 1/21/26. Review of the physician's orders for Resident #1 revealed the following: Carvedilol Oral Tablet 6.25mg by mouth two times daily for Heart Failure/HTN (hypertension). Hold for SBP (systolic blood pressure) Less than 115 and/or heart rate less than 60 (start date 1/21/26 at 2100). Review of the January medication administration record (MAR) for Resident #1 revealed the resident had been administered medications outside of physician ordered parameters four (4) times as shown below: (Copy obtained)On 1/26/26 at 2100, Employee A administered Carvedilol when the resident's BP reading was 114/58.On 1/27/26 at 0900, Employee B administered Carvedilol when the resident's BP reading was 102/72.On 1/27/26 at 1400, the next scheduled B/P reading was recorded and was documented as 92/54. The medication was held.On 1/27/26 at 2100, Employee C administered Carvedilol when the resident's BP reading was 110/60.On 1/31/26 at 2100, Employee C administered Carvedilol when the resident's BP reading was 112/70.Review of a second physician's order for Resident #1 revealed the following: Isosorbide Dinitrate Oral Tablet 20 mg by mouth three times daily for Heart Failure with reduced ejection fraction. Hold for SBP (systolic blood pressure) less than 115 (start date 1/21/26 at 1400, discontinued 1/30/26). Review of the January medication administration record (MAR) for Resident #1 revealed the resident had been administered medications outside of physician ordered parameters five (5) times as shown below: (Copy obtained)On 1/23/26 at 1400, Employee D administered Isosorbide Dinitrate when the resident's B/P reading was 110/71.On 1/26/26 at 2100, Employee A administered Isosorbide Dinitrate when the resident's B/P reading was 114/58. On 1/27/26 at 0800, Employee B administered Isosorbide Dinitrate when the resident's B/P reading was 102/72. On 1/27/26 at 2100, Employee C administered Isosorbide Dinitrate when the Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105531 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 02/05/2026 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)