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 Page 1 of 2 105531 105531 02/05/2026 Aviata at San Jose 9355 San Jose Blvd Jacksonville, FL 32257

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's B/P reading was 110/60.On 1/28/26 at 2100, Employee C administered Isosorbide Dinitrate when the resident's B/P reading was 114/72.Review of a third physician's order for Resident #1 revealed the following: Isosorbide Dinitrate Oral Tablet 20 mg by mouth three times daily every Tuesday, Thursday, Saturday and Sunday for Heart Failure with reduced ejection fraction related to Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris Hold for SBP (systolic blood pressure) less than 115 (start date 1/31/26 at 1400). Review of the January medication administration record (MAR) for Resident #1 revealed the resident had been administered medications outside of physician ordered one (1) time as shown below: (Copy obtained)On 1/31/26 at 2100, Employee C administered Isosorbide Dinitrate when the resident's B/P reading was 112/70. During an interview with the Director of Nursing (DON) on 2/5/26 at 5:15 PM, she confirmed the medications noted above had been administered to Resident #1 outside the parameters of the physician orders and on at least one occasion, on 1/27/26 at 1400 the resident's B/P was taken and found to be below the normal range for this resident. It was documented as 92/54. The DON was asked what her expectation was for the licensed nursing staff as it related to administering medications according to physician ordered parameters. She stated, I expect them to adhere to the 6 rights of medication administration, identifying the right resident, route and so on, and following physician orders. If they have any concerns or discrepancies about the physician orders, they should contact the provider for clarification. She was asked what kinds of in-service education was provided to the licensed nurses related to medication administration. She stated, We provide annual training, and if any concerns or issues arise, we do more in-services. Upon hire they also have that training.Review of the facility's Policy and Procedure titled, Medication-Oral Administration of, Document Name N-853, with an effective date: 11/30/14, and last revised: 8/15/19 revealed the following:Procedure:Review physician's orderReview the MAR (medication administration record) or EMAR (electronic medication administration record) should there be any uncertainties verify the MAR or EMAR with the Physician's Order Sheet (POS) and seek clarification as indicated. (Copy obtained) 105531 Page 2 of 2