Health inspection·September 22, 2022

F 0557 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Certified Nursing Assistant (CNA) F on 9/22/22 at 1:40 PM. CNA F reported that part of the care she provided for residents with urinary catheters was that she emptied the catheter bag and cleaned the area around the catheter site. She was asked when a privacy bag would be placed on a catheter bag, and she reported, at all times. At this time she stated, Resident #60 does not have a privacy bag and he should have one. Residents Affected - Few A review of the facility's policy for Resident Rights-Exercise of Rights (dated 3/2/2019) revealed: Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff or volunteers, must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preference and choices. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105617 If continuation sheet Page 2 of 5 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 105617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250 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 observations, staff interviews and policy and procedure review, the facility failed to ensure staff served meals in a safe and sanitary manner and maintained food service equipment. Failure to clean and maintain cooking and baking equipment and to ensure that food provided to residents is prepared in a clean environment in accordance with professional standards for food service, can place all residents who consumed foods prepared in the facility's kitchen at risk of exposure to food-borne illnesses. The findings include: An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 09/19/2022 at 8:30 AM. During the tour, the dry storage pantry, throughout the kitchen and on the wall behind the preparation table built-up debris and dirt were observed. Food debris was observed in the grooves between the floor tiles. The ice machine room floor had what appeared to be built-up dirt in the grooves between the tiles. The side of the counter next to the trash can was covered with grease buildup and food debris. The trash can lid was covered with food debris. The plastic covering over the standing mixer and meat slicer was heavily soiled with grease and food debris. When asked about the condition of the mixer and meat slicer, [NAME] E stated the mixer was not in use. The leg pipes of the steamer, sitting on the countertop were coated with a brown substance. There were two ovens located next to the convection oven; both were filled with food debris. When asked about the condition of the two ovens next to the convection oven, [NAME] E stated the ovens had not worked in two months. Spillage was observed in the top and bottom convection ovens. Trash and debris were observed on the floor in the dry storage pantry and ice machine room, as well as underneath the steam table and convection oven. A water spillage filled with food debris was observed on the side arm of a food cart. These observations were made again on 09/20/2022 at 10:00 AM and on 09/21/2022 at 11:08 AM. (Photographic evidence obtained) On 09/20/2022 at 10:00 AM, a second observation of the kitchen was conducted. The dry storage pantry and the cook area had built-up dirt and a grainy substance on the floor and food debris in the grooves between tiles. The side of the counter next to the trash can was covered with grease buildup and food debris. The two ovens next to the convection oven were filled with food debris. [NAME] E reported that he tried cleaning the ovens yesterday. The leg pipes of the steamer, sitting on the countertop, were coated with a brown substance. The water spillage, still filled with food debris, remained on the side arm of a food cart next to the food prep area. Spillage was observed in the bottom convection oven. [NAME] E reported that he tried cleaning the ovens yesterday, 9/19/2022. The trash was removed, however, built-up dirt in the grooves between the floor tiles remained on the ice machine room floor. The cleaning schedule was obtained on 9/20/2022. The schedule indicated the floors had been scrubbed, but there was no indication of deep cleaning. (Photographic evidence obtained) On 09/21/2022 at 11:08 AM, an interview with the CDM and a third observation of the kitchen was conducted. During this tour, built-up dirt and food debris in the grooves between floor tiles was observed throughout the kitchen. The side of the counter next to the trash can was covered with grease build-up and food debris. The two ovens next to the convection oven were filled with food debris. The CDM reported she tried cleaning the ovens yesterday, 9/20/2022. She stated she did not recall the kitchen using the two ovens since February 2022. A white plastic container on top of a cart and water spillage filled with food debris was observed on the side arm of the food cart next to the food prep area. Built-up dirt observed in the grooves between the tiles remained on the ice machine room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105617 If continuation sheet Page 3 of 5 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 105617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250 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 floor. When asked about staff in-service trainings, the CDM reported in-service trainings were based on concerns that come up. There are no trainings from corporate. (Photographic evidence obtained) On 09/22/2022 at 1:23 PM, an interview was conducted with Dietary Aide B. When asked who was responsible for cleaning and maintaining the kitchen equipment, she reported all staff were responsible for cleaning. Cooks are responsible for pots and pans, scoops, cooking equipment, and the work area. Dietary Aides are responsible for plates/bowls, utensils, and the work area. She stated staff reported equipment failures to the supervisor, and the supervisor submitted work orders to the maintenance department. On 09/22/2022 at 1:25 PM, an interview was conducted with the CDM. When asked who was responsible for cleaning and maintaining kitchen equipment, she stated, It is everyone's responsibility that is employed in the kitchen. If there is a problem with any equipment or the sink is not working, it is reported to the CDM and the CDM will submit a work order to maintenance. She stated the kitchen had a cleaning schedule. The floor is swept or mopped whenever there is a spillage and at the end of the day when closing the kitchen down. The cook completes a walk through at the end of the night to ensure no spillage is on the floor. Everything is wiped down and sanitized clean. The CDM will walk through in the morning to check the cleanliness of the kitchen. On 09/22/2022 at 2:44 PM, an interview with The Director of Plant Operations revealed he had not received a work order for the two ovens that were not working, nor had he heard of any problems related to the condition of the two ovens. On 09/22/2022 at 2:50 PM, an interview with the CDM revealed the two ovens that were not working were not used because staff are having to bend down and it's bad on your back, so the convection ovens are used. It's harder to take food out when staff are that low to the ground. Staff only use the top burners of the oven. A review of the facilty's policy and procedure entitled Food and Nutritional Services, revised date: 3/2/2019, revealed it read: 13. The facility will procure food from sources approved or considered satisfactory by the Federal, State, or local authorities and store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of foodborne illness. 14. Staff maintain the sanitation of department by assuring that: Floors are kept clean, free of debris, and spills are cleaned-up immediately to avoid accidents. Cleaning schedules are followed, and cleaning procedures are utilized. 17. The facility will dispose of garbage and refuse properly, garbage and refuse containers will be maintained in good condition, and garbage receptacles will be covered when transported to the dumpster from the kitchen. Reference: United States Food and Drug Administration Food Code 2017. 3. Public Health and Consumer Expectations. Clean environment. Page 10. https://www.fda.gov (Accessed 0n 9/26/2022): It is a shared responsibility of the food industry and the government to ensure that food provided to the consumer is safe and does not become a vehicle in a disease outbreak or in the transmission of communicable disease. This shared responsibility extends to ensuring that consumer expectations are met, and that food is unadulterated, prepared in a clean environment, and honestly presented. Reference: United States Food and Drug Administration Food Code 2017. 4.602.12. Cooking and Baking Equipment. Page 568. https://www.fda.gov (Accessed 0n 9/26/2022): Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. Because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105617 If continuation sheet Page 4 of 5 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 105617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250 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 of the nature of the equipment, it may not be necessary to clean cooking equipment as frequently as the equipment specified in § 4-602.11. . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105617 If continuation sheet Page 5 of 5