Health inspection·June 30, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/24/2020 at 1:02 PM (Dietary): Resident has been educated on low sodium and fluid restrictions per HDRD, especially his water intake as he stated that is what he drinks a lot of. A review of Resident #103's physician's orders, revealed an order written on 5/17/2022 for a Fluid restriction - 1000 milliliter (ml) per day, (breakfast and lunch) 240 ml, and at dinner 120 ml each tray by dietary. 133 ml (per shift nursing}, no bedside water. A review of the active Care Plan revealed a focus area for Resistance to care related to the resident's adjustment to the nursing home. He was noted as refusing medication and showers. Goal: The resident will cooperate with care through the next review. Interventions: Allow the resident to make decisions about treatment regime, educate resident, encourage as much participation during care activities, give clear explanation of all care activities prior to and as they occur, praise the resident when behavior is appropriate, provide resident with opportunities for choice during care provision. On 6/29/22 at 9:26 AM, Agency Licensed Practical Nurse (LPN) I stated if a resident did not want to follow an ordered fluid restriction, they could refuse the order, and if they did, staff would notify the doctor and document the refusal in the resident's medical record. On 6/29/22 at 10:08 AM, LPN B stated residents had the right to refuse treatment including fluid restrictions. Nursing would document the refusal, inform the physician and get orders to change the diet or fluid restriction. On 6/30/22 at 11:02 AM, Registered Dietician (RD) J stated she was very familiar with Resident #103 and was aware of his dissatisfaction with his ordered diet. She stated she worked very closely with the dialysis RD and had liberalized his diet. She further stated she was unable to do anything about his fluid restriction, but was informed by the dialysis center that they wanted a strict fluid restriction due to having to increase his dialysis time, which the resident often refused. On 6/30/22 at 1:45 PM, the [NAME] President of Clinical Services and the Director of Nursing were asked whether residents had the right to refuse treatment, and how that was addressed. They stated staff were to speak with the resident's physician and the resident, then document the resident's refusal of treatment. They were then expected to obtain a physician's order to reflect the resident's choices. When they were informed that Resident #103 had verbalized several times his desire to have his fluid restriction removed and no one had done anything about it, they stated they were not aware of Resident #103's requests. 2. On 6/27/22 at 12:20 PM, Resident #57 stated he had expressed to the facility staff that he wanted to get back to Georgia where he had family. He wanted to be transferred to a specific nursing home in Georgia. When asked whether anyone from the facility had followed up with him on his desire to be transferred, he responded that no one had followed up with him on the matter. A record review revealed that Resident #57 was diagnosed with quadriplegia and was designated as his own responsible party. The Social Services department made a Care Plan entry on 5/3/2022 which revealed that the Focus Area was that Resident #57 wished to be discharged home. The Goal was to verbalize and/or communicate required assistance post-discharge and the services required to meet his needs before discharge; Interventions were to establish a pre-discharge plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 2 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was an order (Plan for discharge: Home) signed by Advanced Practice Registered Nurse (APRN) F on 5/16/2022. Per the facility's Discharge to Home Policy, upon determination of discharge, a physician's order for discharge was to include the place of discharge, a complete discharge plan, provide the resident a copy of the discharge plan, and document the final disposition in the resident's clinical record. An interview was conducted with Social Services Representative (SSR) H on 6/30/22 at 12:10 PM. SSR H stated she had been employed by the facility for three years in the Social Services department. When asked to explain the discharge process for a resident who has expressed their desire to leave, SSR H stated a resident who had expressed that they wanted to be transferred, and if they were their own responsible party, the facility would notify the physician, and any other parties such as Physical Therapy, if they were receiving therapy, to better plan for their discharge. SSR H added, If they have a POA (Power of Attorney)/Family member, we contact them as well and try to arrange for their discharge, but all of this depends on the physician's recommendation. When asked how the facility would handle a resident who disagreed with the physician and wanted to be transferred anyway, SSR H stated the facility would abide by the resident's decision. When asked about any local or state transfers, SSR H stated she would get in touch with the other facilities to see whether there were any available beds. For an out-of-state facility, she would call the facility to see if there were available beds, and if so, she would provide the necessary paperwork to start the transfer process. When asked about the timeframe to transfer a resident, SSR H stated if accepted and everything was aligned, it may only take 24-48 hours to transfer the resident. When SSR H was asked if she was familiar with Resident #57, she stated she was and further stated Resident #57 was transferred from Georgia to Florida because there were no Georgia facilities available at that time that would accept him. When [Resident #57] requested to go home, we spoke to the sister who is located in Georgia, and she said that she could not take care of him. SSR H was asked to provide documentation, correspondence or electronic data entry to confirm that this conversation had taken place with the sister, as well as the information on file related to unavailability of beds in Georgia facilities and how that information was shared with Resident #57. SSR H confirmed that there was no documentation to support that a conversation had taken place with the sister, and there was no documentation to support that any information was given to Resident #57 related to his request for a transfer. A review of the facility's admission Packet revealed the following on page 2, paragraph 4: Right to Leave/Refuse Treatment: The Patient's stay with the Center is voluntary. A Patient with capacity can leave the Center at any time, provided the Patient gives the Center adequate notice, a leave of absence order (LOA) from the Patient's physician, and follows the Center's LOA procedures. A Patient leaving the Center is required to sign out in accordance wit the Center's LOA policy. If a physician will not enter an order for discharge, a Patient with capacity, can leave against medical advice, but must follow the Center's policy regarding exiting the facility against medical advice. The Patient has the right to refuse any medical treatment, as defined by law, and to be informed of the consequences of refusing treatment. Upon the Patient communicating any of the above, the appropriate notification and documentation will be provided. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 3 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 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 observation, interviews, and record review, the facility failed to ensure that one (Resident #103) of 42 sampled residents received treatment and care in accordance with professional standards of practice, based on the comprehensive assessment of the resident. Clinical staff failed to complete dressing changes as ordered. Residents Affected - Few The findings include: On 6/28/2022 (Tuesday) at 9:30 AM, Resident #103 was observed lying in bed with his right lower extremity exposed. A gauze dressing was visible. The dressing was dated 6/23/2022 (Thursday). There was serosanguineous (wound drainage containing blood) and dark tan/green drainage on the dressing. Resident #103 stated the dressing was changed about every other day. When he was asked about when the current dressing was placed, he stated, before the weekend. When he was asked how long he had had the wound, he stated, a long time because of bad circulation. A review of Resident #103's medical record revealed he was admitted on [DATE] and readmitted on [DATE]. His diagnoses included polyneuropathy, morbid obesity, type 2 diabetes mellitus with other diabetic kidney complication, end-stage renal disease, peripheral vascular disease, non-pressure chronic ulcer of right foot with unspecified severity, and edema. A review of the Annual Minimum Data Set (MDS) assessment, dated 5/24/22, revealed the resident had adequate hearing and vision; was understood and was able to understand others, and had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. He required extensive assistance of two persons for transfers, bathing and toileting, a one-person assist for personal hygiene, and supervision for eating and dressing. He was documented as occasionally incontinent of bowel and bladder, and he had one non-pressure ulcer to his right lower extremity. A review of the active physician's orders revealed an order dated 6/14/2022 for Iodosorb Gel 0.9%, apply to right calf topically every day shift every Tuesday, Thursday, and Saturday for venous wound. Cleanse area with normal saline, apply iodosorb gel, cover with gauze island with border. A review of the most recent Wound Care Physician progress note, dated 6/21/22, revealed in part: Wound Evaluation and Management Summary: Venous wound of the right calf full thickness. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Wound progress: Deteriorated Plan of care reviewed and addressed Recommendations: elevate legs, float heels in bed. Debridement was done. On 6/29/22 at 1:08 PM, an interview was conducted with the Director of Nursing (DON) and the Wound Care Nurse (WCN). They were shown a photograph of the dressing dated 6/23/22 Resident #103's calf. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 4 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The WCN stated that was her dressing. I use a red sharpie to distinguish my dressings from the nurses. The WCN confirmed that she did not change the dressing on 6/25/22 (due date for dressing change). She stated, No, I did not work that day. On 6/29/22 at 1:46 PM, an interview was conducted with Licensed Practical Nurse (LPN) B, who was assigned to Resident #103 on Saturday, 6/25/22, when the dressing change was due. She stated she did not change the resident's dressing on 6/25/22, but in her rush to complete her documentation, she signed off on the Treatment Administration Record (TAR) that the dressing change was done. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 5 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #103) of 42 sampled residents. The findings include: On 6/28/22 at 9:50 AM, Resident #103 was observed sitting in bed. He had contractures of the forth and fifth fingers of both hands. When he was asked whether he recieved therapy or had splints/braces for his hands, he replied no. He stated while he was in dialysis, he tried to straighten out his fingers but it caused him pain to do so. A review of Resident #103's medical record revealed he was admitted on [DATE] and readmitted on [DATE]. His diagnoses included polyneuropathy, morbid obesity, type 2 diabetes mellitus with other diabetic kidney complication, end-stage renal disease, peripheral vascular disease, non-pressure chronic ulcer of right foot with unspecified severity, and edema. A review of the Annual Minimum Data Set (MDS) assessment, dated 5/24/22, revealed the resident had adequate hearing and vision; was understood and was able to understand others, and had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. He required extensive assistance of two persons for transfers, bathing and toileting, a one-person assist for personal hygiene, and supervision for eating and dressing. He was documented as occasionally incontinent of bowel and bladder, and he had one non-pressure ulcer to his right lower extremity. A review of the active physician's orders revealed an order dated 3/28/22 for bilateral hand splints for contracture preventions to both hands. On 6/30/22 at 1:18 PM, an interview was conducted with the Assistant Director of Nursing (ADON). She stated she did not have Resident #103 on a Restorative program. When she was asked to review Resident #103's orders, she stated she was not aware there had been an order for splints for this resident. She was unable to explain why the order had not been addressed. On 6/30/22 at 1:51 PM, the Director of Nursing (DON) Physical Therapist (PT) Lwere interviewed. They stated they would conduct a payer verification and would have Occupational Therapy do an evaluation tomorrow (7/1/22) to determine the appropriate splints and therapy for Resident #103. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 6 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to assist one (Resident #37) of 42 sampled residents in obtaining routine and 24-hour emergency dental care. The facility also failed to assist the resident In making appointments, and arranging for transportation to and from the dental services locations if necessary or if requested. Residents Affected - Few The findings include: On 6/27/22 at 1:22 PM Resident #37 was observed sitting in a wheelchair. Missing teeth and broken teeth were visible when she spoke. When asked whether she had seen a dentist, she stated someone came and cleaned her teeth. I was supposed to have some teeth removed, but I don't know what happened. A review of Resident #37's medical record revealed she was admitted on [DATE] with diagnoses including unspecified cerebrovascular disease and type 2 diabetes mellitus. A review of her Quarterly Minimum Data Set (MDS) assessment, dated 4/17/22, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points, indicating minimal to moderate cognitive impairment. She was noted with adequate hearing and vision, was understood and understood others. A review of the active Care Plan revealed a focus area for Oral/Dental Health Problems related to poor oral hygiene. The Care Plan was last updated on 4/24/22. Interventions included administration of medications as ordered, coordinate arrangements for dental care, transportation as needed/as ordered, diet as ordered, consult with dietitian and change if chewing/swallowing problems are noted, provide mouth care as per Activities of Daily Living (ADL) personal hygiene. A review of a 4/27/22 Dental Note revealed, I am referring the named patient to see an oral surgeon. Please eval (evaluate) and ext #12, 13 fx at gum line. Concerns: pain with fx teeth. A review of a 5/26/22 Registered Dental Hygenist (RDH) note revealed: Patient presents for an oral prophylaxis today. Seen in room #E-7 in wheelchair. Upper and lower natural teeth with several roots exposed. Brushed and applied fluoride varnish. Dispensed oral care products. Tolerated procedure well. On 6/28/22 at 10:02 AM an interview was conducted with Licensed Practical Nurse (LPN)/Unit Manager (UM) D. When she was asked how appointments for oral surgeons were made, she stated once the Social Services Assistant (SSA) verified the insurance, it was given to the Transportation Concierge (TC). An order was put in, the TC made the appointment with the oral surgeon, and transportation was arranged if the resident had to be seen in the surgeon's office. She stated sometimes the oral surgeon could perform services in the facility. On 6/30/22 at 2:09 PM, SSA H was asked how referrals to oral surgeons were handled. She stated the dental provider dropped off the paper order to their office, she put the order into the electronic medical record, and then the TC looked for an oral surgeon and set up the appointment and transportation. When she was asked what happened with Resident #37's referral, she stated she did not know because the former Social Services Director was handling that. She thought the referral must have come through before she started taking care of the referrals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 7 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 0791 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 8 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 interviews and record review, the facility failed to maintain medical records for each resident that were accurately documented for one (Resident #103) of 42 sampled residents. The findings include: On 6/28/2022 (Tuesday) at 9:30 AM, Resident #103 was observed lying in bed with his right lower extremity exposed. A gauze dressing was visible. The dressing was dated 6/23/2022 (Thursday). There was serosanguineous (wound drainage containing blood) and dark tan/green drainage on the dressing. Resident #103 stated the dressing was changed about every other day. When he was asked about when the current dressing was placed, he stated, before the weekend. When he was asked how long he had had the wound, he stated, a long time because of bad circulation. A review of Resident #103's medical record revealed he was admitted on [DATE] and readmitted on [DATE]. His diagnoses included polyneuropathy, morbid obesity, type 2 diabetes mellitus with other diabetic kidney complication, end-stage renal disease, peripheral vascular disease, non-pressure chronic ulcer of right foot with unspecified severity, and edema. A review of the Annual Minimum Data Set (MDS) assessment, dated 5/24/22, revealed the resident had adequate hearing and vision; was understood and was able to understand others, and had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. He required extensive assistance of two persons for transfers, bathing and toileting, a one-person assist for personal hygiene, and supervision for eating and dressing. He was documented as occasionally incontinent of bowel and bladder, and he had one non-pressure ulcer to his right lower extremity. A review of the active physician's orders revealed an order dated 6/14/2022 for Iodosorb Gel 0.9%, apply to right calf topically every day shift every Tuesday, Thursday, and Saturday for venous wound. Cleanse area with normal saline, apply iodosorb gel, cover with gauze island with border. A review of the most recent Wound Care Physician progress note, dated 6/21/22, revealed in part: Wound Evaluation and Management Summary: Venous wound of the right calf full thickness. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Wound progress: Deteriorated Plan of care reviewed and addressed Recommendations: elevate legs, float heels in bed. Debridement was done. On 6/29/22 at 12:29 PM, a review of Resident #103's Treatment Administration Record (TAR), revealed documentation of a dressing change on 6/25/22 by Licensed Practical Nurse (LPN) B. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 9 of 10 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 105632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Harts Harbor 11565 Harts Rd Jacksonville, FL 32218 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 On 6/29/22 at 1:08 PM, an interview was conducted with the Director of Nursing (DON) and the Wound Care Nurse (WCN). They were shown a photograph of the dressing dated 6/23/22 Resident #103's calf. The WCN stated that was her dressing. I use a red sharpie to distinguish my dressings from the nurses. The WCN confirmed that she did not change the dressing on 6/25/22 (due date for dressing change). She stated, No, I did not work that day. Residents Affected - Few On 6/29/22 at 1:46 PM, an interview was conducted with Licensed Practical Nurse (LPN) B, who was assigned to Resident #103 on Saturday, 6/25/22, when the dressing change was due. She stated she did not change the resident's dressing on 6/25/22, but in her rush to complete her documentation, she signed off on the Treatment Administration Record (TAR) that the dressing change was done. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 10 of 10