Inspection·September 13, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the medications received with the narcotic sheet (at the top of the narcotic sheet it shows the medication delivered and then sign as delivered). She stated that she was not aware about the facility retaining the pharmacy manifest. She added that the pharmacy delivery person normally takes a signed copy back. When asked about the facility's process for narcotic reconciliation, she said, At the beginning of the shift, two nurses count the cards in the cart and then count the narcotic for each resident individually. She added that if a resident refuses medication, two nurses should witness and discard appropriately. When asked when medication is signed off from the narcotic sheet during medication administration, she said, As soon as you take it from the cart. On 9/13/23 at 12:35 pm, a tour of the South Wing was conducted with the DON. Resident #7 was observed in her scooter chair at the nurses' station upset, as she was asking for her morning medication. The assigned nurse was not at the unit and the resident went into the dining room. The DON contacted LPN D via her phone to return to the unit. While waiting for LPN D to return to the unit Resident #9 approached the nurse's station. She stated that she wanted her morning medication. Resident #9 reported to the DON that she had not received her morning medication. She added that there were three other times that the same nurse administered the medication very late. When the DON asked her why she did not report these incidences. Resident stated that the nurse does not work every day and therefore she does not remember, she added, I don't want to put anyone in trouble, I just want my medication. The DON reassured the resident that she would investigate her concerns. The DON was once again asked to provide the pharmacy manifest and audits for the unit. He stated that he could not find any. During an interview with Resident #7 on 9/13/23 at 12:50 am, she confirmed that she had not received her morning medication. She stated she had been asking for her medication since 10:30 am, and she was told that the nurse was on break. She stated that this wasn't the only time she hadn't received her morning medications. When asked about the other occasions, the resident was unable to give any specific timelines. When asked what medication she takes in the morning she said, I really need my anxiety and blood pressure medication, I'm not sure what other medications I get. A clinical record review for Resident #7 indicated that she was admitted to the facility on [DATE], with diagnoses that included anxiety, depression, manic depression, bipolar type schizophrenia and high blood pressure. The quarterly minimum data set (MDS) assessment dated [DATE] indicated the resident had a brief interview for mental status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. The MDS further indicated that resident was receiving antianxiety, antidepressant, opioid and antipsychotic medications. During an interview with Resident #9 on 9/13/23 at 12:55 pm, she confirmed that she had not received her morning medication. She added that it was already time for her afternoon medication and yet she had not received the morning medications. When asked if she has had issues with her medication previously, she said, Not really because there are different nurses working, but this nurse working today is always late getting the medication. When asked if she knew what medication she had not received, she said, My pain pill, blood pressure pill, acid reflux medication and I think there are some others, I can't remember them all. A clinical record review for Resident #9 indicated that she was admitted to the facility on [DATE], with diagnoses that included cirrhosis, Gastroesophageal reflux disease (GERD) and high blood pressure. The quarterly MDS assessment dated [DATE] indicated the resident had a BIMS score of 15, indicating that she was cognitively intact. She required extensive assistance for bed mobility, transfer and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 2 of 4 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 09/13/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/13/23 at 1:00 pm, LPN D arrived at the unit. When asked about her whereabouts, she stated that she was on break. When asked about the facility's protocol for breaks, she mentioned that staff can take two fifteen-minute break and one 30-minute break. When asked if staff are required to clock out during their break time, she said, During the 15 minutes break, we don't have to clock out as long as we do not leave the facility. When asked how long she was away, she said, I had taken a 15 minutes break, and I was in my car, so I didn't clock out. When asked what time she left the unit, she confirmed that she had left around 12:20 pm. When asked if she clocked out because it was more than 15 minutes, she did not answer. When asked if she had completed her morning medication pass, she said, Yes. She opened the computer system and revealed the resident medication administration record for her assigned residents which were green in color (indicating that the medications were administered). When asked if she had administered the medications for Resident #7 and #9. She said that she had administered the medication for Resident #7, but she had not administered to Resident #9, as she was outside smoking. She added, It's my fault, I should have gone to look for her after the smoke break. A random narcotic count was conducted for the cart and multiple discrepancies were identified for the following residents: Resident #4 missing two Ativan Resident #5 missing one Clonazepam and one Oxycodone. Resident #6 missing Acetaminophen and Hydrocodone (Norco) Resident #7 missing one Lorazepam Resident #8 missing two Oxycodone Resident #9 missing Oxycodone (Copies obtained) LPN D and the DON confirmed the discrepancies. LPN D stated that she administered the medications and forgot to sign off. When asked when the medications are signed off during medication administration, she said, As soon as they are taken off from the cart, I should have signed off at the narcotic sheet and the computer. An interview was conducted with the Administrator on 9/13/23 at 2:06 pm. She stated that she had removed LPN D from the floor and an investigation would be initiated. When asked if there was a performance improvement plan after the incident on 7/27/23 she stated, No. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation (Document # N- 1265, Revision date 11/16/202) revealed: Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human right including right to be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Employees at the center are charged with a continuing obligation to treat residents so they are free from abuse neglect, neglect mistreatment, exploitation and misappropriation of property. The policy further indicates on page 9 that the center will review allegations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 3 of 4 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 09/13/2023 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 0602 of abuse, neglect, misappropriation of property and exploitation during the QAPI meetings. QAPI committee will review information including but not limited to: Level of Harm - Minimal harm or potential for actual harm I. The thoroughness of the investigation Residents Affected - Some II. Protection of resident(s) III. Risk factors identified IV. Root cause analysis of the investigation V. Systemic changes that may be required (Copy obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 4 of 4