Inspection·February 29, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and facility policy review, the facility failed to ensure the bathroom shared by two (Residents #1 and #4) residents, out of three resident bathrooms observed were maintained in a safe, functional, sanitary, and comfortable environment. The findings include: On 2/29/24 at 9:55 AM, the shared bathroom for Residents #1 and #4 was observed to have brown debris in a splatter pattern on the wall to the right of the toilet and on the wall to the left of the sink. The bathroom had an unpleasant odor of feces. The sink was partially separated from the wall and loose. The baseboard was separated from the wall in two areas. (Photographic evidence obtained) On 2/29/24 at 12:15 PM, the shared bathroom for Residents #1 and #4 was observed for a second time. The bathroom continued to have brown debris in a splatter pattern on the wall to the right of the toilet and on the wall to the left of the sink. The bathroom continued to have an unpleasant odor of feces. The sink was still partially separated from the wall and loose. The baseboard was still separated from the wall in two areas. (Photographic evidence obtained) An interview was conducted with Employee A, Certified Nursing Assistant (CNA) on 2/29/24 at 1:00 PM, who was caring for Resident #1 and Resident #4. When asked if Resident #1 uses the bathroom in their room. She stated, Her roommate (Resident #4) uses the bathroom. She (Resident #1) is incontinent and has that care provided in her bed. She was asked who is responsible for keeping the resident bathrooms clean. She stated, The janitors, housekeepers. We do change the trashcan liners, but the housekeepers do the actual cleaning. When asked if she noticed if Resident #1's bathroom needed any additional cleaning today. She stated, When I went in there this morning, I noticed that it did need to be cleaned. I noticed all the stuff on the wall. When asked if she had reported any issues with Resident #1's bathroom to maintenance. She stated, No, I haven't. On 2/29/24 at 1:20 PM, the shared bathroom for Residents #1 and #4 was observed for a third time. The bathroom continued to have brown debris in a splatter pattern on the wall to the right of the toilet and on the wall to the left of the sink. The bathroom continued to have an unpleasant odor of feces. The sink was still partially separated from the wall and loose. The baseboard was still separated from the wall in two areas. An interview was conducted with Employee B, Licensed Practical Nurse (LPN) on 2/29/24 at 1:30 PM, who was caring for Resident #1 and Resident #4. When asked if Resident #1 uses the bathroom in her room. She stated, Not at this time, she did in the past. She used to walk around all the time. She doesn't really walk around now; she has declined a little bit. She was asked if her roommate, Resident (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: 105632 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 02/29/2024 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)