Health inspection·June 27, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm [DATE]. His diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), malnutrition, gastroparesis (condition preventing proper stomach emptying), anxiety, anemia (lower than normal amount of red blood cells), dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD - stomach acid irritates the food pipe lining), and adult failure to thrive. (Copy obtained) Residents Affected - Few A review of the care plan, dated 05/15/2024, revealed that the resident had an Activities of Daily Living (ADL)/Self-Care Performance Deficit related to limited mobility, difficulty walking, dementia, schizophrenia and autistic disorder. Goal: The resident will maintain current level of function through the review date. Interventions included: Encourage the resident to use bell to call for assistance. Initiated 02/06/2023 (Copy obtained). A review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/30/2024, revealed that the resident had no impairment in his upper or lower extremities. He used a wheelchair for mobility. He was dependent for eating (required tube feedings), the ability to come to a standing position from a sitting position, and walking 10 feet once standing. He required substantial/maximal assistance with toileting, putting on/taking off footwear, personal hygiene, moving from a sitting to a lying position and from a lying to sitting position, as well as transferring to and from his bed to a chair, for toilet transfers and wheeling 50 feet once seated in hiswheelchair. He required partial/moderate assistance with rolling from left and right. (Copy obtained) A review of the facility's Skills Competency Assessment: Positioning a Resident form used to assess certified nursing assistants' (CNAs) competency and job skills, revealed: 16. Leave resident in comfortable position with call light within reach. (Copy obtained) During an interview with the Administrator on 06/27/2024 at 5:30 PM, she stated the nursing staff were trained using the employee handbook, which covered customer service. They were assessed for their competency using the Skills Competency Assessment form that included ensuring that the call light was always within reach for the resident and staff to use. She was shown the photographic evidence and she confirmed that the call light was not within reach for Resident #109 on the occasions observed by this surveyor, but it should have been. She confirmed that the department heads were assigned to a specific hallway to make rounds each morning in an effort to ensure the residents had their call lights among other things. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 2 of 23 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 06/27/2024 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, a staff cleaning schedule review, and facility policy and procedure review, the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable living environment, by keeping resident care equipment and rooms clean for four (Residents #109, #32, #10, and #46) of five residents who received enteral feedings, from 33 residents sampled for the survey, and a facility census of 117 residents. Failure to maintain a clean living environment can impact residents' enjoyment of their living space due to unsanitary and uncomfortable living conditions. It could also affect their ability to attain/maintain their highest practicable physical, mental, and social well-being. The findings include: During an observation of Residents #10 and #46's room, East #10A and 10B, on 06/24/2024 at 1:25 PM, the gastrostomy tube (g-tube - feeding tube) pole, the pump, the tubing, the floor, the walls, the bed frames, bed rails, privacy curtain, tray table, floor mat, and nightstand were splattered with enteral food product that had dried. The floor mats for Resident #10 had dirt and debris in the folds of the mats. Plastic disposable tubing caps were observed on the floor. (Photographic evidence obtained) During an observation of Resident #109's room, East 30B, on 06/24/2024 at 11:18 AM, the g-tube pole, the pump, the tubing, the floor, the walls, the bed frames, the oxygen concentrator, and the fall mats were splattered with enteral food product that had dried. (Photographic evidence obtained) Disposable tubing caps were observed on the floor next to the wall, under the bed, and dirt and debris were observed in the folds of the fall mats and along the baseboards of the room. (Photographic evidence obtained) During an observation of Resident #32's room on 06/24/2024 at 11:10 AM, the g-tube pole, the pump, the tubing, the floor, the walls, the bed frame, the bed rail and nightstand were splattered with enteral food product that had dried. A light blue liquid that had been spilled was dried on the floor next to the bed and wall. Plastic disposable tubing caps and trash were observed on the floor, under the bed, next to the wall, and on the nightstand. (Photographic evidence obtained) During a second observation of Residents #10 and #46's room on 06/26/2024 at 10:18 AM, the enteral feeding product had not been cleaned off of the equipment or the other surfaces in the room. (Photographic evidence obtained) The floor mats for Resident #10 were observed with dirt and debris in the folds of the mat. Plastic disposable tubing caps were observed on the floor. (Photographic evidence obtained) During a second observation of Resident #109's room on 06/26/2024 at 11:46 AM, the enteral feeding product had not been cleaned off of the equipment or the other surfaces in the room. (Photographic evidence obtained) Disposable tubing caps were observed on the floor next to the wall, under the bed, and dirt and debris were observed in the folds of the fall mats and along the baseboards of the room. (Photographic evidence obtained) During a second observation of Resident #32's room on 06/26/2024 at 11:54 AM, the enteral feeding product had not been cleaned off of the equipment or the other surfaces in the room. (Photographic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 3 of 23 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 06/27/2024 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some evidence obtained) The light blue liquid that was dried on the floor next to the bed was no longer there. Plastic disposable tubing caps and trash were observed on the floor under the bed, next to the wall, and on the nightstand. (Photographic evidence obtained) During a third observation of Residents #10 and #46's room on 06/27/2024 at 10:23 AM, the enteral feeding product had not been cleaned off of the equipment, the wall, or the other surfaces in the room. (Photographic evidence obtained) Plastic disposable tubing caps were observed on the floor next to the wall and on the nightstand. (Photographic evidence obtained) During a third observation of Resident #109's room on 06/27/2024 at 10:28 AM, the enteral feeding product had not been cleaned off of the equipment, the wall, or the other surfaces in the room. (Photographic evidence obtained) Disposable tubing caps were observed on the floor next to the wall, under the bed, and dirt and debris were observed in the folds of the fall mats and along the baseboards of the room. (Photographic evidence obtained) During a third observation of Resident #32's room on 06/27/2024 at 10:33 AM, the enteral feeding product had not been cleaned off of the equipment, the wall, or the other surfaces in the room. (Photographic evidence obtained) Plastic disposable tubing caps and trash were observed on the floor under the bed, next to the wall and on the nightstand. (Photographic evidence obtained) During an interview with Housekeeper I on 06/25/2024 at 10:53 AM, she stated the housekeeping staff were responsible for cleaning the enteral feeding product off of the floors, walls, bed frames and other surfaces in the room. She confirmed that only the nurses could clean the enteral feeding pumps. She stated she was usually assigned to the East wing and had cleaned rooms 10A and 10B, 28A and 30B already today. During an interview with Unit Manager/Licensed Practical Nurse (LPN) E on 06/27/2024 at 11:05 AM, she confirmed that the nursing staff were the only staff that could clean the feeding pumps. She stated the housekeeping staff could clean the enteral feeding product off of all of the other surfaces in the resident's room. Nurses should wipe up the food product right away when it was spilled so it did not dry. During an interview with Director of Environmental Services H on 06/27/2024 at 4:32 PM, she stated the housekeepers should mop up the enteral food product as soon as possible. She wanted the nurses to inform the housekeepers if they were going to start a new enteral food bag, so if food was spilled it could be mopped up right away. If not, then the food product dried and was extremely hard to get up. The resident would have to be moved out of the room due to the strong chemicals in the cleaning products used to get the dried-on food product up. She stated she thought the rooms on the East Wing had been cleaned yesterday because she had been informed that they had enteral food splattered in them. A review of the updated facility housekeeping calendar for the month of June 2024 revealed that rooms [ROOM NUMBERS] had been deep cleaned on 06/13/2024 and 06/17/2024 respectively. room [ROOM NUMBER] had not been deep cleaned in the month of June. room [ROOM NUMBER] was on the original calendar to be deep cleaned on 06/20/2024 but was removed on the updated calendar. Privacy curtain audits had been conducted on the East wing during the week of 06/17/2024 through 06/21/2024. Baseboards had been cleaned every Tuesday and Thursday in the month of June. Fall mats were cleaned every Thursday in the month of June. (Copies obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 4 of 23 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 06/27/2024 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the housekeeping staff schedule revealed that Housekeeper I was scheduled from 06/24/2024 through 06/27/2024 from 7:00 AM to 3:00 PM. (Copy obtained) A review of the facility's policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment (revised 9/2022), revealed: Resident care equipment will be cleaned and disinfected according to CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. A. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue or the vascular system are considered critical items and must be sterile when used, based on acceptable sterilization procedures. B. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible (Note: Some items that may come in contact with non-intact skin for brief period of time are usually considered non-critical surfaces and are disinfected with intermediate-level disinfection). C. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical surfaces include bed rails, beside tables, etc. Non-critical items require cleaning followed by either low or intermediate level disinfection. a. Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Low-level disinfection is generally appropriate for most non-critical equipment. b. Intermediate level disinfection is traditionally defined as destruction of all vegetative bacteria including tubercle bacilli, lipid and some nonlipid viruses, fungi, but not bacterial spores. A review of the facility's policy and procedure titled Five-Step Daily Room Cleaning (revised 10/25/2016) read: Purpose: To teach environmental services employees the proper cleaning method to sanitize a patient room or any area in the healthcare facility. 2. Horizontal surfaces - disinfected. Using a solution of properly diluted germicide, sanitize all horizontal surfaces (allowing for appropriate solution dwell time). As you enter the room, work clockwise around the room hitting all surfaces. Tabletops, headboards, window sills, chairs should all be done. 3. Spot Clean Walls. Vertical surfaces are not completely wiped down daily - but must be spot-cleaned daily. Walls - especially trash cans, light switches and door handles - will need special attention. 4. Dust Mop. The entire floor must be dust mopped - especially behind dressers and beds. Move all furniture to dust mop. All corners and along baseboards must be dust mopped to prevent buildup. Damp mop. The most important area of a patient's room to disinfect is the floor. This is where all air-borne bacteria will settle and so it needs to be sanitized daily. As with dust mopping, start in the far corner of the room, move all furniture necessary and run the mop along the edges first. 6. Spot Clean Walls and/or Partitions. Wipe walls especially by trash containers, light switches and door handles. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 5 of 23 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 06/27/2024 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)

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and facility policy and procedure review, the facility failed to ensure Quarterly Minimum Data Set (MDS) Assessments were completed timely for seven (Residents #83, #105, #87, #76, #28, #59, and #60) of 33 residents sampled for the survey. Residents Affected - Some The findings include: A 06/27/2024 review of the Minimum Data Set (MDS) viewer in the survey shell, revealed no evidence of Quarterly MDS assessments for Residents #83 or #105. An interview with MDS Nurse J on 06/27/2024 at 9:15 a.m., revealed that the last MDS assessment transmitted for Resident #83 was on 01/15/2024. She confirmed that a quarterly assessment was due on 04/16/2024 but was never opened. When she was asked about Resident #105, MDS Nurse J confirmed that the last MDS assessment transmitted for Resident #105 was on 02/15/2024, and a quarterly assessment should have been completed on 05/17/2024, but was not opened. MDS Nurse J was asked how the MDS quarterly assessments were being tracked. She replied they were tracked through the 30-day electronic MDS scheduler report she ran each month. A review of the facility's 30-Day MDS Scheduler Report revealed that Residents #83, #105, #87, #76, #28, #59, and #60 were all overdue for quarterly assessments. A review of the facility's MDS N-1025 policy (effective 11/30/2014 and revised 09/25/2017), read: The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 6 of 23 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 06/27/2024 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain a Level II Pre-admission Screening and Resident Review (PASARR) preventing the ability of the facility to incorporate the recommendations from the PASARR Level II into the resident's assessment, care planning, and transitions of care for one (Resident #87) of three residents whose PASARRs were reviewed, from a total of 33 residents sampled for the survey. The findings include: A review of the medical record revealed that Resident #87 was admitted to the facility on [DATE] with diagnoses including anxiety, schizoaffective disorder, bipolar disorder, and major depressive disorder. Further review of the record revealed that a PASARR Level I was completed on 4/30/2021. Section I of that PASARR did not include the diagnoses of anxiety or schizoaffective disorder. There was no evidence that a Level II PASSAR was completed for Resident #87. Based on Section III of the Level I PASARR, Resident #87 was exempt from a Level II due to: The individual is being admitted under the 30-day hospital discharge exemption. If the individual's stay is anticipated to exceed 30 days, the NF (nursing facility) must notify the Level I screener on the 25th day of stay, and the Level II evaluation must be completed no later than the 40th day of admission, on or before (date): ______ (The date was left blank; however, the 25th day of stay would have been 5/25/2021 and the 40th day would have been 6/9/2021.) A review of the resident's active physician's orders included: Primidone (anticonvulsant) 50 mg every morning for tremor; Lithium (psychiatric medication) 150 mg twice a day for bipolar; Fluoxetine HCL (antidepressant) 20 mg Give 1 capsule by mouth one time a day for depression give with 10 mg for a total of 30 mg total, failed GDR (gradual dose reduction), not the source of patient tremors. Patient having relapse.; Lorazepam (sedative) 1 mg, 0.5mg three times a day for anxiety, and Olanzapine (antipsychotic) 2.5 mg every evening for psychosis. An interview was conducted with the Director of Nursing on 6/27/2024 at 4:32 p.m. He stated he and the Director of Social Services (DSS) were responsible for reviewing the PASARRs for accuracy upon resident admission. He further stated he determined whether or not the PASARR needed to be elevated to a Level II and/or whether the resident's diagnoses on the PASARR matched their admission diagnoses. He stated if the PASARR needed to be updated or called in for a PASARR level II, he or the DSS would contact the appropriate agency to request a screening. He stated he was familiar with Resident #87. He reviewed the Level I PASARR completed on 4/30/2021 and confirmed a Level II screening was required and had not been completed. A review of the facility's policy and procedure titled Preadmission Screening and Resident Review (PASRR), Document Name: SS-402 (Effective Date: 11/8/2021, Revision Date: 11/8/2021), revealed the following: Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectual Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 7 of 23 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 06/27/2024 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)

F 0644 the most appropriate setting. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Few 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 8 of 23 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 06/27/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, medical record review, and facility policy and procedure review, the facility failed to revise the care plan for one (Resident #24) of one resident reviewed for dialysis treatment, out of two residents receiving dialysis, from a total of 33 residents sampled for the survey. Resident #24's dialysis port site was changed; however, his care plan was not revised to reflect the new port site. Failure to update the care plan timely could result in unmet resident needs and negatively impact the resident's health. The findings include: On 06/25/2024 at 10:35 AM, Resident #24 was observed lying in bed. He confirmed that he was receiving dialysis treatments off-site on Mondays, Wednesdays and Fridays. His left upper arm was observed with two puncture holes that had no dressing on them. He stated he no longer had a shunt in his arm; he now had a port in his chest for dialysis treatments. During an interview with Resident #24 on 06/27/2024 at 12:55 PM, he gave permission for observation of the port in his right upper chest wall. He pulled his shirt up and showed the port covered with a dressing. He stated he did not want the shunt in his left arm anymore and told them to put in a port. He could not remember when they did the surgery. He thought it had been a few months ago. During an interview with the East Wing Unit Manager/Licensed Practical Nurse (LPN) E on 06/27/2024 at 1:53 PM, she confirmed that Resident #24 had a port in his right upper chest wall for dialysis treatments. She was not aware that the care plan had not been revised. A review of the medical record face sheet revealed that he was admitted on [DATE] with a re-entry on 01/31/2024. His diagnoses included other mechanical complication of surgically created arteriovenous fistula, subsequent encounter, end-stage renal disease (ESRD). A review of the Nursing Progress Notes revealed a note dated 04/03/2024, which read: Resident returned from dialysis appointment AAOx3 (Awake, alert, and oriented to himself, his location, and the time). Port access to right upper chest intact with bruit and thrill noted. A review of the annual Minimum Data Set (MDS) assessment, dated 05/21/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. He was documented with diagnoses of renal insufficiency, renal failure and ESRD. He received renal dialysis on Mondays, Wednesdays, and Fridays. A review of the Care Plan, dated 06/04/2024, revealed the following Focus Area: Resident needs outpatient dialysis (hemo) related to End Stage Renal Disease (ESRD). He has a left arm arteriovenous (AV) fistula. Interventions: Cleanse left arm with normal saline, pat dry, apply Hydrafera blue foam, cover with dry dressing every day shift every T, Th and Sat. (Tuesdays, Thursday, and Saturdays) for wound management. May use alginate silver and foam until Hydrafera is available. The care plan did not indicate that the resident had a port in his chest. A review of the Physician's Orders revealed an order dated 06/05/2024, which read: Hemodialysis - Assess site right upper chest for bruising/bleeding/symptoms of infection every shift for monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 9 of 23 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 06/27/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled Plans of Care N-1015 (effective 11/30/2014), revealed: An individualized person-centered plan of care will be established by the interdisciplinary team with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedures: Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of each resident and in response to current interventions after the completion of each MDS assessment and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 10 of 23 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 06/27/2024 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (Residents #24 and #59) of three residents sampled for review of ADL care, from a total of 33 residents sampled for the survey. Failure to provide care and services to meet residents' ADL needs can potentially have a negative outcome to the residents' health. Residents Affected - Few The findings include: 1. On 06/25/2024 at 10:35 AM, Resident #24's fingernails were observed to have grown approximately one half inch beyond the end of his fingers. The nails were unclean. The resident stated he did not get his nails trimmed, but he would like to have them trimmed. He thought a nurse had to do it because he was diabetic. During an interview with East Wing Unit Manager/Licensed Practical Nurse (LPN) E on 06/26/2024 at 10:10 AM, she stated the nurses trimmed the fingernails of the diabetic residents and a podiatrist trimmed their toenails. The certified nursing assistants (CNAs) were to conduct a full body skin assessment during shower/bathing time and inform the nurse if a resident's nails needed to be trimmed. If they communicated verbally to the nurse, the nurse might document it in the notes, but might not. It was not on the Treatment Administration Record (TAR). She stated she had the CNAs use a shower form to document any skin issues and concerns such as nails that needing trimming. If a resident was diabetic, the form was to go to the nurse so she could trim the resident's nails. A review of the shower documentation with LPN E revealed that Resident #24 was scheduled to have a shower/bath on Mondays, Wednesdays, and Fridays during the 3:00 PM to 11:00 PM shift. No shower sheets for Resident #24 were found in the binder at the nurses' station. LPN E was asked to produce the shower forms for Resident #24. She looked through the shower binder where the forms were stored and could not find any forms for Resident #24. She left the interview to go look in her office. At 1:15 PM, she returned and stated she could not find any shower forms for Resident #24. An interview was conducted with Resident #24 on 06/26/2024 at 1:49 PM in his room. He had just returned from dialysis. He stated no one had cut his nails since the last interview with this surveyor (06/25/2024 at 10:35 AM). He stated he was willing to allow the staff to cut his nails. He confirmed again that he wanted them cut. His fingernails remained approximately one half inch beyond the end of his fingers. They were unclean. He gave permission to take a photograph of his hand. (Photographic evidence obtained) He confirmed that he could not remember the last time his nails were trimmed. A review of the medical record face sheet for Resident #24 revealed he was admitted on [DATE] with a re-entry on 01/31/2024. His diagnoses included, but were not limited to: Unspecified protein-calorie malnutrition, type II diabetes with other diabetic kidney complication, dependence on renal dialysis, peripheral vascular disease, polyosteorarthritis, iron deficiency, polyneuropathy, and edema unspecified. A review of the annual Minimum Data Set (MDS) assessment, dated 05/21/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15 out 15 possible points, indicating intact cognition. He was documented with no mood disorder, no signs or symptoms of psychosis, and no impairment in his upper extremities. He was noted as dependent on staff for toileting and bathing with set-up assistance only for personal hygiene. He was documented with a diagnosis of type II diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 11 of 23 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 06/27/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Care Plan, dated 06/04/2024, revealed the following Focus Areas: [Resident #24] has an ADL/Self-Care Performance Deficit related to activity intolerance, osteoarthritis, ESRD on dialysis, diabetes, chronic pain, cataracts, fatigue and impaired balance. Interventions included: Bathing/Showering: Check nail length, trim and clean on bath day and as necessary. Report any changes to the nurse. Focus area: Resident is resistive to care related to adjustment to nursing home, refuses medication, refuses showers, fluid restriction recommended but resident declines, diet restrictions and may refuse dialysis at times. Also refuse eyes drops. Interventions: Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Focus area: Resident has Diabetes Mellitus. Educate resident that nails should always be cut straight across, never cut corners. File rough edges with emery board. A review of the nursing progress notes dated from 03/28/2024 through 06/27/2024 revealed no documentation verifying that Resident #24 had refused ADL care. (Copies obtained) During an interview on 06/27/2024 at 1:53 PM with East Wing Unit Manager/Licensed Practical Nurse (LPN) E, she stated she would cut Resident #24's nails herself and left the interview. A review of the facility's policy and procedure titled Care of Nails N-117 (effective 11/30/2014, revised on 09/01/2017) revealed it did not include a policy statement. Procedures were: Perform hand hygiene, explain procedure to resident and bring the following equipment to resident's bedside: basin, towel, emery board, orange stick, nail clippers. Place towel beneath the area to be treated, may soak hand in basin half full of warm water if needed, trim nails, clean nails, apply body lotion to nail area if indicated, clean and return equipment to designated area, discard disposable equipment, perform hand hygiene. (Copy obtained) 2. On 6/25/2024 at 11:35 AM, Resident #59 was observed sitting up in bed. The resident stated he was blind. He was asked about his ADL care and he replied that he wasn't receiving showers. He stated the staff used to give him a bed bath which he was ok with; however, he hadn't received a bed bath in a month. He stated the staff were wiping him off. He preferred the bed bath and wasn't satisfied with being wiped off. He stated his nails had not been cleaned. He was told they would cut them down and it was never done. He showed both of his hands. His nails were jagged and uneven. Several of the nails had a substance, dark brown in color, underneath the tip of the nail. (Photographic evidence obtained) A record review revealed that Resident #59 was admitted to the facility on [DATE] with a readmission on [DATE]. His diagnoses included: Cerebral infarction due to inclusion; type 2 diabetes mellitus; acute kidney failure; legal blindness and peripheral vascular disease. A review of the annual MDS assessment, dated 3/6/2024, revealed that Resident #59 scored 15 out of 15 possible points on the brief interview for mental status (BIMS) assessment, indicating that he was cognitively intact. He had no impairment in his upper extremities and impairment on both sides of his lower extremities. He was assessed as being frequently incontinent of bladder and always incontinent of bowel. A review of the active Care Plan revealed a Focus Area for ADL/Self-Care Performance Deficit related to right below knee amputation. On 6/26/2024 at 1:54 PM, the resident was observed sitting up in bed. He stated he hadn't spoken to anyone else about the bed baths since his initial interview with this surveyor on 6/25/2024 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 12 of 23 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 06/27/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11:35 AM. He further stated staff gave him bed baths regularly then they ended without notice. His fingernails remained jagged and uneven with a brown substance beneath the tips of several nails. (Photographic evidence obtained) Resident #59 was interviewed again on 6/27/2024 at 5:51 PM. He stated he had not received a bed bath yet. He further stated the certified nursing assistant (CNA) came into his room and asked to see his hands. He revealed them to her; however, she did not clip or clean his nails. (Photographic evidence obtained) An interview was conducted with CNA M on 6/27/2024 at 6:13 PM. She stated she was familiar with Resident #59. She said the resident did not like receiving showers. She gave the resident bed baths on Mondays, Wednesdays, and Fridays on the 3:00 PM to 11:00 PM shift. She was asked if she performed nail care when she gave the resident a bed bath. She replied, If he wants his nails cut I would cut them. She did not say when she last performed nail care for this resident. She was asked to provide documentation of the showers Resident #59 had received over the last month. She stated showers were documented in the shower book at the nurses' station. She provided the book for review. A review of the information provided revealed a shower sheet signed by CNA M, dated 6/3/2024, with bed bath handwritten under the resident's name. (Photographic evidence obtained) She was asked if there were any more shower sheets available from 5/1/2024 through 6/27/2024 for Resident #59. She looked through the shower book and confirmed she could not produce the documentation. She stated she gave the resident a bed bath on 6/24/2024 but did not document it. An interview was conducted with LPN N on 6/27/2024 at 6:19 PM. She stated all showers should be documented on a shower sheet and signed by a nurse. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 13 of 23 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 06/27/2024 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interviews and facility policy and procedure review, the facility failed to ensure that residents requiring respiratory care, received such care, consistent with professional standards of practice, by failing to follow physicians' orders for two (Residents #109 and #18) of three residents sampled for review of respiratory therapy, from a total of 33 residents sampled for the survey. Failure to provide needed respiratory care for residents could negatively impact their medical status and functional abilities. Residents Affected - Few The findings include: 1. On 06/24/2024 at 11:18 AM, Resident #109 was observed lying in bed with his eyes closed. He was receiving oxygen at a flow rate of 1.5 liters per minute (L/min) via a nasal cannula connected to an oxygen concentrator next to his bed. (Photographic evidence obtained) On 06/25/2024 at 9:56 AM, Resident #109 was observed in bed with his eyes closed. He was receiving oxygen at a flow rate of 1.5 liters per minute (L/min) via a nasal cannula connected to an oxygen concentrator next to his bed. During an interview on 06/25/2024 at 11:25 AM with Licensed Practical Nurse (LPN) F, she confirmed that she was assigned to this resident. She stated she checked the oxygen concentrator levels when she made her first rounds in the morning. On 06/26/2024 at 11:46 AM, Resident #109 was observed in bed with his eyes closed. He was receiving oxygen at a flow rate of 1.5 liters per minute (L/min) via a nasal cannula connected to an oxygen concentrator next to his bed. (Photographic evidence obtained). A review of the resident's physician's orders revealed an order dated 02/09/2024 for oxygen at a flow rate of 2 L/min every shift for monitoring. (Photographic evidence obtained) A review of the medical record face sheet revealed that Resident #109 was admitted on [DATE] with a re-entry on 02/09/2024. His diagnoses included, but were not limited to, chronic respiratory failure with hypoxia and adult failure to thrive. (Copy obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/30/2024, revealed the resident was assessed with the diagnoses adult failure to thrive and chronic respiratory failure. He presented with shortness of breath or trouble breathing when lying flat. Prognosis: Resident does not have a condition or chronic disease that may result in a life expectancy of less than six months. Oxygen therapy was marked no with the date of 05/02/2024. (Copy obtained) A review of the resident's Care Plan (dated 05/16/2024, and revised on 06/27/2024), revealed the resident had shortness of breath related to a chronic respiratory illness. He was to receive oxygen therapy and nebulizer treatments as needed. (Copy obtained) During an interview with Unit Manager/LPN E on 06/26/2024 at 2:24 PM, she stated the physician's orders for oxygen therapy should have been written for as needed only, but the Nurse Practitioner changed the order on 03/07/2024 to continuous oxygen therapy. LPN E stated she would adjust the resident's flow rate level to 2 L/min. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 14 of 23 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 06/27/2024 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/27/2024 at 10:28 AM, Resident #109 was observed lying bed on his back. He was receiving oxygen via a nasal cannula. The oxygen concentrator flow rate was set between 1.5 L/min and 2 L/min. (Photographic evidence obtained) During an interview with MDS Coordinator/Registered Nurse (RN) G on 06/27/2024 at 4:20 PM, she was asked to review the Quarterly MDS assessment dated [DATE] for the use of oxygen therapy. In section J Health Conditions, the resident was identified as having shortness of breath when lying flat. In section O Special Treatments and Programs, oxygen therapy was not checked off as in use for this resident. She reviewed the electronic medical record and confirmed that the assessment was coded incorrectly. During an interview with the UM on 06/27/2024 at 11:05 AM she confirmed that she went to Resident #109's room on 06/26/2024 and adjusted his oxygen flow rate to 2 L/min. 2. On 06/24/2024 at 12:35 PM, Resident #18 was observed in bed with oxygen infusing at 2.5 liters per minute via nasal cannula. (Photographic evidence obtained) On 06/25/2024 at 11:22 AM, Resident #18 was observed in bed with oxygen infusing at 2.5 liters per minute via nasal cannula. (Photographic evidence obtained) On 06/27/2024 at 10:12 AM, Resident #18 was observed in bed with the oxygen infusing at 3 liters per minute via nasal cannula. (Photographic evidence obtained) A review of the medical record revealed that Resident #18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and Dementia. She had a brief interview for mental status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. She was receiving hospice services for end-of-life care and she required oxygen therapy. A review of the resident's physician's orders revealed an order dated 8/10/2020 for pulse oximetry, an order dated 8/11/2020: Oxygen saturation as needed, notify MD (physician) if less than 90%, an order dated 03/14/2022: Do Not Resuscitate, an order dated 08/31/2023: Oxygen at 2 liters per minute via nasal cannula (NC) as needed, and an active order for Vitas Hospice for COPD and heart failure. A review of the Care Plan revealed a Focus Area for Hospice related to end-stage CHF (initiated 8/31/2023, revised 12/28/2023), a Focus Area for Resident Dependent on Staff for meeting emotional, intellectual, physical, and social needs related to Dementia. (initiated 3/02/2022, revised 12/14/2022), a Focus Area for Resident has Congestive Heart Failure. (initiated 01/10/2019, revised 11/30/2021), a Focus Area for Impaired Cognitive Function/Dementia or impaired thought processes (initiated 01/10/2019, revised 11/30/2021), a Focus Area for Do Not Resuscitate (initiated 01/10/2019, revised 2/24/2022), and a Focus Area for Oxygen Therapy related to CHF. (initiated 01/10/2019, revised 11/30/2021). On 06/27/2024 at 10:12 AM, an interview was conducted with LPN C. She stated she was familiar with Resident #18. When she was asked to describe the resident's needs, LPN C stated, She receives hospice care, she is alert, and she receives oxygen. LPN C was asked to provide the resident's physician's order for oxygen. She checked the order in the electronic medical record and stated, She gets two liters. LPN C was accompanied to the resident's room to verify the oxygen flow rate the resident was receiving. LPN C looked at the flow meter and stated, She is getting three liters. The oxygen flow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 15 of 23 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 06/27/2024 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)

F 0695 rate was set at 3 liters per minute. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure for Oxygen Therapy (effective 11/30/2014, revision 8/27/2017), revealed: Physician's order for oxygen therapy shall include administration modality, FiO2 or liter flow, continuous or as needed (PRN), and PRN orders must include specific guidelines as to when the resident should use the oxygen. Review physician's order, Start (O2) oxygen flow rate at the prescribed liter flow or appropriate flow for the administration device. (Photographic evidence obtained) Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 16 of 23 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 06/27/2024 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)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for one (Resident #64) of a total of 33 residents sampled for the survey. Residents Affected - Few The findings include: On 6/24/2024 at 10:40 AM, Resident #64 was observed sitting in his wheelchair in his room. The resident was asked if he had any concerns with his stay in the facility. He stated he wasn't being scheduled for and/or had missed several medical appointments, and he hadn't seen the cardiologist or the neurologist. Since his admission to the facility, he had lost his financial and insurance benefits. He stated he received a discharge notice for non-payment. He advised the facility that he was homeless and didn't have a safe place to discharge to. They offered to discharge him to a hotel for five days at their cost, and he advised them that he did not have any income. He made several requests of the Social Services Director and Business Office Manager for help in obtaining financial assistance. He stated he still had not received any assistance. He was told that his supplemental benefits ended because he owed child support and was in arrears. They were able to restore his insurance benefits and coverage to pay his monthly fee for residency in the facility. He showed the surveyor a copy of a notice dated 4/23/2024 from the Social Security Administration (SSA). Per the documentation, the resident did not qualify for Supplement Security Income (SSI) benefits. The Explanation stated We were unable to obtain additional information medical and non-medical reports from the following: Harts Harbor Healthcare Center. A review of Resident #64's medical record revealed an admission date of 4/4/2024. His diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; alcoholic cirrhosis; epileptic seizure related to external causes; chronic combined systolic (congestive) and diastolic (congestive) heart failure; personal history of pulmonary embolism; essential (primary) hypertension; other specified cardiac arrhythmia; other chest pains; syncope and collapse; other pancytopenia; thrombocytopenia and chronic pain syndrome. A review of the annual Minimum Data Set (MDS) assessment, dated 4/10/2024, revealed a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. He was documented as feeling down, hopeless and/or depressed 7-11 days during the lookback period. No behaviors were documented. No impairment in upper/lower extremities was documented, and the resident was independent with activities of daily living and mobility. A review of the Nursing Home transfer and Discharge Notice (AHCA form 3120-0002, dated 5/1/2024), revealed that the location to which the resident was being discharged was 10520 Balmoral Circle [NAME], FL 32218. Reason for discharge or transfer: Your bill for services at this facility has not been paid due to reasonable and appropriate notice to pay. A review of the Fair Hearing Request for Transfer or Discharge from a Nursing Home (AHCA form 3120-0003, dated 5/1/2024), revealed: I disagree with the transfer or discharge for the following reason(s): Never had follow ups with neurology and cardiology from [acute-care hospital name] in two years and two months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 17 of 23 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 06/27/2024 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)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A psychiatric consultation dated 5/29/2024 revealed: Resident reports improvements with depression however, he continues to have persistent symptoms. Patient needs more time with current regimen to see full beneficial effects, do not recommend any changes at this time. A physician's note dated 5/30/2024 revealed: Chief complaints: chronic disease management; Celiac; postural orthostatic tachycardia syndrome (POTS); resident also has diagnoses of seizure disorder and neuropathy. Celiac disease: Dietitian is following patient placed on low gluten diet, bowel regimen increase lactulose to twice daily and Miralax twice daily with effective results; Seizure-Keppra 500 mg (milligrams) twice daily, no breakthrough seizures; Neuropathy/chronic pain - gabapentin 400 mg three times daily, currently on oxycodone 15 mg four times daily in-house pain management is monitoring titration and prescribing; depression: Trazodone 100 mg at bedtime - patient is followed by psychiatry and psychology; anxiety: Lorazepam 0.5 mg four times daily - psychiatry is following titration medications and prescribing. An interview was conducted on 6/26/2024 at 2:56 PM with the Business Office Manager (BOM). She stated she applied for benefits for Resident #64 and he was not approved. Medicaid was covering his room and board; however, due to external financial obligations he did not get approved for financial benefits. She stated he did not have any income, therefore he was denied financial benefits from another state agency. She provided the notice dated 4/23/2024 from the Social Security Administration (SSA), which the resident had previously provided stating he was denied benefits. The BOM reviewed the letter with the surveyor. The documentation was reviewed. The surveyor directed her to the section titled: Explanation which stated We were unable to obtain additional information medical and non-medical reports from the following: Harts Harbor Healthcare Center. She stated she called the SSA and was advised there was no additional information needed from the facility. She could not provide any documentation to confirm this, nor could she state whom she spoke to and/or when the call was made. She then stated she was not aware that additional information was required or action that needed to be taken. She stated the resident was taken to the office of SSA after the letter was received. Again, she could not provide any information about when this occurred. She stated the resident got out of his wheelchair and walked into the SSA building. She then stated this was why he was denied financial benefits; he did not present himself as disabled. An interview was conducted on 6/27/2024 at 4:32 PM with the Director of Nursing (DON). He confirmed that the resident was issued a facility discharge notice. When asked why, he stated, The facility could not meet his financial needs. He stated Resident #64 had expressed in a care plan meeting that he could not meet his financial obligations to the facility due to external financial obligations. The facility felt the resident would do better in a more independent setting. After reviewing the discharge notice dated 5/1/2024 (Photographic evidence obtained), the DON confirmed the address to discharge to was a hotel. He was asked if that was a safe discharge location. He stated it was safe for Resident #64. He confirmed the resident did not have any income and added the resident may have had access to more financial assistance if he were in the community. He stated the resident was advised of the discharge and that he stressed concerns with being able to get to and from his medical appointments if he was discharged . He stated the resident had a meeting with the BOM and a SSA representative. He stated the facility transported the resident to an appointment and would not permit him to come inside with him adding that he [the resident] removed himself from his ambulatory device and walked into the office. He again confirmed the resident had no income at the time. He stated the appointment was on 4/1/2024. He denied knowledge of any additional information requested from SSA. He was asked when the resident had last seen a cardiologist. He stated the resident was followed by the facility cardiologist in house. He could not confirm the last time the resident had been seen by the cardiologist. He stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 18 of 23 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 06/27/2024 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)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had requested to see another physician for a second opinion. The resident requested to see his previous provider; however, he had not done so citing insurance coverage as a possible reason. The DON confirmed the resident had not seen a neurologist. He was asked if the resident had any diagnoses which would warrant him seeing a neurologist. He responded; He has the headaches and seizures. On 6/27/2024 at 5:38 PM, the DON advised the survey team that cardiology notes were not in the system for Resident #64. He provided documentation indicating the resident was seen by the cardiologist during the survey on 6/26/2024 at 5:39 PM. Additional information provided revealed the resident's visit prior to this was on 5/30/2023. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 19 of 23 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 06/27/2024 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and facility policy and procedure review, the facility failed to ensure that its medication error rate was not 5% or greater. There were 25 opportunities for error with two errors identified, resulting in an error rate of 8% and involving one (Resident #75) of six residents observed during medication administration, from a total of 33 residents sampled for the survey. Residents Affected - Few The findings include: On 06/26/2024 at 9:48 AM, Licensed Practical Nurse (LPN) D was observed administering medications to Resident #75. She administered Torsemide 10 mg (1) tablet by mouth, and she administered Advair 100-50 mg (milligrams), 2 puffs, without providing the resident with water to rinse/spit following inhalation, or instructions to rinse his mouth well and spit following inhalation. A review of Resident #75's active physician's orders revealed an order for Torsemide as follows: Torsemide oral tablet, 10 mg, give three tablets by mouth one time a day for congestive heart failure (CHF), order dated 2/14/2024, start date 2/15/2024. Further review of Resident #75's activie physician's orders revealed and order for Advair as follows: Advair Diskus Inhalation Aerosol Powder breath Activated 100-50 MCG/ACT (micrograms per actuation) (Fluticasone-Salmeterol), 2 puff, inhale orally one time a day for COPD (chronic obstructive pulmonary disease), rinse mouth well and spit after each use. A review of the facility's policy and procedure for Administration of Medications (revised April 2019), revealed: 4. Medications are administered in accordance with prescriber orders, including any required time frame. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 20 of 23 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 06/27/2024 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)

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility, licensed for 180 beds, failed to employ a qualified social worker on a full-time basis. Residents Affected - Few The findings include: The personnel file for Director of Social Services (DSS) L was reviewed during random record reviews for facility staff. An application, dated 5/3/2024, for the position of Director of Social Services was observed. (Photographic evidence obtained) There was no documentation in the personnel file verifying DSS L's credentials for the position of DSS. On 6/27/2024 at 1:15 PM, the Human Resources Director (HRD) provided a copy of what she stated were DSS L's credentials. (Photographic evidence obtained) Per the documentation, DSS L received a Bachelor of Science degree in Interdisciplinary Studies. The HRD stated she knew the degree was invalid. She confirmed that DSS L was hired as the DSS. She stated it should have been Manager and not Director due to lack of credentials. She confirmed the facility did not have another individual staffed as the DSS. A phone interview was conducted on 6/27/2024 at 1:33 PM with the educational institution, where based on documentation provided, DSS L had obtained her degree. The HRD was also present during the call. The educational institution advised the survey team that the program of study DSS L had obtained her degree in did not focus on social work or psychology. The representative at the educational institution stated it was a brotherhood program intended for individuals seeking missionary work. Upon hearing this, the HRD stated a new position title and job description would be generated for DSS L. A review of the facility's employee roster revealed DSS L's Job Code: SSDIR 1 (Social Services Director) with a hire date of 5/15/2024. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 21 of 23 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 06/27/2024 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and facility policy and procedure review, the facility failed to help prevent the development and transmission of diseases and infections by failing to properly clean and disinfect a glucometer for one (Resident #59) of six residents observed during medication administration, from a total of 33 residents sampled for the survey. Residents Affected - Few The findings include: On 6/26/2024 at 10:13 AM an observation was made of Licensed Practical Nurse (LPN) A cleaning and disinfecting the glucometer used for Resident #59. LPN A wiped the glucometer with an antibacterial wipe for 30 seconds and immediately placed it back in the pouch, wet. On 06/26/2024 at 10:22 AM, an interview was conducted with LPN A. She was asked to explain the process for sanitizing the glucometer. She stated, I wipe it down after each use and put it back in the pouch. She was asked, according to her training and the facility's policy, how long she should wipe the glucometer. She stated, I'm not sure about that. I just know I must sanitize it between each resident. She was asked, according to her training and the facility's policy, how long the glucometer should be allowed to dry before it was placed back in the pouch. She stated, I'm not sure. I usually wipe them down and put them back in the pouch, but I will find out and get back with you. On 6/27/2024 at 11:30 AM, a review of the facility Skills Competency Assessment for Glucometers (10/2021) revealed the employee should demonstrate skills and competence in cleaning and disinfecting the meter with a disinfectant wipe per the manufacturer's recommended wet time to include: Follows the two-step process for cleaning and disinfecting. Cleaning: Cleans the entire surface of meter three times horizontally and three times vertically, inverts the meter so the test strip is facing down and cleans around the test strip port. Disposes of the wipe. Disinfecting: Obtains a new disinfectant wipe and repeats the procedure above to remove blood-bourne pathogens. Disposes of the wipe. The surface remains wet per the manufacturer's instructions. Wipes the meter dry with a paper towel after the recommended wet time. A review of the facility's policy and procedure for Blood Glucose Monitoring and Disinfecting (effective 11/30/2014, revised 3/1/2021 - Document Name: N-700), revealed that the procedure for cleaning and disinfecting the meter was with disinfecting wipes per the manufacturer's guidelines. A review of the instructions provided by the Assure Prism Multi Blood Glucose Monitoring System revealed that the meter should be cleaned and disinfected after each use on each patient. Cleaning included wiping the entire surface of the meter three times horizontally and three times vertically using one towelette and properly disposing of the towelette. The disinfecting of the meter included wiping the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens. Properly dispose of the towelette. The treated surface must remain wet for the recommended contact time. Once contact time is complete, wipe meter dry. A review of the Super Sani-Cloth Gemicidal Disposable Wipe Technical Data Bulletin revealed that the contact times for multi-drug resistant bacteria, enveloped viruses, non-enveloped viruses and bloodborne pathogens was two minutes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 22 of 23 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 06/27/2024 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, facility pest control management documentation, and facility policy and procedure, the facility failed to ensure the pest control service was effective when cockroaches and flying insects were observed in resident rooms and the activities room. Ineffective pest control could lead to transmission of disease and infection. Residents Affected - Few The findings include: On 06/24/2024 at 10:30 AM, 12:32 PM, and 1:20 PM, live cockroaches were observed in the activities room. (Photographic evidence obtained) On 06/25/24 at 10:35 AM, one gnat flying in the room and two gnats on the privacy curtain were observed in room [ROOM NUMBER]A on the East Wing. A black fly was observed on the B-bed in room [ROOM NUMBER]A. (Photographic evidence obtained) During an interview with Resident #24 on 06/25/2024 at 10:22 AM in room [ROOM NUMBER]A on the East Wing, a gnat flew by his face and he swatted at it. It landed on the privacy curtain. When asked if the gnats bothered him, he stated, You see me doing this. He waved his hand in front of his face to show how he tried to swat them away. He stated the facility had a pest control program, but it was not working. He stated, I know they spray. During an interview with the Administrator on 06/27/2024 at 5:30 PM, she stated the facility filed for bankruptcy on June 1, 2024. The contracted pest control company at that time refused to provide anymore services due to past due bills not being paid. The last time the pest control company provided services was on 05/30/2024. She stated she had a new company ready to begin services, but the corporate office had not signed the contract yet. She acknowledged that there were pests in the building. A review of the contracted pest control receipts for service, dated 05/28/2024, revealed the company treated multiple areas for cockroaches and monitored five fly lights for flying insects. The next receipt for service prior to 05/28/2024, was dated 04/05/2024. On both occasions the activities room was treated for cockroaches. On both occasions the service technician documented no activity, indicating that he/she did not observe pests in the facility. (Copies obtained) A review of the facility's policy and procedure titled Pest Control HL-200 (effective 11/30/2014), revealed: Policy: The facility will maintain a pest control program, which includes inspection, reporting and prevention. Procedure: 1. A pest control contract will be maintained with a licensed exterminator. 3. Treatment will be rendered as required to control insects and vermin. 4. Any unusual occurrence or sighting of insects should be reported immediately to the Supervisor. Proper action will be taken. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 23 of 23