Health inspection·October 22, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a wander guard on. When asked about the LOA process, she stated that she was not aware of the process and assumed the receptionist knew the process.During a phone interview on 10/22/25 at 1:45 pm, with Employee B, Receptionist, she stated that she has been working at the facility for almost a year. She stated that prior to the incident she had not participated in any type of drill. She explained that when a resident wants to go out, she checks to see if the resident is permitted to leave the facility with or without someone with them. When asked about Resident #1, she explained that she was not aware of the caution elopement book and had not been informed of it. She thought that if residents had a sheet on their sign out book they could go outside. She explained that the HRC asked her to sign the resident out. The resident had a wheelchair but got up and walked out of the facility and did not say where he was going. She confirmed that she had not received any training on LOA.On 10/22/25 at 2:09 PM, an interview was conducted with the Director of Nursing (DON). He explained that the facility conducted elopement assessment upon admission, quarterly, on change on condition and any elopement incident. He mentioned elopement drills are conducted at least monthly and can be conducted more frequently. Drills are conducted by the maintenance department. However, when there is an incident all the department heads can assist. When asked about the LOA process, he explained that the resident must sign out with the nurse then the receptionist at the front. The receptionist verifies with the nurse that the resident has signed out at the nurse's station. If they are going out for an extended time the nurses coordinate with the pharmacy and physicians to make sure all the patient's orders are in place. When asked about the incident with Resident #1, he explained that on 8/23/25 the weekend supervisor informed him that the resident signed out the facility, which he should not have been able to do. When asked about Resident #1's wander guard, he explained that the daytime receptionist (Employee C) stated that resident had attempted to go out of the facility earlier during the day and she redirected him. Resident #1's hand wander guard activated the alarm during this time. The Resident removed his wander guard prior to the incident where he signed himself out. When asked for the elopement assessment, he stated that after the incident it was noted that assessments were not completed per the policy. The DON could also not produce the elopement drills conducted before the incident. After the incident he stated that ANE and elopement training/drill was conducted, however the process for LOA was not conducted. When asked how often the elopement binder was audited, he stated on admission and any changes on condition.Review of the facility's policy titled Leave of Absence Document Name N760 Revision date 6/14/25 revealed the following:Process: A patient/resident is allowed a leave of absence (LOA) from the center in accordance with safe medical practice and state and federal regulations. During admission process patient/residents receive information regarding the Leave of Absence procedure. Procedure: 1. Obtain a physician's order for the patient/resident to leave the center.2. Obtain the signature of the patient/resident or resident representative indicating the date and time of departure on the Release of Responsibility for LOA form. a. Indicate by their signature that they are taking responsibility for the patient/resident and have notified the nursing staff of the anticipated departure and acknowledge release of responsibility to center, its personnel or the attending physician for a decline in condition or accident while the patient/resident is on LOA. Review of the facility's policy titled Elopement/wandering risk guideline Document Name N-1031 Revision Date 8/1/20 revealed the following:Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. Initiate individualized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 2 of 6 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 10/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm interventions based on Patient/Residents' risk. Document individualized interventions in the patient/resident Care Plan and Kardex. If utilizing a wander monitoring system device check placement of the device every shift and functionality every day.Maintain the Elopement Risk Alerts in an easily accessible location. Complete routine elopement drills monthly and review in QAPI meeting. QAPI: Review trends of elopement drills by the QAPI team. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 3 of 6 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 10/22/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy and procedure review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies related to elopement. Facility staff permitted Resident #1 who was an elopement risk to sign out of the facility without an escort. The facility did not implement the corrective action noted in their Performance Improvement Plan (PIP). There was a total of 12 residents at risk for elopement. Review of the medical record for Resident #1 revealed an admission date of 3/17/23 and re- entry on 7/7/24. His diagnoses included metabolic encephalopathy, obesity, major depressive disorder, alcohol abuse, insomnia, tobacco use and anxiety disorder.Review of Resident #1's Care plan initiated on 11/15/23 indicated he may go out on LOA with meds and escort. Resident/family members must sign out every LOA. Resident was care planned as an elopement risk/wanderer related dementia and impaired safety awareness. The resident will not leave facility unattended. Interventions included to assess for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident prefers electronic monitoring device: a wander guard on right wrist needs to be changed 7/20/26.Further record review revealed that on 8/23/25, Resident #1, went to the receptionist and requested to sign out of the facility. The receptionist provided the resident the sign out book, which he signed and exited the facility through the main entrance.Review of Resident #1 current physician orders revealed the following:-Wander guard - Expiration Date 7/26.-Wander guard - Check for placement on Right wrist every shift for monitoring 5/30/24.- Wander guard - Check for function each day- every night shift for monitoring 7/20/23.- May go out with responsible party 3/18/23.- Document Resident behaviors every shift r/t exit seeking- every shift for patient safety - 8/24/25.Review of Behavior note dated 8/23/25 for Resident #1 revealed the on-call Team Health was notified regarding elopement.Review of Behavior note dated 8/24/25 for Resident #1 indicated that the resident continued to be 1:1 supervision, no changes noted at this time in the client or client condition, staff will continue to monitor the client.Review of Social Services note dated 8/25/25, revealed the Director of Social Services discussed the elopement that occurred with resident. Resident reported he does not remember signing himself out or trying to cross the street. Resident reported he is not trying to leave the facility and feels safe.Resident #1 had only two Elopement assessment dated [DATE], 7/21/24 which indicated that the resident was at risk of elopement.During an interview with Employee A, Human Resource Coordinator (HRC) on 10/22/25 at 1:22 pm, she stated that on 8/23/25, she was the manager on duty. She explained that she was at the front desk when Resident #1 asked to sit on the porch. The receptionist asked if he could go out, and I told him he had to sign out. The HRC came back to the front and looked outside. She saw what appeared to be a man standing on the facility's lawn. She asked the receptionist if that was the resident who asked to go outside. She noticed his wheelchair was still in the facility. Resident #1 had walked to the neighbor across the street to ask for a ride to the store. The HRC then went outside and helped the resident back to the facility with the assistance of the neighbor across the street. When asked if the resident was wearing a wander guard, she stated she did not recall him having a wander guard on. When asked about the LOA process, she stated that she was not aware of the process and assumed the receptionist knew the process.During a phone interview on 10/22/25 at 1:45 pm, with Employee B, Receptionist, she stated that she has been working at the facility for almost a year. She stated that prior to the incident she had not participated in any type of drill. She explained that when a resident wants to go out, she checks to see if the resident is permitted to leave the facility with or without someone with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 4 of 6 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 10/22/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them. When asked about Resident #1, she explained that she was not aware of the caution elopement book and had not been informed of it. She thought that if residents had a sheet on their sign out book they could go outside. She explained that the HRC asked her to sign the resident out. The resident had a wheelchair but got up and walked out of the facility and did not say where he was going. She confirmed that she had not received any training on LOA.On 10/22/25 at 2:09 PM, an interview was conducted with the Director of Nursing (DON). He explained that the facility conducted elopement assessment upon admission, quarterly, on change on condition and any elopement incident. He mentioned elopement drills are conducted at least monthly and can be conducted more frequently. Drills are conducted by the maintenance department. However, when there is an incident all the department heads can assist. When asked about the LOA process, he explained that the resident must sign out with the nurse then the receptionist at the front. The receptionist verifies with the nurse that the resident has signed out at the nurse's station. If they are going out for an extended time the nurses coordinate with the pharmacy and physicians to make sure all the patient's orders are in place. When asked about the incident with Resident #1, he explained that on 8/23/25 the weekend supervisor informed him that the resident signed out the facility, which he should not have been able to do. When asked about Resident #1's wander guard, he explained that the daytime receptionist (Employee C) stated that resident had attempted to go out of the facility earlier during the day and she redirected him. Resident #1's hand wander guard activated the alarm during this time. The Resident removed his wander guard prior to the incident where he signed himself out. When asked for the elopement assessment, he stated that after the incident it was noted that assessments were not completed per the policy. The DON could also not produce the elopement drills conducted before the incident. After the incident he stated that ANE and elopement training/drill was conducted, however the process for LOA was not conducted. When asked how often the elopement binder was audited, he stated on admission and any changes on condition.Review of the facility Quality assurance projects revealed elopement Performance Improvement Plan dated 8/25/25. The root cause was identified as Receptionist should always verify the elopement binder. The plan included:1.Audit performed of current residents in house to determine at risk/Updated Elopement Risk Assessments as appropriate for all residents identified at risk/Orders and Care Plans Updated as appropriate for all residents identified at risk/Nursing Staff education initiated on identifying residents at risk for elopement & elopement risk assessments & elopement Policy and procedure.2. Education initiated with all-staff on abuse and neglect (ANE), elopement policy and procedure, elopement books, LOA books, and LOA process. Drills initiated every shift until all current employees have participated then drills per routine guidance. 3. Staff Education provided on door security, and responding: 1. Education provided to IDT team on updating resident assessments, plan of care, orders, elopement books, etc. as changes occur with resident status. Weekly audits of residents at risk for elopement & elopement books to be performed by DON/Designee. Review of the facility weekly audits of residents at risk for elopement and elopement books revealed there were only three audits.Further review of the elopement book there revealed there were 13 residents noted as at risk of elopement. Resident #2 who was noted as an elopement risk had been discharged on 10/5/25.Clinical record review for Resident #3 revealed that she was admitted to the facility on [DATE], her diagnoses included asthma, bipolar disorder, current episode mixed, severe, with psychotic features, major depressive disorder, recurrent, anxiety disorder, need for assistance with personal care.Review of elopement assessments dated 11/15/24, 8/24/25 indicated that the Resident #3 was not an elopement risk.Further review of the quarterly MDS with and ARD of 7/26/25, indicated that the resident had a brief interview of mental status score (BIMS) of 15 out of 15 indicating normal cognitive status. No (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105632 If continuation sheet Page 5 of 6 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 10/22/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wandering behaviors noted.Care plan revised on 1/19/22 indicated that Resident #3 is an elopement risk/wanderer- wander guard in place to right ankle. exp Feb. 2026.Quarterly MDS ARD 7/26/25 - BIMS 15 No wandering (Care plan was not updated).During an interview with Employe C Certified Nurse Assistant (CNA) on 10/22/25 at 4:35 pm, she stated that she had worked in the facility for almost 20 years and was familiar with Resident #3. She stated that Resident #3 was independent with her care alert and oriented and able to make needs know. She stated that resident had no exit seeking behaviors.During interview with the Administrator on 10/22/25 at 5:29 pm, he stated that he coordinated QAPI. When asked how he ensured that the plan identified in the PIP was followed. He stated that PIP is discussed during clinical meeting conducted daily. He stated that the Elopement PIP was still ongoing and the facility was still conducing audits and training. When asked for the weekly audits of residents at risk for elopement & elopement books, he stated that the DON was responsible to conduct the audit he confirmed that there were only three audits (Copies obtained). He stated that he did not review the audits during the September QAPI.Reviewed facility policy and procedure titled Quality Assurance Performance Improvement Program (QAPI) Document Name: PI-215 revised 10/24/25, revealed the following:Page 6: Performance Improvement Projects: The center utilizes performance improvement projects to improve a systemic problem or improve quality in absence of a problem. Performance Improvement Projects (PIPs) are based on the centers services and resources identified in the Facility Assessment. At a minimum, the center must conduct one performance improvement project annually. a. The PIP should focus on high-risk or problem prone areas, identified by the center.b. The team may consist of one or more team membersc. The team will complete the following functions: i. Collect and analyze data. ii. Determine Root Cause. iii. Determine steps for resolution.iv. Implement corrective action.v. Evaluate effectiveness of the actions.vi. Report progress to QAPI committee. Event ID: Facility ID: 105632 If continuation sheet Page 6 of 6