Inspection·January 21, 2022

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cold because the staff delivered it too late. He further stated the certified nursing assistants (CNAs) helped to serve meals on other units first, he would be served his tray later. Resident #64 was interviewed on 1/19/22 at 10:00 a.m. She stated she was unaware that she could put her preferences on her meal ticket. She had eaten grits, toast, coffee, and juice for breakfast, but would have preferred a biscuit instead of toast. She said she often ordered out for pizza or Chinese food. The Registered Dietitian (RD) was interviewed on 1/21/22 at 4:40 p.m. She stated she had recently returned to work at the facility full-time. She restarting the Food Committee meetings, as she was unable to find minutes for the past few months. She stated she was beginning to communicate with the residents more directly. Over the past year, she had only assisted the Certified Dietary Manager (CDM) on a quarterly basis. She said she had been involved with resident food preferences in the past year, but was now going to take on more responsibility. She had redone some food preferences. She said she had not been privy to the past six months of Food Committee notes, or Resident Council meeting notes. She said if something was brought up to her, she would find out what the residents' preferences were and then meet with the residents. She said she spoke with the dietary staff, but they do come and go. She had also spoken with the kitchen staff to see whether there were any current concerns. She helped to resolve them if she was made aware. She believed that the resolution process for resident concerns was currently a broken system. She said the last CDM was no longer at the facility, and a lot of things fell off. She said she would now be here five days a week, perhaps not all day, but would try to get to the facility every day. She had given her phone number to the residents, so she could be informed if there were problems that required correction. She said some RDs did not want to work on food. The Activities Director (AD) was interviewed on 1/21/22 at 5:05 p.m. She stated she scribed the minutes during the Resident Council meetings. If there was a resident complaint, she wrote up a grievance and gave it to the appropriate department for follow up. In the next monthly meeting, she would ask if old business had been resolved. She said she was not involved in what the resolutions were. If there was a group grievance, she would not write it up, but would bring it to the following morning's stand-up meeting. The staff from the assigned department would then take ownership of the concern. Social Services would investigate for resolutions, but there had not been a Social Services Director at the facility for a few weeks. She said she did not oversee whether resolutions to concerns were completed/not completed, nor did she oversee/follow up if the residents continued to state the same concerns. The Administrator (NHA) was interviewed on 1/21/22 at 5:35 p.m. He stated grievances were discussed in the morning meetings. The departments would then discuss resolutions. If there were concerns or difficulties in the resolution process, he would develop a performance improvement plan. The facility's policy on Complaint/Grievance, initiated on 11/30/14 and last revised on 8/9/18, revealed: The intent of this guideline is to support each resident's right to voice grievances and to assure that after receiving a complaint/grievance, the center actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 2 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility facility failed to develop and implement a discharge care plan for one resident (#84) in a total sample of 44 residents. The findings include: On 01/18/22 at 2:45 PM, Resident #84 was observed accompanied by a staff member for one on one (1:1) supervision. In an interview on 01/18/22 at 2:55 PM, Resident #84 stated she did not want to be at the facility and had notified the staff about her willingness to leave but no one responded. While holding back tears, she continued to state that she came to the facility to stay with her husband who passed away in December. She added that since her husband's death her depression had increased. She also mentioned that her roommate passed away as well and she was now afraid to sleep. She requested a psychologist. A review of the clinical record revealed that Resident #84 was admitted to the facility on [DATE] with a primary diagnosis of polyneuropathy. Secondary diagnoses included schizoaffective disorder - bipolar type and anxiety disorder. A review of the January 2022 Physician's Order Sheets revealed current orders including buspirone 10 mg (milligrams) two times a day for anxiety, trazadone 50 mg at bed time and melatonin 5 mg at bedtime, both for insomnia. A review of the admission Minimum Data Set (MDS) assessment, dated 10/18/21, revealed the resident had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. She was documented as independent for all actvities of daily living (ADLs). A review of the resident's care plan revealed that she demonstrated behaviors related to her diagnosis of schizoaffective disorder and anxiety as evidenced by confabulation, attempts to remove other residents' items from their rooms without permission, and entering into other residents' rooms uninvited. Resident is physically aggressive toward staff, as evidenced by pushing staff. Interventions included but were not limited to Resident on 1:1 supervision. There was no care plan available that was related to the resident's plan for discharge. (Copy obtained) On 01/20/22 at 12:11 PM, Licensed Practical Nurse (LPN)/Unit Manager K, stated the resident had been having increased behaviors of wandering from room to room, hence the 1:1 supervision. She added that the behaviors had increased after the resident's spouse's death, and that the facility's plan had been to have the resident placed in another facility, but she was not sure if the intervention was ever pursued. When asked about the resident's psychiatric evaluation, LPN K stated the resident was seen weekly by psychiatry and had been prescribed Zyprexa (antipsychotic medication), but she refused to take the medication and therefore it was discontinued. When asked if other interventions had been attempted, LPN K stated the resident was alert and oriented, and it had been difficult to get her to do anything she was unwilling to do. LPN K mentioned that psychiatry had been seeing her quite often and had not deemed a psychologist's visit necessary at this time. LPN K stated he was not sure what the resident's discharge plan was, as it was not outlined in her care plan. During another interview with Resident #84 on 01/20/22 at 12:44 PM, she stated she did not want to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 3 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be in the facility. She reiterated that she was in the facility because of her husband and he had passed way. The facility was not making any progress on her plan for discharge. A review of the Social Services progress note dated 12/30/21 read, The administrator, the unit manager for [Resident 84's] unit, and I had a meeting with her today to discuss a few things that have been brought to our attention. A few residents on Resident 84's hall, 300 hall, as well as a few residents from the 200 hall, have been complaining about [Resident #84] wandering into their rooms, taking things from their rooms, and placing them in other rooms, moving things around in their rooms, and interrupting their conversations with each other. [Resident #84] denied all of these things. She accused the unit manager of lying about the accusations that other residents have made. The unit manager tried to explain that the residents on her unit came to her upset and trying to find a resolution to their problems. [Resident #84] became very upset and called the unit manager a liar. We also spoke with the resident about her hygiene. [Resident #84] is refusing showers and not allowing staff to assist her with her bathroom needs. Again [Resident #84] denies refusing help. We asked her what we can do to be more accommodating toward her, since she feels the unit manager doesn't like her and the residents on her unit are telling lies about her. [Resident #84] said she would like to move to an Assisted Living Facility (ALF) or Independent Living (IL). I told [Resident #84] I would look into those options for her, and I would keep her posted on the facilities I find for her, so we can work on a transition plan that will best suit her needs. In an interview on 01/20/22 at 1:58 PM, Social Services Assistant (SSA) L stated the resident had mentioned she would like to be discharged to another facility. SSA L confirmed that the request for placement was not followed up on. When asked about the discharge care plan, she stated the Social Services Director (SSD) was responsible for developing the care plan upon admission. She confirmed that Resident #84's care plan was never developed. On 01/20/22 at 4:02 PM, MDS Coordinator M stated discharge plans were initiated upon admission and evaluated as needed. When asked about the discharge care plan, she stated Social Services was responsible for that particular care plan. When asked about the discharge care plan for Resident #84, she confirmed it was missing. When asked if she conducted care plan audits, she stated she was new at the facility and planned to review all care plans quarterly for completeness. On 01/20/22 at 4:10 PM during an interview with the Director of Nursing (DON), he stated Resident #84 was placed on 1:1 supervision due to safety concerns. The resident had a behavior of going into other residents' rooms and did not remember having done it. He added that psychiatry and corporate would determine when it was safe to discontinue Resident #84's 1:1 supervision. When asked about the resident's discharge plan, the DON stated he was not sure about that and would check with corporate. He stated the resident wanted to return to her apartment, but the resident's son and sister-in-law stated she was not safe. The DON confirmed there was no documentation to verify that communication took place. A review of the facility's policy and procedure titled: Discharge Planning (effective 11/30/2014), revealed it was the facility's policy to evaluate the resident's health status and formulate the best plan of discharge for each resident. Discharge Planning begins the day of admission. The process involves the resident and family, Care Management/Social Services and other members of clinical team. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 4 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. An initial evaluation of a resident is completed upon admission. A discharge goal and length of stay will be established upon admission and reviewed/revised at plan of care conferences. The goal is based upon clinical findings, availability of community and family resources and resident/family goals. 2. Discharge planning record will be completed within seven (7) days after admission. Discharge planning is adjusted as appropriate. 3. All discharge plans will be reviewed after sixty (60) to ninety (90) according to level of care. ( Copy obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 5 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to identify and provide needed care and services that are resident centered for one (Resident #61) of five residents reviewed for planning and set-up of follow-up appointments, from a total of 44 sampled residents. Specifically, the facility failed to ensure professional standards of practice with regard to a cardiology follow-up appointment as set out by admission documentation to the facility, and documented physician's orders. Additionally, the facility failed to ensure that the resident received or was receiving in-house cardiology services. Residents Affected - Few The findings include: A review of Resident #61's medical record revealed that she was admitted on [DATE] with a primary diagnosis of heart failure. Additional diagnoses included HTN (hypertension), atherosclerotic heart disease of native coronary artery without angina pectoris, shortness of breath, pain, and presence of automatic (implantable) cardiac defibrillator. The resident was designated as a Full Code (in the event of cardiac/pulmonary arrest, cardiopulmonary resuscitation was to be initiated), and scored 15 out of a possible 15 points on her BIMS (brief interview for mental status), indicating no cognitive impairment. She underwent a R (right) heart catheterization on 11/23/21 prior to admission to the facility. An interview with Resident #61 was conducted on 01/18/22 at 12:41 PM. She verbalized concerns regarding follow-up appointments with her cardiologist and pulmonologist. She stated she still needed to be seen by each of those specialists. She stated she was admitted on [DATE] after having a defib put in. A cardiology consultation, dated 11/16/21 for elevated cardiac enzymes, documented that the resident had a history of Systolic Heart Failure (reported EF (ejection fraction) of 15-20% in 2019) and was being followed by a cardiology group with no recent documented outpatient visits. The resident's 12/3/21 hospital discharge form (3008) stated the resident had an internal cardiac defibrillator. A review of the 12/3/21 hospital discharge medical record documented a physician follow-up appointment was to be scheduled in 1-2 weeks, along with a cardiac-physio appointment in 1-2 weeks. A Social Services progress note dated 12/20/21, documented in part that they had followed up with [Resident #61] this morning about her DC (discharge) information. She informed me she is not going back to the previous place. The progress note also documented that the resident had spoken with facility staff about starting an application for her to become LTC (long term care). I let the resident know that I would follow up. A physician's order dated 12/4/21, documented a follow-up appointment with Cardiology-Electro physio in 1-2 weeks. A physician's order dated 12/4/21, documented an in-house pulmonary consult. Further review of the resident's medical record revealed no evidence of a cardiology (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 6 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 follow-up/consult since the resident's admission on [DATE]. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON) on 1/21/22 at 3:06 PM regarding the follow-up appointment process, he stated once a resident was admitted to the facility, the Unit Coordinator/Transport Aide established a list of follow-up appointments for the resident and coordinated these with corporate transportation. This individual was currently unavailable at the facility, however. The DON verbalized that the team of clinicians, i.e.: Unit Manager and DON took on that responsibility in this instance. Residents Affected - Few An interview with Unit Manager G was conducted on 1/21/22 at 3:24 PM. She stated Resident #61 had been seen by in-house cardiology every Tuesday and Thursday. She further stated with regard to the 12/3/21 discharge order and 12/4/21 physician's order to be seen by Cardioloy-Electro physio in 1-2 weeks, she would have to contact that physician to determine if she could continue being followed by the in-house cardiology physician. A request was made to review documentation of the in-house cardiology follow-up/consults, and Unit Manager G stated she would provide the documentation for review. At the completion of the recertification survey on 1/21/22 at 6:43 PM, no documented evidence of in-house cardiology follow-ups/consults were provided for Resident #61. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 7 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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, interviews and record review, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice, for two (Residents #73 and #355) of 44 sampled residents. Residents Affected - Few The findings include: 1. On 1/18/2022 at 11:22 a.m., Resident #73 was observed sitting up in bed in his room, which was located on the COVID unit. The resident stated he was supposed to be receiving Oxygen (O2) but he had not received it. He stated when he was taken to the COVID unit, he was given an oxygen concentrator but it didn't work. He stated staff confirmed the concentrator was not working and removed it from his room. He stated it had not been replaced. On 1/19/2022 at 10:25 a.m., Resident #73 was observed to have been moved to another room. O2 still was not present in the resident's new room. Resident #73 stated he was told that someone would be bringing the O2 sometime today. On 1/19/2022 at 1:55 p.m., Resident #73 was observed resting in bed. O2 was still not present in the resident's room. He confirmed that the O2 had not been delivered. On 1/20/2022 at 3:21 p.m., Resident #73 was observed sitting up in bed. O2 was still not present. Again, the resident stated that no one had provided O2 as ordered. On 1/21/2022 at 12:10 p.m., Resident #73 was observed eating in bed. O2 was not observed in his room. He stated staff had not mentioned anything further about the O2 and confirmed that as of this interview, it had not been delivered. A review of Resident #73's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, acute kidney failure, retention of urine and chronic stage 3 kidney disease. A review of the physician's orders reveaeld an order effective 1/14/2021 for oxygen (O2) via nasal cannula. A review of the January 1, 2022 through January 20, 2022 medication administration record (MAR) and treatment administration record (TAR) revealed no order for O2, nor any orders for O2 monitoring, including checking the resident's O2 saturation level. A review of the resident's care plan, last reviewed on 12/8/2021, included interventions to: administer medications as ordered and assess oxygen saturations every shift. During an interview on 1/21/2022 at 12:22 p.m. with Licensed Practical Nurse (LPN)/Unit Manager G, she confirmed that O2 was not present and she could not explain why. She asked the resident about the O2 and he stated he had not had O2 since it was ordered. He explained to her that the initial O2 concentrator did not work, was removed from his room and was never replaced. He also advised the LPN that his O2 saturation levels were not being taken as ordered. She chuckled. LPN G did not respond (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 8 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 to the resident's claims, but stated she would have to contact the physician regarding the order for O2. Level of Harm - Minimal harm or potential for actual harm 2. On 1/18/2022 at 11:50 a.m., Resident #355 was observed lying in bed receiving O2 via nasal cannula (NC). The oxygen flow rate was observed to be set at 5 liters per minute (LPM). Resident #355 stated, The O2 is supposed to be at 5 LPM; it is at 5, right? Oh ok, yes that's where it's supposed to be, at 5. Residents Affected - Few On 1/19/2022 at 12:00 p.m., Resident #355 was observed sitting in a chair receiving O2 via NC with a flow rate of 5 LPM. A review of the resident's medical record revealed an admission date of 1/12/2022 with diagnoses including hypotension, acute renal failure, and an order for oxygen saturation monitoring. The resident's admission form did not mention oxygen therapy, a flow rate or delivery device for administration of oxygen therapy. Oxygen therapy orders were not found anywhere in the resident's medical record (hard chart or electronic medical record). On 1/20/2022 at 2:04 p.m., LPN H was asked to find O2 therapy orders for Resident #355. She proceeded to search for the orders and then stated, I don't see the orders for oxygen therapy. I would know if a resident had orders for oxygen either by orders for it from the doctor, in the MAR, or from the morning report. I see the orders for the oxygen saturation monitoring, but I'll be honest, I didn't see orders for the oxygen orders themselves. Well, in case of no orders and a resident is on O2 but there are no orders, I will let my unit manager (LPN G) know and notify the doctor. On 1/20/2022 at 2:19 p.m., the physician gave verbal orders for respiratory therapy for Resident #355 as follows: Oxygen at 2 liters via nasal cannula - continuous. On 1/20/2022 at 3:17 p.m., Resident #355's O2 flow rate was set at 5 LPM. (Photographic evidence obtained) On 1/20/2022 at 3:19 p.m., LPN H asked, Did you see the new oxygen therapy orders for [Resident #355]? She was informed that the new order was reviewed for 2 LPM, however the resident's O2 remained set at 5 LPM. LPN H immediately went to Resident #355's room and adjusted the flow rate to 2 LPM. Resident #355 was informed of the physician's order and acknowledged the flow rate change. On 1/21/2022 at 9:49 a.m., the facility's Oxygen Therapy policy and procedure (effective 11/30/2014 and revised 08/28/2017) was reviewed. On page one under Procedures was documented, Physician's order for oxygen therapy shall include: Administration modality, FiO2 or liter flow, Continuous or PRN, PRN orders must include specific guidelines as to when the resident is to use oxygen. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 9 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure accurate acquiring, receiving, dispensing, and administration of medications for four (Residents #20, #201, #204, and #206) of a total sample of 44 residents. The findings include: 1. A review of facility records revealed an a allegation of misappropriation dated 11/30/21. The documentation stated that on 11/30/21, as Licensed Practical Nurse (LPN) P, assigned to Resident #20, prepared to change the resident's Fentanyl (narcotic pain medication) patch, she identified that there were no patches remaining and contacted the pharmacy. The Pharmacist reported patches were delivered to the facility on [DATE] at 8:41 PM and were signed as having been received by Registered Nurse (RN) Q. The Director of Nursing (DON) was notified. A review of Resident #20's medical record revealed an admission date of 08/02/19 and a re-entry date of 7/10/21 with a primary diagnosis of polyneuropathy. Secondary diagnoses included quadriplegia and chronic pain syndrome, contractures of the left leg, and pain at the knees. A review of the Quarterly Minimum Date Set (MDS) assessment, dated 10/11/21, revealed a Brief Interview for Mental Status (BIMS) score of 15 our of a possible 15 points, indicating intact cognition. The resident required extensive assistance for bed mobility and toileting. A review of the physician's orders revealed orders for: Fentanyl patch 25 micrograms per hour (mcg/hr), change patch every 72 hours, oxycodone 10 mg (milligrams) every 4 hours as needed for pain, gabapentin 600 mg three times a day, acetaminophen (Tylenol) 650 mg by mouth every 6 hours as needed for mild pain for a pain scale of 1-3/0-10. A review of the care plan revealed that Resident #20 had chronic pain related to spondylosis with myelopathy, morbid obesity, recent complaints of knee pain, and a decline in function. In an interview on 01/20/22 at 11:39 AM, Resident #20 denied having pain. He stated he received a pain patch and revealed one patch on his left upper shoulder. He added that there were a few days that the patch was missing and had been informed that the pharmacy had not delivered it. A review of the January 2022 electronic medication administration record (EMAR), revealed the fentanyl patch was not administered on 1/11/22 or 1/17/22 with a description that read, Awaiting order from pharmacy. (Copy obtained) On 01/20/22 at 11:56 AM, LPN N explained that medications were re-ordered when there was a 5-day stock to ensure that residents did not miss any medication. She stated the process of re-ordering medication was electronic and pharmacy would call the facility if and when there were issues with the re-ordering process. When asked what would happen if medication was not delivered on time, she replied, The first thing is to check if the medication is in the emergency kit and obtain pharmacy authorization for controlled drugs. If medications are not available, the physician would be notified of missed doses. When asked to explain the process for controlled medication reconciliation, she stated medications were signed off after administration, the oncoming and offgoing nurse counted the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 10 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication at the beginning of each shift, and when narcotics were received from the pharmacy, two nurses signed the narcotic sheet and also the manifest. In an interview on 01/20/22 at 12:07 PM , LPN K/Unit Manager stated the facility received the emergency drug kit (EDK) replacement daily. When asked about Resident #20's having missed the fentanyl medication on 1/11/22 and 1/17/21, she said, There is no reason for the resident to miss the medication, since medications are available in the EDK box. She added that if there were issues with the pharmacy delivery, the nurses should notify the manager to request an as soon as possible (STAT) delivery. LPN K stated she was on leave when the other medication went missing. When asked about the facility's process for receiving medications from the pharmacy, she stated two nurses should co-sign the controlled drugs and sign the manifest. A copy of the manifest was left at the facility and another copy was sent back to the pharmacy. She confirmed that at the time Resident #20's medication went missing, he staff on duty had not followed this policy. In an interview on 01/20/22 at 4:20 PM, the DON stated on 11/30/21, he was informed that Resident #20's fentanyl patches were missing. After contacting the pharmacy, he was informed that the medications were delivered on 11/28/21. He stated after an extensive search, the medication could not be located. When asked about the process for receiving medication from the pharmacy, he confirmed that on 11/28/21, the nurses on duty did not follow the policy. He added that education was provided to nursing about medication administration and controlled substance reconciliation, and that he conducted audits for controlled substances and missing medication. The DON could not provide a copy of the medication audit he stated he completed. He was asked about Resident #20's missed doses of fentanyl patches on 1/11/22 and 1/17/22. He confirmed that the medication was not administered and stated he would follow up with the nurses involved, as the medication had been available in the EDK. He also confirmed that the physician was not informed of the missed doses. A review of the facility's policy and procedure titled Inventory Control of Controlled substances, effective 12/01/07 and last revised on 01/01/13, revealed the following: The facility should maintain a separate, individual controlled substance record on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substance Declining Inventory Record. This record should include: Resident name: Prescription number, Medication name, strength, dosage form dosage: and Total quantity received by the facility. (Copy obtained) 2. A review of Resident #206's medical record revealed an admission date of 1/17/2022. Her primary medical diagnosis was novel coronavirus (COVID-19) with a secondary diagnosis of sepsis. A review of the admission Nursing Assessment, dated 1/17/2022, revealed Resident #206 was alert and oriented to person, place, and time. She required assistance from staff for activities of daily living (ADLs). On 1/18/2022 at 2:25 p.m., an interview was conducted with Resident #206. She explained that she had not received her intravenous (IV) antibiotics since being admitted to the facility. A review of Resident #206's physician's orders revealed an order dated 1/17/2022 for Zosyn 4.5 grams (gm) to be given intravenously every 8 hours for a diagnosis of sepsis. The first dose was scheduled to be given on 1/17/2022 at 9:00 p.m. (Photographic Evidence Obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 11 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #206's medication administration records (MARs) for January 2022, revealed the Zosyn (antibiotic) was not administered on 1/17/2022 9:00 p.m., on 1/18/2022 6:00 a.m., on 1/18/2022 2:00 p.m., on 1/18/2022 10:00 p.m., or on 1/19/2022 6:00 a.m. (Photographic Evidence Obtained) A review of the nursing progress notes revealed entries dated 1/17/2022 9:44 p.m. and 1/18/2022 at 5:59 a.m. which indicated the facility was awaiting delivery of the Zosyn from the pharmacy. The notes did not indicate that the resident's physician had been notified off the errors. (Photographic Evidence Obtained) On 1/20/2022 at 1:25 p.m., an interview was conducted with the Unit Manager. She confirmed that Resident #206 was ordered to receive Zosyn three times daily for a diagnosis of sepsis. The Unit Manager confirmed that the resident had not received any doses of Zosyn since admission on [DATE]. The Unit Manager explained that she called the pharmacy on 1/19/2022 and asked them to send the medication after she had been made aware the medication was not available. She further explained that she had to contact the pharmacy again on 1/20/2022 and ask again for the medication to be sent and that when she called the pharmacy on 1/20/2022, the pharmacy informed her that they did not have an order for the medication. When asked about the facility's processes for medications that were not available, the Unit Manager explained that the physician should be notified that the medication was not available for administration. She was not sure whether any of the assigned nurses on 1/17/2022, 1/18/2022, or 1/19/2022 had contacted the physician. She stated she notified the Infectious Diseases practitioner and new orders were obtained to extend the resident's dosages and obtain labs to ensure no harm had come to the resident. According to the Centers for Disease Control at https://www.cdc.gov/sepsis/what-is-sepsis.html (accessed on 1/21/2022 at 3:05 p.m.), Sepsis is the body's extreme response to an infection. It is a life-threatening emergency and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. According to WebMD at https://www.webmd.com/drugs/2/drug-16577/zosyn-intravenous/details (accessed on 1/21/2022 at 3:15 p.m), Zosyn is a penicillin antibiotic that works by stopping the growth of bacteria. 3. A review of Resident #204's medical record revealed a readmission date of 1/12/2022. His primary diagnosis was urinary tract infection. Resident #204 required extensive to total assistance by staff for activities of daily living. A review of the resident's physician's orders revealed an order for vancomycin 750 milligrams (mg) to be given intravenously twice daily for the treatment of a urinary tract infection. (Photographic Evidence Obtained) A review of the medication administration records (MARs) for January 2022, revealed the vancomycin had not been administered on 1/13/2022 at 9:00 a.m., on 1/16/2022 at 9:00 a.m., on 1/17/2022 at 9:00 a.m., or on 1/19/2022 at 9:00 a.m. (Photographic Evidence Obtained) A review of Resident #204's nursing progress notes revealed no entries indicating the physician had been notified of the missed doses of vancomycin. On 1/21/2022 at 1:25 p.m., during an interview with the Unit Manager, she reviewed Resident #204's medication administration records and confirmed that the resident's vancomycin had not been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 12 of 13 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 105653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered on 1/13/2022 at 9:00 a.m., on 1/16/2022 at 9:00 a.m., on 1/17/2022 at 9:00 a.m., or on 1/19/2022 at 9:00 a.m. 4. A review of Resident #201's medical record, revealed an admission date of 1/17/2022. The resident's primary medical diagnosis was COVID-19. The admission Nursing Assessment, dated 1/17/2022, indicated the resident was alert and oriented to person, place, and time. Resident #201 required assistance by staff for activities of daily living. A review of Resident #201's physician's orders revealed an order for Levaquin 750 mg to be given once daily for a respiratory infection. The first dose was due to be given on 1/18/2022 at 9:00 a.m. (Photographic Evidence Obtained) A review of the medication administration record revealed that the 1/18/2022 9:00 a.m. dose had not been administered. The reason was marked as See Nurse's Notes. (Photographic Evidence Obtained) A review of Resident #201's nurses notes revealed an entry dated 1/18/2022 at 10:03 a.m. which indicated the Levaquin was not administered, but it did not specify a reason the medication was not administered. On 1/21/2022 at 1:25 p.m., during an interview with the Unit Manager, she reviewed Resident #201's medication administration records and confirmed that the resident's Levaquin had not been administered on 1/18/2022 at 9:00 a.m. According to WebMD at https://www.webmd.com/drugs/2/drug-14492-8235/levaquin-oral/levofloxacin-oral/details (accessed 1/21/2022 at 3:20 p.m.), Levaquin is an antibiotic medication used to treat bacterial infections. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 13 of 13