Inspection·November 9, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to maintain cleanliness and good repair of the walls in the chemical storage closet, kitchen floors, and baseboards. Live roaches were observed crawling on plastic drink lids and packages of bread. The facility failed to seal and date mark two open bundles of bread on the bread rack and failed to clean one of two microwaves located in the north unit nourishment room. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 11/06/23 at 7:25 a.m. During the tour, the kitchen floor tile was covered with food substance and grime. Floor tiles were cracked around the cook and prep area, in and around the utility room, and between the drink and ice machine area. Baseboards were cracked, filled with debris, and pulled away from the wall in the cook and prep area, the dish machine room, the utility room, and behind the drink machine next to the door entrance from the dining room. A utility cart holding plastic cups and lids had dark residue around the bottom shelf and a live roach crawling on the plastic container of lids. The wall panel was pulled away from the wall in the dish machine room and utility room. (Photographic evidence obtained) No date markings were observed on two open bundles of bread located on the bread rack in the dry storage room. A live insect was observed crawling in one open bundle of bread, which was provided to the Certified Dietary Manager (CDM) to discard. Another observation was made again on 11/07/2023 at 9:04 a.m. During this time, new observations of two open bundles of bread were on the bread rack in the dry storage room with no date marking. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 11/8/23 at 11:30 a.m. New observations of black substances of unknown origin were spread over the walls and door in the chemical storage closet located in the dish room next to the utility room. The chemical storage closet floor tile was filled with loose dirt and debris. Used standing mop water was found sitting in a mop bucket in the utility room. Baseboards were cracked, filled with debris, and were pulled away from wall behind the drink machine next to the door entrance from the dining room and cracked and stained floor tiles were observed in the nourishment room on the north unit. (Photographic evidence obtained) On 11/08/23 at 11:45 a.m., the microwave in one of two nourishment rooms located on the north unit was observed to have food debris and black substances of unknown origin resembling biological growth (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105653 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 11/09/2023 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)