Inspection·July 24, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on record review and interviews, the facility failed to protect the resident's rights to be free from physical abuse for one (Resident #1) of three residents reviewed for abuse. The findings include:A review of the medical record for Resident #1 revealed an admission date of 8/16/2021. His medical diagnoses included quadriplegia; major depressive disorder; chronic pain; anemia; neuromuscular dysfunction bladder; polyneuropathy; and diabetes mellitus. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #1 required assistance of one staff member for most activities of daily living.A review of the nursing progress notes for Resident #1 revealed an entry dated 7/23/2025 08:32 - Between 0500-0545 this writer was working down 300 hall passing medication when police entered building asking who's the nurse and CNA for the resident, I had no idea what was going on at the time. CNA previously came down hall and told me she was gone for the shift and that she leaves early because of school. I didn't think anything of it because staff stated she always leaves early and had prior arrangements. Resident called 911 and reported abuse. Full body assessment was completed once notified by police and resident. Upon assessment there is bright red abrasions on right upper quadrant, right forearm, and right hand. Patient stated he's not in pain. VS are WNL- Temp: 98.2 BP 130/80 RR 18 HR 96 SPOs 98%. DON, administrator, and doctor notified of incident. Family made aware. A review of the Physician Progress Note for Resident #1 dated 7/23/2025 15:31- APRN (Advanced Practice Registered Nurse) was notified by DON that resident made allegations of physical abuse in regard to a nurse. Resident was examined sleeping in bed in no acute distress. APRN woke resident. Resident denies pain. Resident showed APRN his right hand. Erythema, dry flaking skin, and five small open abrasions were noted between resident's lateral wrist and lateral little finger MCP joint. No bleeding was noted. No scabbing noted. Additionally, on residence lateral right lower quadrant of his abdomen were six to seven straight lined excoriations. No open areas, and no bleeding. Resident has bilateral upper extremity contractures, including within his fingers. He is able to move his bilateral upper extremities with some movement in his fingers. Complete movement of fingers was not appreciated by APRN.During an interview conducted on 7/24/2025 at 9:20 AM with the Administrator, she said, I received a phone call from the DON that police was in the facility, that a resident had stated that he was physically assaulted because he asked for ice. The CNA has been suspended pending investigation.During an interview conducted on 7/24/2025 with Director of Nursing (DON), she said, When the nurse called the CNA, she said that she took the phone and put it on the dresser. That he used another phone to call 911. There were abrasions to the abdomen and scratches to the right hand. I had the nurse do a head-to-toe assessment.During an interview conducted on 7/24/2025 at 9:35 AM with Resident #1, he stated, It started during the night. That CNA always had a snotty attitude. I asked for a cup of ice. She told me the ice machine was broken, I told her the other CNAs go to the other side to get it, she said she wasn't. I told her I would write a grievance on her, and she sat the urinal unemptied back on my (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 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 07/24/2025 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)