Health 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 Page 1 of 2 105653 105653 07/24/2025 Aviata at Orange Park 1215 Kingsley Ave Orange Park, FL 32073

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few table, and started screaming at me, calling me a cripple. I told her I was recording her when I really wasn't. That's when she began trying to snatch my phone from me. There was a struggle. She hit me on the arm. She scratched me on my stomach and my hand. When she took my phone, she looked through it looking for the recording I said I took of her. She then put my phone on the dresser under the TV and said now I want to see your crippled ass go get it. I called 911 from the phone I play games on. (Photographic evidence obtained)During an interview conducted on 7/24/2025 at 9:45 AM with Resident #1's roommate, he was asked if he witnessed the incident. He said that he only heard what was going on because the curtain was between them but stated that it happened just as Resident #1 said.During an interview conducted on 7/24/2025 at 9:50 AM with Resident #2, she stated, Everybody here is very good. No problems with anyone. Nobody has complained about any of the staff. I heard him screaming at the CNA, he was saying that she hit him. He called her all kinds of names.During an interview conducted on 7/24/2025 at 9:55 AM with Assistant Director of Nursing (ADON), she said, The DON called at 7:30. The CNA had left and didn't tell anyone that anything had happened.Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation, issue date of 11/30/2014, last approval date of 11/16/2022, reads, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees at the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. 105653 Page 2 of 2