Inspection·November 20, 2025

F 0803 TID. The resident's meal ticket documented regular, 3oz. Level of Harm - Minimal harm or potential for actual harm A review of Resident #67's nutritional assessment, dated 10/21/2025, revealed regular, regular texture, thin liquids, bedtime (HS) snack. The resident's meal ticket documented regular, 3oz. Residents Affected - Few During an interview conducted with the Registered Dietitian (RD) on 11/20/2025 at 11:31 AM, she confirmed that she worked 16 hours per week (Tuesdays and Fridays) to provide clinical services to the facility. At 3:29 PM on this date, the RD was asked to explain the difference between large protein, double protein, and regular protein. She stated she did not think the facility had double protein or it would be a larger portion of protein; 1/2 servings versus 2 servings. The regular would be 1 serving at 3oz., large would be 1-1/2 servings at 4 1/2 oz., and the double would be 2 servings at 6 oz. During an interview with the Food Service Director on 11/20/2025 at 11:41 AM, she was asked if a resident's diet order was for double portions, what are they served? She stated, It is specified if it is double protein or double portion. Double protein and large portion is more of each item. A review of the facility's policy titled Therapeutic Diets (Effective 5/2014, Revised 10/2022), revealed: Policy Statement: All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Procedures: . 3. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. (Copy Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 2 of 4 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 11/20/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, and facility policy and procedure review, the facility failed to follow proper food safety sanitation standards and food handling practices to prevent injury to residents and the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to serve dinnerware and trays in clean and good condition, clean food debris stuck on and around the meat slicer blade, and clean one of two microwaves located in the 300-600 unit nourishment room. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure that compromises residents' well-being.The findings include:A tour of the kitchen was conducted on 11/19/2025 at 11:00 AM. During the tour, cracked plates, cracked bowls, and meal trays with rusted, cracked edges were observed on the tray line and dish rack located across from the reach-in refrigerator. It was also observed that the meat slicer, located on the bottom shelf of the prep table, was filled with food debris on and around the blade. One of two microwaves in the nourishment room located on the 300-600 unit, was filled with food debris stuck on and around the inside of the microwave. (Photographic evidence obtained)An interview was conducted on 11/20/2025 at 10:31 AM with [NAME] A, who reported that all kitchen staff were responsible for cleaning kitchen equipment after each use. Dietary Aides were assigned to washing dishes and watching for broken and rusted dinnerware and utensils. The Dietary Manager was responsible for cleaning the microwave ovens in the nourishment rooms.An interview was conducted on 11/20/2025 at 10:48 AM with Dietary Aide B, who reported that all staff/the [NAME] were responsible for cleaning the meat slicer daily. Dietary Aides washed dishes using the dish machine and were responsible for ensuring dinnerware and utensils were clean and in good condition. Nursing was responsible for cleaning the microwave ovens in the nourishment rooms.An interview was conducted on 11/20/2025 at 11:03 AM with Dietary Aide C who reported cooks were responsible for cleaning the meat slicer after each use. Dietary Aides washed dishes using the dish machine and were responsible for ensuring dinnerware and utensils were clean and in good condition. Dietary Aide C reported that she was unsure of who cleaned the microwave ovens in the nourishment rooms, and stated Dietary was not responsible for that task.An interview was conducted on 11/20/2025 at 11:41 AM with the Food Service Director who reported that Dietary Aides were responsible for running the dish machine and reporting any concerns with dinnerware and utensils to the Certified Dietary Manager/Food Service Director. The cooks were responsible for cleaning kitchen and food service equipment such as the meat slicer after each use. The Food Service Director was unsure of who was responsible for cleaning the microwave ovens in the nourishment rooms.A review of the facility's policy and procedure titled Environment (Effective 5/2014, Revised 6/2025), revealed:Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.Procedures:. 3. All food contact surfaces will be cleaned and sanitized after each use. (Copy obtained)According to the FDA Food Code (2022) at https://www.fda.gov/media/164194/download, (Accessed on 11/25/2025), revealed:Chapter 4. Equipment, Utensils, and Linens 4-6 Cleaning of Equipment and Utensils, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Cleanability; 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be: (1) Smooth; (2) Free of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 3 of 4 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 11/20/2025 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)

F 0812 breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; and (3) Free of sharp internal angles, corners, and crevices. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105653 If continuation sheet Page 4 of 4