Inspection·August 19, 2021

F 0658 Level of Harm - Minimal harm or potential for actual harm resident and document the evaluation in the medical record. It also directed the nurse to contact the resident's physician. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 2 of 9 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 105663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Green Cove Springs 803 Oak St Green Cove Springs, FL 32043 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to provide assistance with showers for one (Resident #16) of three residents reviewed for activities of daily living (ADLs), from a total of 34 residents in the sample. Residents Affected - Few The findings include: A review of Resident #16's medical record revealed an admission date of 7/7/2016. Medical diagnoses included cerebral infarction with spastic hemiplegia affecting left nondominant side. A Minimum Data Set (MDS) assessment, dated 6/2/2021, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. The assessment did not identify any resident behaviors or rejection of care. The resident was documented as totally dependent for bathing and required extensive assistance with personal hygiene. On 8/19/2021 at 10:45 AM, an interview was conducted with Resident #16. He was lying in his bed. His hair was greasy and matted. He explained that he hadn't received a shower in over a month. He stated he wasn't aware of his shower schedule and that any time he asked for a shower, the staff told him they were too busy. A review of the resident's comprehensive care plans revealed a focus area for ADL self-care performance deficit. Interventions identified the resident as being totally dependent on one staff member to provide a bath/shower as necessary. Another intervention directed staff to provide bathing and showering per resident requested schedule and routine. (Photographic Evidence Obtained) A review of the care flow records for Resident #16 revealed no documented showers between 7/20/2021 and 8/17/2021. (Photographic Evidence Obtained) On 8/19/2021 at 10:55 AM, an interview was conducted with Certified Nursing Assistant (CNA) D. She confirmed that she was assigned to Resident #16, but that she was employed by an agency and was not familiar with his care. She was asked how she obtained information unique to each resident in order to provide needed care. She explained that the agency staff had access to the kiosk. She was asked to locate the shower schedule for Resident #16 but she was unable to do that. On 8/19/2021 at 11:01 AM, an interview was conducted with Licensed Practical Nurse (LPN) B. She confirmed that she was assigned to Resident #16. She was asked whether Resident #16 required assistance with showers and whether he received them regularly. The nurse stated, I don't think he refuses them. I don't know. I've never seen him get one, though. When asked how she ensured her assigned residents received showers, the nurse stated, Well, we are supposed to look at the CNAs' documentation. The nurse was asked to review Resident #16's care flow records. She confirmed that no showers had been documented for the most recent 30 days. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 3 of 9 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 105663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Green Cove Springs 803 Oak St Green Cove Springs, FL 32043 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 reviews, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Residents #21 & #81) of three residents reviewed for pressure ulcers, from a total of 34 sampled residents. Residents Affected - Few The findings include: 1. A review of Resident #21's medical record revealed a [AGE] year-old male admitted on [DATE] with diagnoses including hemiplegia, colostomy and chronic obstructive pulmonary disease (COPD). Resident #21 required extensive assistance from one person for bed mobility, transfers, dressing and toileting. The most recent quarterly Minimal Data Set (MDS) assessment, dated 6/8/2021, revealed that Resident #21 had multiple stage 4 pressure ulcers and was receiving wound care. A review of an 11/6/2020 physician's order revealed that weekly skin sweeps were to be performed on Fridays during the day shift. A 4/23/2021 physician's order was written to apply skin protectant to the healed sacral wound site and cover it with a dry dressing every evening. An 8/17/2021 physician's order indicated the left and right buttock wounds were to be cleansed with normal saline and patted dry. Calcium alginate was to be applied and covered with a dry dressing every Monday, Wednesday, and Friday. A review of the Wound Physicians Group notes revealed that on 8/2/2021, the physician identified an unstageable deep tissue injury (DTI) of the right posterior upper thigh with orders to apply a hydrocolloid dressing three times per week for 30 days. A review of the Wound Physicians Group note dated 8/16/2021, revealed that Resident #21's visit was rescheduled. A review of the Care Plan dated 6/10/2021, revealed a focus area for pressure injuries with interventions that included administering treatments as ordered and to monitor for effectiveness. A review of Resident #21's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2021, revealed that the application of skin protectant to the healed sacral wound site was not documented as having been completed on 8/2, 8/4, 8/7, 8/11, or 8/17/21. The treatment for the left and right buttock wounds revealed it had initially been ordered daily, but was not documented as having been done on 8/2, 8/4, 8/7, or 8/11/21. The MAR/TAR had no entry for the treatment of the DTI at the right posterior upper thigh (ordered by the Wound Physicians Group physician on 8/2/2021). There was no indication that this treatment was being completed by nursing. A review of the facility's policy and procedure for Pressure Injury Records, document WC-130 (revision date 4/1/2017) revealed, To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. One site will be recorded per page. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 4 of 9 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 105663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Green Cove Springs 803 Oak St Green Cove Springs, FL 32043 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/18/2021 at 10:19 AM, an interview was conducted with the Director of Nursing (DON). When asked who performed resident wound care, she stated the facility used a wound treatment nurse, but when the wound treatment nurse was not available, the assigned nurse was responsible for providing and documenting the treatments. On 8/18/2021 at 11:18 AM, an interview was conducted with the Corporate Nurse Consultant (CNC). The CNC confirmed that the required documentation of Resident #21's pressure injury had not been completed since June of 2021. On 8/18/2021 at 2:34 PM, Licensed Practical Nurse (LPN) A was observed performing wound care for Resident #21. The DTI of the right posterior thigh was not treated with a hydrocolloid dressing. LPN A used calcium alginate on the wound site. On 8/19/2021 at 5:33 PM, an interview was conducted with the DON regarding the process of transcribing the Wound Physicians Group orders. The DON stated the wound treeatment nurse was to download the Wound Physicians Group notes, review them and transcribe any new orders. She further stated at this time the wound treatment nurse did not have access to download the Wound Physicians Group notes. The DON stated the notes and orders had not been downloaded, so the orders were not being transcribed. 2. A review of Resident #81's medical record revealed an admission date of 9/5/2018. Medical diagnoses included stage four pressure ulcer of the sacral region, dementia, and unspecified psychosis. A five-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 points, indicating severe cognitive impairment. The assessment indicated the resident required extensive assistance of two or more persons for bed mobility. She had an indwelling urinary catheter and was incontinent of bowel. The resident had a stage 4 pressure injury. A review of the resident's comprehensive care plans revealed a focus area for Activities of Daily Living (ADL)/Self-Care Deficit. The intervention for bed mobility indicated the resident required the extensive assistance of 1-2 staff to turn and reposition in bed as necessary. A second focus area was identified for the resident's sacral pressure injury. Interventions included assist to turn and reposition and pressure reducing devices as ordered. A review of the resident's physician's orders revealed an order dated 6/7/2021, which directed staff to provide Resident #81 with a positioning wedge to place the resident in side-lying position for pressure relief of the buttocks. The order read, Alternate from side-lying to supine (on her back) every 2 hours. Ensure pt (patient) is not in side-lying (position) during meals. On 8/16/2021 at 10:15 AM, Resident # 81 was observed lying in bed on her back. No positioning pillows or devices were in place. On 8/16/2021 at 11:24 AM, Resident # 81 was observed lying in bed on herb back. No positioning pillows or devices were in place. On 8/16/2021 at 1:30 PM, Resident # 81 was observed lying in bed on her back. No positioning pillows or devices were in place. On 8/18/2021 at 10:13 AM, Resident # 81 was observed lying in bed on her back with the head of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 5 of 9 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 105663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Green Cove Springs 803 Oak St Green Cove Springs, FL 32043 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 0686 bed elevated to above 35 degrees. No positioning pillows or devices were in place. Level of Harm - Minimal harm or potential for actual harm On 8/18/2021 at 2:06 PM, Resident # 81 was observed lying in bed on her back. She was repeatedly yelling out, Grandma, help me. A purple positioning wedge was observed sitting on the floor between the resident's dresser and armoire. Residents Affected - Few On 8/18/2021 at 4:48 PM, Resident # 81 was observed lying in bed on her back. Her eyes were closed. A purple positioning wedge was positioned under the resident's knees. Her heels were touching the mattress. On 8/19/2021 at 10:46 AM, an interview was conducted with Certified Nursing Assistant E. She confirmed that she was caring for Resident #81. She explained that the resident had a big wound on her bottom. When asked about pressure injury interventions, she stated, We turn her every two hours. She stated the resident was turned when she came in at 7:00 AM and she had just placed the resident on her back. A review of the resident's physician's orders revealed an order dated 6/7/2021, which directed staff to provide Resident #81 with a positioning wedge to place the resident in side-lying position for pressure relief of the buttocks. The order read, Alternate from side-lying to supine (on her back) every 2 hours. Ensure pt (patient) is not in side-lying (position) during meals. On 8/18/2021 at 3:42 PM, an interview was conducted with the Director of Nursing (DON). She was asked what her expectation was for turning and repositioning a resident with a pressure injury. She stated, They should be turned and repositioned frequently and as needed. She further explained that the facility did not have a specific time frame for turning and repositioning. When asked whether a resident with a stage four pressure injury would need to be turned and repositioned at least every two hours, she replied yes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 6 of 9 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 105663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Green Cove Springs 803 Oak St Green Cove Springs, FL 32043 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to provide effective pain management by 1) Failing to administer pain medication prior to treatment of a stage four pressure injury, and 2) Failing to identify non-verbal indicators of pain (and failing to intervene appropriately) during treatment of a stage four pressure ulcer for one (Resident # 81) of two residents reviewed for pain management from a total of 34 residents in the sample. Residents Affected - Few The findings include: A review of Resident # 81's the medical record revealed an admission date of 9/5/2018. Her medical diagnoses included stage four pressure ulcer of the sacral region, dementia, and unspecified psychosis. A five-day Minimum Data Set (MDS) assessment, dated 7/29/2021, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 points, indicating severe cognitive impairment. The assessment indicated the resident required extensive assistance of two or more persons for bed mobility, and that she had an unhealed Stage 4 pressure injury. A review of the resident's comprehensive care plans revealed a focus area for a pressure injury to her sacrum. An intervention on the care plan read, Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Continued review of the care plans revealed a focus area for the potential for pain. Interventions included, Administer analgesia as per orders. Give 1/2 hour before treatments. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. (Photographic Evidence Obtained) A review of the resident's physican's orders revealed an order dated 4/8/2021 for acetaminophen 650 milligrams every four hours as needed for pain. (Photographic Evidence Obtained) A review of the resident's medication administration records (MARs) for August 2021, revealed no documented administration of the acetaminophen. (Photographic Evidence Obtained) On 08/19/2021 at 12:45 PM, an observation was made of wound care provided to Resident #81. The wound care was provided by the Unit Manager (UM). Upon entering the room, the resident was positioned on her back. Certified Nursing Assistant E assisted the resident to turn on her left side. An adhesive island dressing was observed on the resident's sacrum. As the UM began removing the adhesive dressing from the resident's skin, the resident furrowed her brow and repeatedly stated, Grandma, help me. The behaviors continued as the UM continued removing the dressing. Once the adhesive dressing was removed from resident's skin, the UM sprayed a wound cleanser onto gauze sponges and began to clean the stage IV pressure injury with the gauze sponges. As the sponges made contact with the wound edges and wound bed, the resident again furrowed her brow and threw her right leg over the side of the bed. She then began repeatedly kicking the bed frame with the heel of her right foot while repeatedly stating, Ouch, ouch, ouch. The UM finished cleaning the wound and then began packing the wound with calcium alginate. As he was placing the calcium alginate in the wound, the resident began to kick the bed frame with the heel of her right foot repeatedly until the UM finished. The wound was then covered and the resident was positioned on her back. On 8/19/2021 at 2:01 PM, an interview was conducted with the Director of Nursing (DON) regarding her expectations for the management of pain in residents with pressure injuries. She stated, My goal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 7 of 9 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 105663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Green Cove Springs 803 Oak St Green Cove Springs, FL 32043 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is to keep them pain free. She explained that she would expect staff to offer pain medication prior to wound care or treatments. Concerns regarding Resident #81's pain were discussed with the DON during the interview. On 8/19/2021 at approximately 6:00 PM, the DON provided a copy of a physician's order for pain medication to be given around the clock. She also provided a copy of a nursing progress note regarding communication to the pain management physician and the new order for pain medication. However, the order and the progress note referenced a different resident and were not written for Resident #81. (Photographic Evidence Obtained) The facility's pain management policy titled, Pain Management Guideline was reviewed. The policy was revised on 8/28/2017. The policy indicated it's purpose was to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The process directed staff to evaluate pain using either the resident's self report of pain or by using the resident's non-verbal clinical indicators. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 8 of 9 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 105663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Green Cove Springs 803 Oak St Green Cove Springs, FL 32043 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that the resident's medical record included documentation that indicated, at a minimum, the following: That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal for two (Residents #94 and #12) of five residents reviewed from a total of 34 residents in the sample. Residents Affected - Few The findings include: A review of Resident #94's medical record revealed that the resident signed a consent form to receive the influenza immunization on 12/7/2020. No documentation was found in the medical record to support evidence of administration of the immunization. A review of Resident #12's medical record revealed that the resident signed a consent form to receive the pneumococcal immunization on 9/28/2020. No documentation was found in the medical record to support evidence of administration of the immunization. On 8/19/2021 at 4:13 PM, an interview was conducted with the Director of Nursing (DON). She confirmed that she was unable to find evidence verifying that the immunizations were administered to these two residents. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 9 of 9