Health inspection·March 30, 2023

F 0558 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 2 of 23 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 03/30/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of resident records, the facility failed to review and revise the plan of care to reflect the discontinuation of a gastrostomy tube (G-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and fluids) after the resident resumed food and medications by mouth for one (Resident #46) of three residents reviewed for g-tubes from a total of 36 residents in the sample. The findings include: An interview was conducted with Resident #46 on 03/29/23 at 10:10 AM. He was speaking very loudly and threatened that he was about to rip his g-tube out. Resident #46 lifted his shirt to show the insertion site and the tube. He reported he was eating by mouth and insisted the tube was supposed to have been removed. A record review for Resident #46 found he was admitted to the facility on [DATE]. He had a 5-day Minimum Data Set (MDS) assessment with an assessment reference date of 2/8/23, that noted he had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating that he was cognitively intact and able to make daily decisions. He was coded as being totally dependent for eating. His primary medical conditions included stroke, dysphagia (difficulty swallowing) following cerebral infarction (stroke), non-Alzheimer's dementia, malnutrition (protein, calorie), and adult failure to thrive. Resident #47 had one surgery involving the gasgtrointestinal tract prior to admission. He was assessed with no swallowing difficulty and no weight loss, and had a feeding tube. Resident #46 was care planned on 2/15/23 for requiring tube feedings related to dysphagia following cerebral infarction. The goal was to remain free of signs/symptoms or complications related to tube feedings through the next review date. Interventions include, but were not limited to, head of bed elevated 45 degrees during and thirty minutes after tube feeding; check for placement and gastric contents/residual volume as ordered; provide local care to g-tube site as ordered and monitor for signs of infection; Registered Dietician (RD) to evaluate quartery and as needed . and make recommendations for changes to tube feeding as needed. Resident #46 had a physician's order for nothing by mouth (NPO) which was started on 1/28/23 but discontinued 2/19/23, as was an order for medications through his PEG (pericutaneous endoscopic gastrostomy) tube. He also had an active diet change order for a regular diet, dysphagia advanced texture and nectar thickened fluids and an order that he receive 1:1 supervision with all meals. Both orders were written 2/19/23. (Photographic copy obtained) Resident #46 also had the following physician's orders: Jevity (a liquid food for administration via g-tube) 1.5 calories, 320 cc (cubic centimeters) via g-tube every 6 hours per bolus. (Started 1/31/2023 and discontinued 3/7/2023). GI (gastrointestinal) consultation to evaluate and remove PEG tube due to no longer being in use (3/14/23). Zyprexa (medication used to treat psychosis) 5 milligrams (mg), give 1 tablet via DH-Tube (Dobhoff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 3 of 23 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 03/30/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm tube, a type of nasogastric tube inserted into the nostril and down the esophagus into the stomach) at bedtime for paranoia (started 1/29/23 ). Depakene Oral Solution (used for seizure disorders) 250 mg/milliliters, give 5 ml via DH tube two times day for stroke as ordered (started 3/1/2023 with no end date). Residents Affected - Few Tramadol (pain medication) oral tab 50 mg: Give 0.5 mg by mouth every 8 hours as needed for pain (start 3/10/2023). (Photographic copy obtained) Nursing progress notes revealed that on 3/7/23, nursing staff spoke with the Registered Dietitian (RD) regarding Resident #46's declining/refusing gastric feedings. The resident was consuming 100% plus of all meals daily. The RD instructed the resident/staff that he should consume food by small teaspoons and consume foods slowly. Gastric feedings were discontinued. An interview was conducted with the RD on 3/30/23 at 1:13 PM. She explained that Resident #46 recently had his g-tube placed for altered mental status and stroke. The g-tube was to remain in place until speech therapy could see him and upgrade his diet, which was done as of 2/19/23. Resident #46 was now eating by mouth. The APRN (Advanced Practice Registered Nurse) was interviewed on 3/30/23 at 2:07 PM. She confirmed that she wrote an order for the g-tube to be removed, since Resident #46's diet was upgraded, and the tube could come out. She stated the resident was taking all food and medications by mouth. When told his physician's orders and MARs reflected three different routes of administration for medications (by mouth, through a DH tube and through the g-tube), she said, No, that should be removed. His is taking everything by mouth. She had no explanation why there were orders for medication through a DH-Tube and confirmed he did not have one. An unidentified nurse behind the desk overheard the conversation and confirmed when an order for medications via g-tube was discontinued, all accompanying orders should be revised as well to reflect the resident's status. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 4 of 23 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 03/30/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, a review of resident records, and the facility's policy and procedure for Care of Nails, the facility failed to provide appropriate grooming, personal hygiene and oral care to three (Residents #88, #94 and #20) of six residents reviewed for activities of daily living (ADLs), from a total of 36 residents in the sample. Residents Affected - Few The findings include: 1. An observation of Resident #88 was made on 3/27/23 at 11:03 AM. He was in his bed and his feet were protruding from under the bedding. His toenails were long, jagged and thickened. The nails on both great toes were approximately an inch long and at least one of the nails on his smaller toes was beginning to curl under. Resident #88 confirmed his nails needed care. He said he was supposed to be on the list for the podiatrist. An observation on 3/28/23 at 9:41 AM, found Resident #88 in bed with his feet protruding from under the blanket. His toenails were in the same condition as the previous day's observation. He still did not know if the podiatrist would be seeing him but stated he would like to be seen. (Photographic evidence obtained with verbal consent at this time) Certified Nursing Assistant (CNA) F was interviewed on 3/28/23 at 10:24 AM. She stated Resident #88 could perform a lot of his ADLs with set up and some help. She provided no nail care to residents. Restorative provided all nail care unless the resident was diabetic, then the nurse did it. In an interview with Licensed Practical Nurse (LPN) I on 3/28/23 at 1:53 PM, she stated the podiatrist came to the facility once a week. The residents had to be put on the list. There was a purple folder on the west wing that contained that list. When the podiatrist came in he went to the list, then he placed a star next to the residents' names when he saw them. LPN I stated she was not sure if Resident #88 was on the list. Resident #88 was interviewed on 3/29/23 at 10:18 AM. He was in bed with his toenails in the same condition as they had been on 3/27 and 3/28/23. He said he still didn't know if he would be seeing a podiatrist. They were supposed to put him on the list. The Social Services Director (SSD) was interviewed on 3/29/23 at 2:30 PM. She stated residents were not necessarily signed up for podiatry visits unless the resident or family requested it or if nursing staff identified a need. The staff put the resident's name in the purple folder and the podiatrist saw them if their name was on the list. That was their system/process. On 3/30/23 at 10:15 AM, the SSD was asked for any podiatry visits for Resident #88, since a brief review of his record at this time found none. She stated she would contact the podiatrist and have them sent over. A review of the podiatrist's folder found Resident #88's name was not on the list and the enclosed list was blank. Resident #88 was interviewed on 3/30/23 at 10:20 AM. He said he told the nurses to put him on the list for podiatry. He hoped to be seen soon because he was supposed to start working with therapy on standing up and he couldn't put his tennies on with his toenails like this. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 5 of 23 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 03/30/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA A was interviewed on 3/30/23 at 10:21 AM. She stated CNAs were supposed to care for the residents' nails. The doctor had to do the toenails, but he never does. She stopped reporting the need to nursing because nothing gets done. When told of the condition of Resident #88's toenails, CNA A said, It doesn't matter if it is reported, the podiatrist never sees the patients on this hall. She said she had only seen him here maybe once. CNA A said the nurse was supposed to notify the podiatrist when a resident needed services, but didn't, so she didn't report the need anymore. The Director of Clinical Services (DCS) was interviewed on 3/30/23 at 11:19 AM. She stated care staff, the resident or the family were to report the residents' need for podiatry care. Staff were supposed to write the resident's name in the book. She was shown the photograph of Resident #88's toenails and agreed they were in need of podiatry care. She picked up her telephone, called another staff member to request Resident #88 be seen explaining Resident #88's nails look horrible. The DCS had no explanation for why Resident #88 was told he would be put on the list but was not. She said, There is no way you can see that (his toenails) and not say something. A record review for Resident #88 found he was admitted to the facility on [DATE]. He had diagnoses including diabetes mellitus and morbid obesity. He had a quarterly Minimum Data Set (MDS) assessment dated [DATE], that noted a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, reflecting that he was cognitively intact and independent with daily decision making. He required extensive assistance with personal hygiene. Resident #88 had a physician's order dated 8/9/22 for podiatry as needed. (Photographic copy obtained) A second search of the records found no podiatry visits. On 3/30/23 at 4:03 PM, Resident #88's podiatry notes were received from his office. A review found there was only one documented visit on 2/21/22. The report was illegible. There were no subsequent visits documented. 2. Resident #94 was observed in the east wing day room on 3/27/23 at 11:50 AM. He was sitting at a table working on a word search puzzle. Both of his hands were observed with a dark brown substance resembling feces underneath his fingernails. The nails appeared to be stained dark yellow/orange in color and coated with the matter, as were his fingers on both hands. Resident #94 had no explanation for what was on his hands and under his nails. On 3/27/23 at 12:00 PM, Resident #94 was observed in the same room feeding himself lunch. His nails and hands were in the same condition and it did not appear as though he had been assisted to clean them before eating. On 3/28/23 at 9:28 AM, Resident # 94 was again observed in the east wing day room drinking some orange colored juice. His fingernails were still impacted with the dark brown substance underneath, but the substance on his fingers was now mostly removed. Resident #94 stated he did not know if staff provided his nail care and would not answer when asked what was under his nails. Resident #94 stated he received bed baths but not showers. With his verbal consent his hands and nails were photographed. (Photographic evidence obtained) A record review for Resident #94 found he was admitted to the facility on [DATE] and was his own responsible party. He had an admission MDS assessment dated [DATE], which assessed him with modified independence for daily decision making. No refusal of care was noted. Resident #94 required extensive assistance with toilet use and hygiene and was always incontinent of bowel and bladder. Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 6 of 23 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 03/30/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included aphasia (loss of ability to understand or express speech), cerebrovascular accident (CVA or stroke) and hemiparesis/hemiplegia (weakness or the inability to move one side of his body). Resident #94 was care planned on 12/30/22, and reviewed on 1/2/23 and 3/20/23, for his activities of daily living (ADL) self-care performance deficit related to hemiplegia, status-post (following) stroke, muscle weakness, difficulty walking, reduced mobility, lack coordination and multiple medical comorbidities. The goal was to improve his current level of function through the next review date. Interventions included, but were not limited to: Bathing/showering: check nail length and trim and clean on bath day and as necessary. Report changes to nurse. Toileting- requires extensive assistance by staff. (Photographic evidence obtained) A review of nursing progress notes found Resident #94 refused nail care on 2/8/23 and 2/22/23. There were no nail care refusals documented after 2/22/23. CNA F was interviewed on 3/28/23 at 10:26 AM. She stated she was assigned to Resident #94 and he required moderate assistance with ADLs. He was incontinent of bowel and bladder. She provides no nail care to residents; restorative aides provided all nail care unless the resident was diabetic. CNA F said she brought a bin of soapy water for residents to wash their hands, usually once a day in the morning, and sometimes twice during the shift. CNA H was interviewed on 3/28/23 at 12:52 PM. She stated nail care was provided by the CNAs including clipping and using the orange stick to clean underneath, unless the resident was diabetic. She stated it should be done daily in her opinion. Some residents play in their feces including Resident #94, who also sometimes refused showers. An observation of Resident #94 was conducted on 3/28/23 at 1:50 PM. He was in the day room, and his hands and nails were now very clean and free of all previously observed matter. He confirmed the staff had cleaned them. He was not sure who the staff member was who did it. The east wing Unit Manager was interviewed on 3/28/23 at 1:53 PM. She was asked if she knew who provided nail care to Resident #94. She speculated that perhaps his CNA did. When told his assigned CNA reported only restorative aides provided nail care, Licensed Practical Nurse (LPN) I, who was standing nearby, laughed and looked surprised. She corrected, saying, CNAs do provide the nail care, including cutting and cleaning the resident's nails unless they're diabetic. Activities also does spa days, where they cut, clean and even paint nails. The spa days are on the activities calendar. The activities calendar for March 2023 was reviewed and reflected the Nail Spa was on the calendar for March 4, 7, 13, 24, 26, 18, 20, 21, 26 and 28th. (Photographic copy obtained) CNA A was interviewed on 3/30/23 at 10:21 AM. She confirmed she was the staff member who cleaned Resident # 94's nails on Tuesday afternoon (3/28/23). When asked what was on his hands and under his nails, she replied, Poop. He digs in his diaper. When asked how his nails were in that condition and hadn't been addressed, she shrugged and said it was because no one cleaned them for him. When told Resident #94 was observed eating with his soiled hands earlier that day, she shrugged her shoulders and did not respond. CNA A said the CNAs were expected to care for their assigned residents' nails and hands, but no one did it. Nobody cares. An interview was conducted with the Director of Clinical Services (DCS) on 3/30/23 at 11:30 AM. When advised and shown the picture of Resident #94's nails, she agreed the nails and fingers were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 7 of 23 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 03/30/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few soiled and caked with what appeared to be feces. The DCS had no explanation for why staff did not address the condition of his hands or assist him to clean his hands before feeding himself. The facility policy titled Care of Nails, policy # N-1173, effective 11/30/14 and revised 9/1/17, read: Procedure: Perform hand hygiene; explain procedure and bring the following equipment to the resident's bedside: Basin, optional, towel, [NAME] board, orange stick, nail clippers. Place towel beneath area to be treated. May soak hands in basin half full of warm water if needed. Trim fingernails, clean nails . (Photographic copy obtained) 3. A review of the clinical record revealed that Resident #20 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia/hemiparesis, dysphagia, protein calorie malnutrition, and anemia in chronic kidney disease. A review of the physician's orders, dated 10/28/22, revealed orders for: Oral care qshift (every shift), Enteral (tube) feeding every 4 hours, 170 cc H20 (100 cubic centimeters of water), FEES (fiberoptic endoscopic evaluation of swallowing) to assess swallow function (10/14/22). Resident receives SLP (speech language pathologist) services effective as 2/14/23, 5x/week (five times a week) for 2 weeks. Goals with focus on swallowing, apply drain sponge on G- tube area. Check residual every shift and notify MD of greater than 100cc. Jevity 1.5 type of feeding 70ml/hr x 20hrs (70 milliliters per hour for 20 hours), off at 6:00 a.m. and on at 10:00 a.m. A review of a dietary note dated 3/13/23, revealed Jevity 1.5 goal rate at 70ml/hr x20hrs off at 6:00 a.m. and on at 10:00 a.m. A review of the care plan dated 1/17/22, indicated that the resident had an ADL self-care performance deficit related to impaired mobility and multiple medical comorbidities. Resident has own teeth and requires oral inspection every shift with mouth care as ordered. Resident requires total assistance by staff with personal hygiene. A 2/25/23 progress note read, Resident does not cooperate with the care. He is known to refuse medication and treatments, shower/bed bath, mouth care. Has been known to refuse to be hospitalized related to dementia, anxiety disorder, major depressive disorder, acute and chronic respiratory failure, hypoxia and hypercapnia. A Community Life progress note, dated 3/16/23, revealed, Spent 15 minutes with resident. Activities assisted with mouth care and washing of hands and face. Resident seemed to enjoy the the visit. A review of the quarterly MDS assessment, dated 1/25/23, revealed a BIMS score of 10 out of a possible 15 points, indicating moderate cognitive impairment. The resident required extensive assistance of two staff members for bed mobility and toilet use. The resident was totally dependent for toileting and personal hygiene. A review of a dietary progress note, dated 3/13/23, revealed a body mass index (BMI) of 22, weight stable. Resident to continue to be NPO (nothing by mouth) with 200 cc water flushes. During a telephone interview with the RD on 3/30/23 at 12:54 PM, she stated assessments were conducted upon admission, re-admission and as needed based on communication with the nursing department or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 8 of 23 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 03/30/2023 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 Level of Harm - Minimal harm or potential for actual harm weight loss. When asked about Resident #20, she stated she saw the resident frequently because he received his nutrition via a feeding tube. He was on 70 ml of Jevity 1.5 (enteral nutritional product) and 200 ml water flushes. She added that if she changed anything, she put the new orders in the electronic medical record and the nurses had to acknowledge the changes. She added that she also verbally notified the physician and the nurse of any changes. Residents Affected - Few On 3/30/23 at 2:41 PM, the Director of Clinical Services (DCS) reviewed the RD's progress notes and the physician's order. She stated if the RD changed the orders, she should put the new orders in the electronic medical record. She further stated the current order was added by the RD. On 3/27/23 at 11:58 AM, the resident stated oral care had not been provided yet today. On 3/28/23 at 10:29 AM, the resident was observed lying in bed with tube feeding running at 70ml/hr. A whitish substance was observed on the resident's mouth. Resident # 20 confirmed that oral care had not been provided. On 3/28/23 at 3:09 PM, the resident stated oral care had still not been provided today. On 3/29/23 at 12:20 PM, CNA A stated she had been employed by the facility for two years. She stated she had always worked on the long-term care side of the facility (East Wing) and was familiar with all the long-term care residents. If there was a new resident, she would obtain the information regarding their functional ability from the nurse or a resident interview. When asked about the care for Resident #20, she stated the resident refused care at times. She added that if a resident refused care, the nurse was notified and it should be documented in the electronic medical record. She confirmed that she had not performed oral care for the resident. The nurse did not ask. When asked if the nurses were expected to provide oral care, she replied no and added that if the nurses saw that it needed to be done, they should inform the CNAs. She added that most of the time this resident refused care because the water was always cold. When asked about staffing, she stated she was assigned 25-27 residents most of the time, and it was difficult to meet the residents' needs. When asked about the residents' meals, she stated they were always complaining about the food and the dietary department did nothing about it. She added that residents did not consistently receive snacks and when dietary did bring the residents snacks there were never enough of them for the residents, so the staff did not pass them out. They waited until a resident came to the nurses' station and asked for a snack. On 3/29/23 at 1:48 PM, Resident #20 was observed uncovering himself. He stated he had called for the CNA to change him, they came in and turned the call light off and said they'd be back. Resident #20 was asked to push the light again. At this time, he stated again that the staff did not provide him with oral care. A review of the CNA Task List for March 2023 revealed that there was no documentation of Resident #20's refusal of care. (Copies obtained) On 3/29/23 at 2:52 PM, a staff member was observed going into Resident #20's room to provide care. During a 3/29/23 interview with LPN B at 2:40 PM, she stated Resident #20 received 170 cc water flushes every 4 hours. She added that his feeding tube clogged up easily. When asked about oral care for the resident, she stated the nurses were expected to ensure it was done but the CNAs were responsible for doing it. When asked what happened when the resident refused care, she stated the CNAs were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 9 of 23 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 03/30/2023 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 supposed to notify the nurse. She denied anyone having notified her that Resident #20 refused care. Level of Harm - Minimal harm or potential for actual harm On 3/30/23 at 10:41 AM, the Clinical Supervisor confirmed that oral care was not performed for this resident. She reviewed the orders and stated the orders were not entered the appropriately because they did not appear in the TAR (treatment administration record) or the CNA task list. Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 10 of 23 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 03/30/2023 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, a review of resident records, and the facility's policy and procedure titled G-Tube Care, the facility failed to 1) Follow treatment ordered by the physician for G-tube (G-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and fluids) dressing changes, 2) Arrange G-tube removal in a timely manner, and 3) Prevent complications of the G-tube, specifically, recurrent stoma infections for one (Resident #80) of three residents reviewed with G-Tubes, from a total of 36 residents in the sample. The findings include: A review of Resident #80's medical record found he was admitted to the facility on [DATE] with a planned discharge to an acute-care hospital on [DATE] and a readmission on [DATE]. His diagnoses included type 2 diabetes mellitus, major depressive disorder, gastrostomy status (status post-surgical procedure creating an opening in the stomach for the introduction of food through a feeding tube, G-tube), and moderate protein-calorie malnutrition. On 03/26/23 at 2:00 PM, Resident #80 was observed in his room sitting on his bed. When asked whether he was satisfied with his care, Resident #80 pointed to his feeding tube site (abdomen) and stated, This tube had to be removed a long time ago, but the hospital of Veteran's Administration (VA) needs more information in order to proceed. The dressing around the G-tube was soiled with serosanguineous (contains both blood and blood serum) drainage. The date on the dressing was 3/24/23. (Photographic evidence obtained) Resident #80 stated his G-tube dressing was not changed last night, 3/25/23. On 03/27/23 at 3:30 PM, Resident #80 was observed in the Activities area. He stated, I have been waiting for you the whole day. Please follow me to my room; I want to show you something. Upon entering the resident's room, he lifted his shirt to expose an intact dressing covering the G-tube site. The dressing was dated 3/27/23. The resident stated the dressing was changed this morning. As of 3/27/23, the dressing had not been changed since 3/24/23. On 3/29/23 at 9:40 AM, Resident #80 was observed in his room sitting on his bed. His G-tube site dressing was observed with a scant amount of blood and was dated 3/27/23. He stated the dressing was not changed last night, 03/28/23. A review of the Significant Change Minimum Data Set (MDS) assessment, dated 1/26/23, revealed that Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating that he was cognitively intact. He required supervision with bed mobility and transfers, limited assistance with dressing and toileting, and was noted as independent walking in his room and for eating. The MDS indicated that Resident #80 had gained weight, was using a feeding tube and had 25% or less fluid intake by tube feeding. The Care Plan, dated 7/18/22 and revised on 2/6/23, revealed that Resident #80 had a G-tube related to a history of dysphagia (trouble swallowing). The goal was that the resident would remain free from side effects or complications related to the tube feeding through the next review date, on 5/7/23. Interventions included: Gastroenterologist consult as ordered (initiated 11/11/22). Provide local care to the G-tube site as ordered, monitor for signs and symptoms of infection (initiated 7/18/22). Isolation precautions (initiated 3/28/23). Registered dietitian to evaluate quarterly and as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 11 of 23 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 03/30/2023 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 0693 Level of Harm - Actual harm needed, making recommendations for changes to the tube feeding as indicated (initiated 7/18/22). ST (Speech Therapy) evaluation and treatment as ordered (initiated 7/18/22). Swallow test as ordered (initiated 11/11/22). Residents Affected - Few A review of the resident's physician's orders revealed: 3/27/23 - Isolation type - Enhanced MRSA/Stoma (MRSA - Methicillin-resistant Staphylococcus Aureus, bacterial infection that is resistant to many of the antibiotics used to treat an ordinary staph infection). 2/9/23 - Enteral stoma (an artificial opening made into a hollow organ) care Q shift (every shift). 2/9/23 - Cleanse gastric stoma site once daily with NS (normal saline). Apply sterile drain sponge to site every night shift. 1/6/23 - Order cultures from stoma site d/t (due to) discharge bloody/smelly site. Order to start mupirocin (antibiotic) topical cream 2%. Apply cream TID (three times daily) for 10 days for skin infection. 11/28/22 - Consult GI (gastroenterologist) to evaluate and reassess the changing or removal of PEG (percutaneous endoscopic gastrostomy) feeding tube due to skin redness/odor around the stoma. 9/27/22 - Consistent Carbohydrate (CCD) diet, regular texture, regular/thin liquid consistency. A review of the Registered Dietitian's progress note dated 10/4/22 revealed: Spoke with Speech Language Pathologist (SLP) and she reported the resident has been eating >1 week since the tube feed TF was decreased and switched to nocturnal. Given resident's consistent PO (oral) intake and ability to meet hydration needs via PO, recommend discontinue TF (feeding tube) entirely. Will monitor and if change in clinical status, will reassess need for supplemental nutrition support. A review of the Meal Percentage intake forms for March 2023 revealed that Resident #80 was eating 76-100% of his meals. A review of Resident #80's weight history revealed that he had gained 17.8% from 12/29/22 to 3/6/23. A review of the February and March 2023 electronic Medication Administration Record (eMAR) found that the gastric stoma site was scheduled to be cleaned and the dressing changed daily, on every night shift, however, on 2/21/23, 3/26, 3/29, 3/30 and 3/31/23, the signature box used to indicate completion of the task for cleansing the stoma site and changing the dressing was not signed off by the nurse indicating that the care had been provided. Further review of the March 2023 MAR revealed that signature boxes indicating stoma care had been provided every shift, were not signed off by the nurse to verify that care was provided on 2/10/23 or 2/13/23 during the night shift. Stoma care was not signed off by nursing as having been provided on both the day and night shifts on 2/21/23; on the day shift on 3/12, 3/30, or 3/31/23; on the evening shift on 3/24, 3/29, 3/30 or 3/31/23, or on the night shift on 3/26, 3/29, 3/30, or 3/31/23. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 12 of 23 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 03/30/2023 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 0693 Level of Harm - Actual harm Residents Affected - Few 3/25/23 and 3/28/23, both signature boxes had nurses' initials in them, indicating stoma care was done and a dressing applied, but observations on 3/26/2023 and 03/29/2023, revealed that dates on the dressing were 3/24/23 and 3/27/23 respectively. A review of an infection progress note dated 1/19/23, revealed that Resident #80 was on contact precautions due to MRSA in his g-tube stoma at that time. A review of the laboratory reports revealed a history of infection at the G-tube stoma site: On 2/01/23 - Aerobic culture wound: Light growth Yeast. On 1/10/23 - Aerobic stoma culture: Light growth Proteus Mirabilis, heavy growth MRSA. On 12/03/22 - Aerobic culture wound: Moderate growth Proteus Mirabilis (a bacterial infection), light growth MRSA. On 11/04/22 - Aerobic culture wound: Heavy growth Escherichia Coli, ESBL (Extended Spectrum Beta-Lactamase - a bacterial infection that is resistant to antibiotics). Heavy growth Klebsiella Pneumoniae (a bacterial infection), and heavy growth MRSA. A review of the March 2023 Treatment Administration Record (TAR) revealed the following: Consult GI as soon as possible to remove the PEG tube. Patient may go to outpatient GI hospital for PEG tube removal [every shift for] no longer in need/frequent/recurrent infection. Start date: 2/1/23. Discontinuation Date: 3/10/23. Nursing signatures were documented on each shift from 3/1/23 through the day shift on 3/10/23. Refer to the 11/28/22 physician's order above for a GI consult to change or remove the G-tube due to skin redness/odor around the stoma. A review of the ARNP's (Advanced Registered Nurse Practitioner) progress note from 03/03/23, revealed that the resident had an appointment on 03/07/23 with the VA for a G-tube consult for removal. As of 3/29/23, the resident's G-tube remained in place. A nursing progress note dated 2/13/23 revealed, Contact isolation has been discontinued as discussed with provider. Resident's stoma has been re-cultured which revealed yeast present at stoma, not MRSA. Education provided to staff and resident regarding his new status of Enhanced Barrier due to his history and current G-tube that hasn't been discontinued by GI yet. Will continue to follow care. A review of Licensed Practical Nurse (LPN) L's 2/17/23 progress note revealed, This writer placed a call to [Provider name] regarding follow up for g-tube. Resident needs referral from insurance, have been making multiple calls with no response back. Spoke with billing at GI who will help with referral process to get follow up, will keep in contact once referral is obtained. Nursing and Doctor will be made aware. On 03/29/23 at 9:50 AM, Resident #80's sister was interviewed. She shared how frustrating the situation had been for her and her brother. He was supposed to have it done. (referring to removal of the G-tube) She stated they (she and her brother) had an appointment at [hospital name], she could not remember the date, for the G-tube removal. Her brother had been prepared for the procedure at the hospital, and they were told that he had a $300.00 co-pay, which she was prepared to pay. She said she was not sure why her brother was not accepted for the procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 13 of 23 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 03/30/2023 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 0693 Level of Harm - Actual harm Residents Affected - Few On 03/29/23 at 10:02 AM, an interview was conducted with LPN K. She was familiar with Resident #80. She stated the resident had a telehealth appointment with his gastroenterologist, and they were waiting for authorization in order to remove his G-tube. She said the VA was delaying the process. On 03/29/23 at 10:05 AM, an interview was conducted with LPN I. She was assigned to Resident #80 this shift. She stated the resident did not use his feeding tube; he had been eating and drinking with no problems. The problem was with the VA and the resident's insurance. On 03/29/23 at 1:42 PM, an interview was conducted with the Wound Care Nurse. She stated the night shift nurses were responsible for dressing changes for Resident #80. She confirmed that stoma care had not been provided and the dressing had not been changed if the signature boxes on the MAR were empty. She was aware that Resident #80 had been experiencing recurrent MRSA and Proteus Mirabilis infections of his stoma site, and the tube had been ordered to be changed or removed a long time ago per his doctor's order dated 11/28/22. She was not sure why Resident #80 had been unable to get to the doctor for gastric tube removal since that time. On 3/29/23 at 2:40 PM, the Director of Nursing (DON) was interviewed with the Clinical Supervisor present. She was advised that Resident #80's G-tube site care/cleaning and dressing changes were being signed off by nursing as having been done, when the care had not been completed. She had no explanation and acknowledged the findings. She was made aware that Resident #80 had a physician's order (11/28/22) and recommendations (10/4/22) from the Registered Dietitian for G-tube removal, however, as of 3/29/23, the resident still had the G-tube. On 3/30/23 at 12:47 PM, a telephone interview was conducted with the Registered Dietitian. She stated, I have spoken to the Speech Therapist, and she confirmed that [Resident #80] is able to eat and swallow with no problems. She stated the resident was not eating through the tube, and his weight has been stable. She confirmed the presence of the tube was a risk for infection and said she had recommended the discontinuation of the G-tube back in October (2022). On 3/30/23 at 1:24 PM, a telephone interview was conducted with the facility's Medical Director. He stated he would like to see a calorie count for Resident #80 from the Registered Dietitian. The Medical Director was informed that Resident #80 had been gaining weight and eating/drinking with no concerns noted. Additionally, there had been recurrent infections at the G-tube stoma site. He then said, Okay, I will place the order to discontinue the G-tube. A review of the facility's policy and procedure titled G-Tube/J-Tube Care revealed: Clinical Nurses shall provide routine care to Gastrostomy and Jejunostomy tubes in order to maintain patency of the tube and good skin integrity. If the site appears to be locally infected, notify the physician. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 14 of 23 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 03/30/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours on February, 27, 2023. Nurse staffing in nursing homes has a substantial impact on the quality of care and outcomes that residents experience. Failure to staff a registered nurse for at least 8 hours a day could result in a negative impact on resident care. The findings include: A review of the Payroll Based Journal Staffing Data Report for the period covering July 1, 2022 through September 30, 2022, rvealed that the facility's submitted weekend staffing data was excessively low. A review of the facility's staffing calculations from February 5, 2023 through March 25, 2023, revealed there was no RN on duty at all on February 27, 2023, a Monday. (Copies obtained). An interview was conducted with the Director of Nursing on 3/29/23 at 1:40 PM. She stated the facility only employed two registered nurses currently, herself and the Minimum Data Set (MDS) Coordinator. The facility relied on Staffing Agencies for RNs. She confirmed that at times, she had to work a resident care assignment and administer medications. She stated in the last month, she had to work a resident care assignment twice. On March 5, 2023, she had to help with medication administration because the assigned nurse had to leave at 3:00 AM. On March 7, 2023, she had to come to take a resident care assignment because an agency nurse did not show up for work. She added that normally the unit managers and the supervisors were expected to be on call, but they had all resigned. In an interview with the Administrator on 3/29/23 at 2:00 PM, he confirmed that there was no RN assigned to work on 2/27/23. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 15 of 23 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 03/30/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews with staff, and a review of the facility's policy and procedure for Medication Management for Psychotropic Medications, the facility failed to ensure behavior monitoring was conducted for one (Resident #83) of five residents reviewed for unnecessary medication use, from a total of 36 residents in the sample. Residents Affected - Few The findings include: On 3/28/23 at 12:30 p.m., Resident #83 was observed eating lunch in the day room. She had bruising noted under both her left and right eyes. She reported she fell and hit something, but she was not sure what that was. The resident had some confusion and was unable to remain focused during the interview. A record review was conducted for Resident #83, which noted an admission date of 6/9/22 with a readmission on [DATE]. Her diagnoses included schizo-affective disorder with a physician's order for Haldol (antipsychotic medication) 10 mg (milligrams) BID (twice daily), ordered on 3/6/23. There was also a 2/23/23 order for Lorazepam (benzodiazepine sometimes used for agitation), 1 mg every 8 hours as needed for aggression, and Trazodone (antidepressant) 150 mg at bedtime, ordered on 2/22/23. A review of the resident's March 2023 Medication Administration Record (MAR), revealed that no behavior monitoring was documented. A review of the March 2023 Treatment Administration Record (TAR) and progress notes, revealed two progress notes concerning behaviors. An interview was conducted with Licensed Practical Nurse (LPN) D on 3/28/23 at 1:29 PM. She stated behaviors were documented on the resident's MAR, TAR or Progress Notes. Behaviors would also be documented in the nursing notes. LPN D reviewed the MAR, TAR and Progress Notes, and reported that only two incidents of behaviors were documented on the same day this month. An interview was conducted with the Director of Nursing (DON) on 3/28/23 at 1:56 PM. She was asked where behaviors would be found in the electronic medical record, and she replied that behaviors would be charted in progress notes or in the electronic MAR. She confirmed that Resident #83 had no behavior monitoring in place after reviewing the electronic record. The DON reported finding a note on 3/6/23 indicating no behaviors, but later the same day at 12:13 PM, cursing and yelling at the nurses' station. She confirmed that the charting was inconsistent, and reported side effects of medications would be in the nursing notes and the provider would be notified. The DON stated the nurses were responsible for documentation of behavioral monitoring and it was not done. An interview was conducted with LPN D on 3/30/23 at 10:34 AM. She stated Resident #84 did have behaviors such as yelling out, getting up constantly out of her wheelchair, requiring constant redirection, and she was combative and verbally abusive toward staff. A review of the facility's policy and procedure for Medication Management for Psychotropic Medications (revision date of 3/23/18), revealed under Procedure #4: Monitor behavior and side effects every shift utilizing the Behavior Monitoring Flow Record. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 16 of 23 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 03/30/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews with staff, and a review of the facility's policy and procedure for Medication Management for Psychotropic Medications, the facility failed to ensure psychotropic medications ordered as needed included a stop date for one (Resident #83) of five residents reviewed for unnecessary medication use, from a total of 36 residents in the sample. Resident #83 was receiving Lorazepam (benzodiazepine sometimes used for agitation) as needed for aggression with no stop date noted or rationale for continuing the medication beyond 14 days. The findings include: On 3/28/23 at 12:30 PM, Resident #83 was observed eating lunch in the day room. She had bruising noted under both her left and right eyes. She reported she fell and hit something, but she was not sure what that was. The resident had some confusion and was unable to remain focused during the interview. A record review was conducted for Resident #83, which noted an admission date of 6/9/22 with a readmission on [DATE]. Her diagnoses included schizo-affective disorder with a 2/23/23 physician's order for Lorazepam (benzodiazepine sometimes used for agitation) 1 mg (milligram) every 8 hours as needed for aggression. Further review of the medical record revealed no stop date for the as needed medication, or documentation of a rationale for its continuation. A review of the March 2023 Medication Administration Record (MAR) revealed that the resident received Lorazepam on 3/6/23 and 3/22/23. An interview was conducted with Licensed Practical Nurse (LPN) D on 3/28/23 at 1:29 PM. She reviewed the MAR and confirmed that Lorazepam 1 mg is ordered as needed and did not have a stop date. An interview was conducted with the Director of Nursing (DON) on 3/28/23 at 1:56 PM. She reviewed the resident's order for Lorazepam 1 mg as needed and confirmed that there was no stop date when there should have been. She stated she would alert her psychiatric Advanced Registered Nurse Practitioner (ARNP) and request a stop date. The facility's policy and procedure for Medication Management for Psychotropic Medications (revision date of 3/23/18) was reviewed. Stated under Procedure #7: Whenever needed (prn), physician's orders for psychotropic medications are limited to 14 days, unless the physician believes it is appropriate to extend beyond 14 days and documents the rationale in the medical record. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 17 of 23 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 03/30/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff and resident interviews, a review of resident records and the resident handbook, the facility failed to ensure that food received and/or prepared by resident families, friends and/or other outside sources was handled safely once it was brought into the facility for two (Residents #18 and #88) of two residents observed storing and eating unrefrigerated perishable foods in their rooms, from a total of 36 residents in the sample. The findings include: During lunch observation in the Activities room on 03/27/23 at 12:47 PM, Resident #18 was observed eating a salad. A bottle of store-brand ranch salad dressing was on the table next to him. It was opened, partially used and at room temperature. The label on the bottle listed perishable ingredients including egg yolk, buttermilk, milk and warned: Contains Milk and Eggs. Instructions were to Refrigerate after opening. Photographic evidence was obtained. Resident #18 stated it was his dressing and he kept it in a drawer in his room. He gets a salad every day at lunch. Certified Nursing Assistant (CNA) H was interviewed on 03/28/23 at 12:52 PM. She confirmed some residents kept food in their rooms like canned foods, crackers, and other non-perishable foods, which was okay. There were no residents with refrigerators in their rooms, but some would keep milk and other perishable items in their rooms even though staff ask them not to. CNA H stated she would remove any unsafe items and offer to store perishable food in the activity room refrigerator. Staff would label the food with the resident's name before storing it there. Resident #18 was observed again in the activities room on 03/28/23 at 12:54 PM, his same bottle of salad dressing on the table. There was now only about an inch of dressing left in the bottom of the bottle. His salad arrived with 4 small single-serve packets of ranch dressing. (Photographic evidence obtained) Resident #18 put the dressing on his salad. The surveyor stepped away, then returned to the table moments later to see his salad swimming in dressing. Resident #18 explained he went through about a bottle of his ranch dressing a week. Licensed Practical Nurse (LPN) I was interviewed on 03/28/23 at 2:03 PM. She stated residents could keep non-perishable foods in their rooms, but perishable foods were kept in the nourishment room refrigerators. The food was dated, labeled with the resident's name, and must be discarded in three days if perishable or brought from home. Salad dressings and condiments were disposed of on or by the expiration date on the bottle. On 03/28/23 at 2:30 PM, Resident #18 showed this writer where he kept his food. He opened the bottom drawer of the nightstand in his room explaining his sister brought in most of his food. There was a large bottle of unopened ranch salad dressing in the drawer. (Photographic evidence obtained) Resident #18 explained that he finished his other bottle of dressing at lunch today. When asked about refrigeration, Resident #18 insisted the dressing was safe in the drawer. Staff had offered to put it in the refrigerator, but he never gave them an answer. Further inspection of the resident's room found there was no refrigerator. On 03/29/23 at 10:05 AM, during an interview with the Director of Clinical Services (DCS) in her office, an unopened bottle of store brand-ranch salad dressing was observed sitting on the side table. It was the same size and brand observed in Resident #18's drawer but was not labeled with a name. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 18 of 23 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 03/30/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a visit to Resident #88's room on 03/29/23 at 10:18 AM, a wax bag containing chicken wings was observed on his overbed table. There were crumbs surrounding the bag. Resident #88 explained his brother brought the chicken in last night and he ate it this morning. He was asked if the chicken had been refrigerated overnight and he said no. When advised the chicken should have been refrigerated after four hours at room temperature, Resident #88 insisted he does this all the time at home. When asked if staff offered to put the chicken in the refrigerator overnight, at first, he said the staff didn't see it. Then Resident #88 said the certified nursing assistant (CNA) gave him a baggie (small trash can liner) to put the chicken in and offered a basin to put the wrapped wings in because we don't want any roaches in here. He declined use of the basin and put the chicken in the baggie overnight. Resident #18 was observed on 03/29/23 at 12:51 PM at lunch. He had a salad (mostly eaten) and approximately 10 used packs of the single-serving ranch dressing on the table next to him. There was no bottled dressing on the table. When asked where his salad dressing was, he said staff took it from him because (this writer) told them it needed to be in the refrigerator. Resident #18 confirmed nobody brought it to him to use at lunch today. The DCS was interviewed on 03/29/23 at 12:59 PM and asked if the bottle of dressing, which was still on the table in her office, was Resident #18's. She confirmed it was and stated it had been removed from his room. She said Resident #18 was told he could use the individual packets of dressing the facility provides and have as many as he likes, since he prefers a lot of dressing. The DCS pointed out the removed dressing was still unopened. When asked why Resident #88 was not provided with his preferred dressing at lunch, given the bottle was unopened and safe for him to eat, she did not provide a reason. The DCS said staff was going to put his name on it and put it in the refrigerator. CNA A was interviewed on 03/30/23 at 10:21 AM. She was asked about residents storing food in their rooms. CNA A said most of the residents on the east wing did that, but there was only one small dorm-sized refrigerator on the unit for perishable food storage. When asked what staff did if residents brought in perishable foods and there was no room in the refrigerator, she said, Nothing. They just leave it in the room. When told Resident #88's chicken sat at room temperature overnight, she said, That happens all the time, with other residents too. When asked what she did when that happened, she replied, Nothing, that she would just leave the food in the room unless it was milk, which she would throw away. CNA A said they needed more refrigerator space. When asked if residents ever suffered from stomach upset as a result of eating unsafely stored food, she said yes. CNA A again insisted more cold storage was needed, since a lot of the residents ordered food in from stores and had more food than the current cold storage room could accommodate. She confirmed there were no personal refrigerators in resident rooms. In an interview with the DCS on 03/30/23 at 11:30 AM, she confirmed that all perishable food should be refrigerated. When told of the observation of Resident #88's chicken in addition to the observations of Resident #18's salads, she stated the foods should have been refrigerated. The DCS was advised one employee reported they just left the food in the room if there was no refrigerator space. She had no explanation for why that was occurring when there was a refrigerator on each unit. She was advised the refrigerator was only dorm-sized and acknowledged that many residents ordered food out. The DCS acknowledged there was insufficient space for accommodating all resident's perishable foods. She agreed a full-sized refrigerator was needed and that staff should be storing resident foods safely. The Admissions Coordinator (AC) stated in an interview on 03/30/23 at 12:53 PM, that on admission, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 19 of 23 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 03/30/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm he verbally advised new residents of the policy for bringing in food from outside sources. The residents also received a handbook. All perishable foods must be refrigerated. The AC provided the resident handbook which stated on page 9 that food provided by family that required refrigeration would be stored in a refrigerator designated for such items. All items must be in a sealed, disposable container marked with the resident's name, the type of food and the date brought in. (Photographic evidence obtained) Residents Affected - Few The facility's Policy #031 Food: Safe Handling for Foods from Visitors stated, Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. Procedures stated: 1. staff will request visitors bringing in food . notify a staff member of nursing or the activities departments. 2. Responsible staff will determine if the food item is for immediate consumption or stored for later use . . 4. When food items are intended for later consumption, the responsible staff will: Ensure the food is stored separately . from facility food. Label foods with resident name and current date. Determine if food items are shelf stable and whether they can be stored in the resident's room or under refrigeration . (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 20 of 23 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 03/30/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews with staff, the facility failed to dispose of garbage and refuse properly and in a manner to prevent invitation, harboring and feeding of pests which can carry infectious diseases. This had the potential to affect all 103 residents residing in the facility at the time of the survey by risking exposure to vermin and disease. Residents Affected - Many The findings include: An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 03/27/23 at 9:37 AM. The tour concluded with the inspection of the three garbage dumpsters which were situated on the southwest side of the facility. The chain link cage that enclosed the dumpsters was ajar and one of the dumpsters had one of two lids open. The area surrounding the dumpsters was littered with copious amounts of trash including food containers, used gloves, cardboard and other trash. The wooden privacy fence behind the dumpsters had a panel that had fallen into the wooded area and the waste extended into the woods. An interview with the CDM at this time found all departments use and were responsible for maintaining the cleanliness of the dumpster area. She confirmed the presence of trash and debris, agreeing it appeared it had been accumulating over time, and not just over the weekend. (Photographic evidence obtained) On 03/27/23 at 10:48 AM, the CDM came into the conference room and requested that the dumpster area be observed again. She had it cleaned up. She was assured it would be observed again by the end of the survey. On 3/28/23 at 03:35 PM, she reported again she had the area cleaned up. On 03/29/23 at 9:40 AM, the CDM asked if the dumpster area had been inspected again since she had it cleaned. She also reported she had in-serviced her staff on maintaining the area. The CDM was reminded all departments needed to be re-trained, not just her dietary staff. She acknowledged the reminder. A final inspection of the dumpsters was conducted on 03/30/23 at 9:56 AM. The fallen wooden fence panel had been erected, but there was still trash, food containers and medical waste strewn about behind the dumpsters and in the wooded area. The middle dumpster had bags of waste protruding from the cracks between the container doors. (Photographic evidence obtained) In an interview with the Director of Clinical Services (DCS) on 03/30/23 at 11:30 AM, she was asked who was responsible for maintaining the cleanliness of the dumpster area. She said the maintenance department was, and she called the Maintenance Manager to her office. He arrived in the DCS's office and when asked the same question, he said housekeeping was responsible for the maintenance of the dumpsters and surrounding areas. The DCS called the Housekeeping Supervisor to her office, and he was asked if he was responsible for cleaning around the dumpsters. He replied his department does some of the cleaning. They were all shown the before and after photographs and confirmed the area's still unacceptable condition. The DCS agreed that even after the clean-up it was insufficient to keep vermin out. The DCS then telephoned the facility Administrator to clarify who was responsible for the cleaning the area. He stated the Maintenance department was responsible. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 21 of 23 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 03/30/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of resident records, and interviews with staff, the facility failed to ensure resident clinical records were accurately documented and reflective of the care provided for one (Resident #46) of three residents reviewed with gastrostomy tubes (g-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and liquids), out of 25 residents whose clinical records were reviewed, from a total of 36 residents in the sample. The findings include: An interview was conducted with Resident #46 on 03/29/23 at 10:10 AM. He was speaking very loudly and threatened that he was about to rip his g-tube out. Resident #46 lifted his shirt to show the insertion site and the tube. He reported he was eating by mouth and insisted the tube was supposed to have been removed. A record review for Resident #46 found he was admitted to the facility on [DATE]. He had a 5-day Minimum Data Set (MDS) assessment with an assessment reference date of 2/8/23, that noted he had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating that he was cognitively intact and able to make daily decisions. He was coded as being totally dependent for eating. His primary medical conditions included stroke, dysphagia (difficulty swallowing) following cerebral infarction (stroke), non-Alzheimer's dementia, malnutrition (protein, calorie), and adult failure to thrive. Resident #47 had one surgery involving the gastrointestinal tract prior to admission. He was assessed with no swallowing difficulty and no weight loss and had a feeding tube. Resident #46 was care planned on 2/15/23 for requiring tube feedings related to dysphagia following cerebral infarction. The goal was to remain free of signs/symptoms or complications related to tube feedings through the next review date. Interventions include, but were not limited to, head of bed elevated 45 degrees during and thirty minutes after tube feeding; check for placement and gastric contents/residual volume as ordered; provide local care to g-tube site as ordered and monitor for signs of infection; Registered Dietician (RD) to evaluate quarterly and as needed . and make recommendations for changes to tube feeding as needed. (Photographic evidence obtained) Resident #46 had a physician's order for nothing by mouth (NPO) which was started on 1/28/23 but discontinued 2/19/23, as was an order for medications through his PEG (pericutaneous endoscopic gastrostomy) tube. He also had an active diet change order for a regular diet, dysphagia advanced texture and nectar thickened fluids and an order that he receive 1:1 supervision with all meals. Both orders were written 2/19/23. (Photographic copy obtained) On 3/14/23, a GI (gastrointestinal) consultation was ordered to evaluate and remove the PEG tube due to it no longer being in use. (Photographic evidence obtained) Review of additional current physician's orders found three conflicting routes of administration for his medications, including by mouth, through the (now discontinued g-tube) and through a DH tube (Dobhoff tube, a type of nasogastric tube inserted into the nostril and down the esophagus into the stomach) which the resident did not have. Orders included: Jevity (a liquid food for administration via g-tube) 1.5 calories, 320 cc (cubic centimeters) via g-tube every 6 hours per bolus. (Start 1/31/2023, discontinued 3/7/2023) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 22 of 23 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 03/30/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Zyprexa (medication used to treat psychosis) 5 milligrams (mg), give 1 tablet via DH-Tube at bedtime for paranoia (started 1/29/23). Depakene Oral Solution (used for seizure disorder) 250 mg/milliliters give 5 ml via DH-Tube two times day for stroke as ordered (started 3/1/2023). Residents Affected - Few Tramadol HCL (hydrochloride) oral tab 50 mg, give 0.5 mg by mouth every 8 hours as needed for pain (start 3/10/2023). A review of the medication administration record (MAR) found nurses were signing off that they were giving medications through all three administration routes even though the g-tube was not in use and the resident never had a DH-Tube. (Photographic evidence obtained) An interview was conducted with the Registered Dietician (RD) on 03/30/23 at 1:13 PM, who confirmed the resident still had the g-tube but was eating by mouth now. The APRN (Advanced Practice Registered Nurse) was interviewed on 03/30/23 at 2:07 PM. She confirmed that Resident #46's G-tube could come out, as he was taking all food and medications by mouth. When told his physician's orders included three different routes of administration for medications, including by mouth, by DH-Tube and g-tube, she said, No, that should be removed. She confirmed Resident #46 did not have a DH-Tube and had no explanation why there were ever orders written for medication via that route. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 23 of 23