Inspection·February 13, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assigned to the resident. He was asked if residents were permitted to keep medication/antiseptics of any kind in their rooms. He stated, It depends on their status and whether the doctor approved it. Also, the facility has to determine the cognitive status of the resident and Speech Therapy has to approve them for their swallowing reflex. He was asked what the facility process was if medications/antiseptics were found in the resident's room that had not been approved. He stated, We tell the resident we must remove it and that they are not allowed to have medication in the room because another resident might take it and overdose, and we notify the doctor. He was asked if the facility permitted residents to use/keep aerosol disinfectant sprays/isopropyl alcohol in their rooms. He replied, No. He was accompanied to Resident #84's room to observe the items located on the resident's chest of drawers. He was asked why the resident had disinfectant spray, hydrogen peroxide, and isopropyl alcohol located on his chest of drawers. (Photographic evidence obtained). LPN A did not offer an explanation. On 02/12/25 at 1:26 PM, an interview was conducted with Certified Nursing Assistant (CNA) B who was assigned to the resident. She reported that she was familiar with Resident #84. She was asked if the facility permitted residents to keep medications/antiseptics in their rooms. She stated, Definitely not. She was asked if the facility permitted residents to keep disinfectant sprays and/or isopropyl alcohol in their rooms. She stated, Yes, I'm not going to say that they are allowed, but he usually keeps it in the drawer. On 02/13/25 at 2:54 PM, an interview was conducted with the Maintenance Director who was asked if the facility permitted residents to have, use or keep any type of aerosol sprays in their rooms. She stated, No, they are not allowed to have any. She was asked for the documentation explaining the facility's policy pertaining to the use or possession of aerosol sprays in resident rooms. No policy was provided prior to the survey exit. A review of the facility's policy and procedure titled Administering Medications (Revised April 2019), revealed: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with the prescriber's orders, including any required time frame. 27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the facility's policy and procedure titled Medication Storage (Undated), revealed: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the resident and is in accordance with Florida Department of Health guidelines. A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. A review of the Hazardous Material Storage and Handling/MSDS(Material Safety Data Sheet) (S-270) (Effective 11/30/14), revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 2 of 7 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 02/13/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Hazardous materials shall be stored and handled in a manner that shall minimize the risk of injury or property damage. 2. The facility shall maintain Material Safety Data Sheets (MSDS) for all materials used or stored. Each department shall maintain those sheets appropriate Residents Affected - Few to their operation. Executive Director shall house a complete set accessible to all personnel. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 3 of 7 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 02/13/2025 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to clean the juice dispenser hose attachment connected to the thickened water bag in box and the 100% apple blend juice (regular consistency) on the juice machine. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A follow-up tour of the kitchen was conducted on 02/12/25 at 11:21 AM. During the tour, the juice dispenser attachment connected to the thickened water bag in box and the 100% apple blend juice (regular consistency) was observed with brownish-orange substances around the hose attachment area connected to thickened water bag and the 100% apple blend juice (regular consistency). Two juice dispenser hoses that were hanging from the juice rack below the bag in boxes, were observed with dusty substances and a greasy buildup on the external parts of the hoses. On 2/13/25 at 3:14 PM, the same observations were made again of the juice dispenser attachment connected to the thickened water bag in box and the 100% apple blend juice (regular consistency) as well as the two juice dispenser hoses hanging below the bag in boxes. (Photographic evidence obtained) An interview was conducted on 02/12/25 at 11:56 AM with Dietary Aide D. When asked who was responsible for cleaning the juice machine hoses, she replied, The Kitchen Manager cleans the machine weekly. An interview was conducted on 02/12/25 at 2:26 PM with Kitchen Manager E. She stated the Dietary Aide removed, soaked, cleaned, sanitized and reattached the nozzles back to the bag in box once cleaned. On 02/13/25 at 3:12 PM, Kitchen Manager E reported that the two hoses hanging from the juice rack below the bag in boxes were not utilized. A review of the facility's policy and procedure titled Equipment (Revised: 9/2017), revealed: All food service equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food equipment will be clean and free of debris. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 4 of 7 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 02/13/2025 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 other debris. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 5 of 7 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 02/13/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility record review, staff interview, and a review of facility policy and procedure, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are especially at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. This had the potential to affect all residents residing in the facility. Residents Affected - Many Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. The findings include: From 02/10/25 through 02/13/25 a review of the facility's infection control and water management program was conducted. The facility water management program binder was provided for review, and it contained a copy of the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, A Practical Guide to Implementing Industry Standards. U.S. Department of Health and Human Services Centers for Disease Control and Prevention, dated 06/24/21. (Copy obtained) Further review of the water management program binder revealed that the program had no documentation indicating that the facility had conducted an annual review of the water management program. The program did not include control measures to include points in the system where critical limits could be monitored, and where control could be applied, such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. It did not specify testing protocols and acceptable ranges for control measures, and documented results of testing of pH levels of disinfectant in the water. There were no confirmatory procedures, including verification steps to show that the program was being followed as written, or validation to show that the program was effective. A review of the facility's policy titled Water Management Program (effective 08/01/17) revealed: The facility will provide a source of domestic water supply, as safe as possible, to residents, staff and visitors. The center will strive to eliminate the source of, or distribution of, unacceptable levels of preventable contamination (including but not limited to Legionella, cryptosporidium, arsenic) within the water and HVAC systems. Section D stated, Establish water safety control limits (ex. Temperature and disinfectant levels) and where control limits should be applied. Develop responses and ways to intervene when measurements are outside the established limits. (Photographic evidence obtained) Further review of the water management policy revealed in Attachment C water management information that included where the main water supply came into the building, location of water systems components, and a check list to check water supply components, which was left blank. (Photographic evidence obtained) During an interview with the Director of Maintenance on 02/13/25 at 11:22 AM, she confirmed that she had received no training on the water management program. She confirmed water testing for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 6 of 7 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 02/13/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many pathogens had not been done since she was hired in August 2024. She stated she had no testing kit for the disinfectant levels in the water. There had not been any testing other than what was completed by an outside provider in September 2024. When asked about control limits, the Director of Maintenance stated she was not aware of any control limits. She stated there were no water safety team members as stated in the water management policy, and she did not use the CDC (Centers for Disease Control and Prevention) toolkit guide included in the water management binder. When asked, she stated there was no water flow diagram that she was aware of, but she did regularly flush the hot water heaters and tested water temperatures in resident rooms with the range being between 105-110 degrees. The main hot/cold valves were used to either increase or decrease the temperature to get it within acceptable limits. Monthly cleaning/checks were performed on all ice machines. Proof of testing was requested on 02/13/25 at 11:30 AM. Proof of testing was requested again at 12:30 PM on 02/13/25. No proof of testing was provided prior to the survey exit. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105663 If continuation sheet Page 7 of 7