Health inspection·February 17, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few call light was missing a clip to hold it in place. The CNA stated that the resident never presses his button anyway. An interview was conducted with Employee T, Occupational Therapy Assistant (OTA) on 02/17/2022 at 1:20 PM, who was familiar with Resident #92. The OTA stated that she was familiar with the type of call button for the resident, and that his level of hand dexterity was appropriate for the type of call button he had been provided. She stated each call light should have a clip, and she recommended it be clipped to his person. The Director of Nursing (DON) was interviewed on 02/17/2022 at 2:45 PM. The DON was unaware of any call light policy at the facility. The DON stated that department heads make rounds to check each room daily in the morning, and again at 2:30 PM. The facility did not keep records of the rounds. The DON stated that it was the responsibility of all staff to ensure the call button lights remained reachable, and that there was frequent training on call lights, but not necessarily as to the proper placement. She confirmed that call light buttons should always be accessible to residents. The DON was unaware as to the call button status or placement for Resident #92. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 2 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the resident's right to make choices about aspects of his or her life by failing to make appointments for health care services for one (Resident #51) of three residents reviewed for medical appointments, out of a total of 41 residents in the sample. The findings include A clinical record review for Resident #51 revealed he was admitted to the facility on [DATE]. On 02/14/2022 at 2:11 PM, an interview was conducted with Resident #51. He reported, he had been waiting to see an orthopedic surgeon and a dermatologist. A review of the resident's Quarterly Minimum Data Set (MDS) assessment completed on 01/04/2022, documented his Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. Further record review for Resident #51 revealed a physician referral made on 12/15/2021 to see an orthopedic doctor. A dermatology consult referral was made and signed on 12/15/2021. A second referral form for a dermatology consult was signed off by prescribing physician on 01/20/2022. Appointments for these referrals could not be found. On 02/17/2022 at 11:04 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN)/Unit Manager. She reported, she had just started a month ago and was not aware of Resident #51 needing appointments. She also stated, she had made a couple of appointments for other residents but only because they were left on her desk. She reported there is no scheduling nurse currently. On 02/17/2022 at 2:45 PM, an interview was conducted with the Director of Nursing (DON). She reported that the unit clerk makes the appointments, but we do not have one at this time. She reported the unit manager is currently doing the scheduling. On 02/17/2022 at 3:41 PM, a second interview was conducted with the DON. She was asked if Resident #51 has any upcoming appointments. She stated No, none that I've found. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 3 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/14/2022 at 11:14 AM and again on 1:45 PM, the toilet seat and rim in room [ROOM NUMBER] (Resident #19's room) were observed with dry debris. (Photographic evidence obtained) On 02/14/2022 at 11:26 AM, the air conditioning/heating wall unit filters in room [ROOM NUMBER] (Resident #49's room) were observed with thickened dust and debris. (Photographic evidence obtained) On 02/14/2022 at 12:09 PM, the air conditioning/heating wall unit filters in room [ROOM NUMBER] (Resident #151's room) were observed with thickened dust and debris. (Photographic evidence obtained) On 02/14/2022 at 12:45 PM, room [ROOM NUMBER]'s (Resident #92's room) floor and over-the-bed table were both covered with dried liquid splatter. On 02/15/2022 at 9:07 AM, room [ROOM NUMBER] was observed. The resident's toilet rim and seat were observed with dark dry debris. The floor in the resident's room was observed unclean and was sticky to the feet when ambulating from the residents' position to bathroom and around resident's bed. (Photographic evidence obtained) On 02/15/2022 at 9:23 AM, room [ROOM NUMBER] was observed. The air conditioning/heating wall unit filters were thickened with dust and debris. (Photographic evidence obtained) On 02/15/2022 at 10:51 AM, room [ROOM NUMBER] was observed. Enteral feeding liquid was observed splattered on the over-the-bed table, and on the floor. On 02/16/2022 at 12:35 PM, room [ROOM NUMBER] was observed. The enteral feeding liquid was still observed on the floor and table. The maintenance manager was interviewed on 02/16/2022 at 1:40 PM. He stated that all facility hallways were being cleaned and disinfected according to facility practices. The communal shower room on the 100-200 hallway was observed on 02/16/2022 at 1:50 PM. Broken tiles were observed sitting on one of the corners of the shower area. (Photographic evidence obtained) On 02/16/2022 at 2:39 PM, room [ROOM NUMBER] was observed. Resident's bathroom paper holder was unclean and dusty, with debris. A dirty phone charging cable was plugged into the bathroom outlet. (Photographic evidence obtained) On 02/17/2022 at 8:40 AM, the communal shower room on the 100-200 hallway was observed. The broken tiles were observed in the same position as previously seen on 02/16/2022. The communal shower was observed in continuous use throughout 02/17/2022. On 02/17/2022 at 9:25 AM, room [ROOM NUMBER] was observed. The resident's bathroom was still unclean, and with debris. The phone charger was still plugged into a bathroom outlet that was unclean. Two certified nursing assistants (CNAs) were interviewed on 02/17/2022 at 1:58 PM. They said that all staff contribute to clean the surfaces in the residents' rooms as needed, when they see it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 4 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unclean or messed-up. Both staff members verbalized that if something is spilled onto the floor, we clean it ourselves, unless it doesn't come out easy, then we call housekeeping. It was also verbalized that by one of the staff members it is everyone's responsibility to clean up after themselves, but housekeeping does the harder cleaning. The environmental services staff (EVS) was interviewed on 02/17/2022 at 2:12 PM. They stated that it was their responsibility to clean each resident room daily. This task was divided between 3 EVS staff members throughout the facility. Specifically, the staff member stated that her role included dusting furniture items, cleaning all floors and bathroom including toilet and sink, contact areas such as the bed including bed rails and call bell, and bedside table. When asked about the deep cleaning of each room, the EVS staff member verbalized that this task, which included the AC/Heating unit vents, was performed by maintenance and it was usually done once a week. A review of the facility's policy and procedure entitled, Interim Recommendations for Routine & Terminal COVID-19 Isolation Room/Unit Cleaning and Kitchen Floor Wet Mop Procedures dated 02/18/2021 read: [Contracted Environmental Services Group] and its subsidiaries promotes the health and safety of all employees, as well as that of the clients and residents we serve. Purpose: To assist in preventing the spread of COVID-19 (Coronavirus-2109) from isolation rooms units to non-infected areas/persons. Cleaning: When you clean a surface you remove all visible debris. Clean Walls: Using an EPA (United States Environmental Protection Agency) approved solution, wipe down vertical surfaces. (Copy obtained) Based on observations, interviews, record review and facility policy and procedure review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, and provide maintenance services as necessary in five resident rooms (102, 500, 501, 512 and 511) affecting six (Residents #4, #59, #19, # 49, #151, and #92) out of a total of 41 residents in the sample. Specifically, there were concerns with sticky floors in bathrooms, dead roaches, debris on floors and under resident's beds, enteral feeding product splattered on feeding pumps, IV poles, walls, mattresses, bed frames and floors, and Air Conditioning (AC)/Heating units filters were not clean. A clean-living environment is necessary to reduce the spread of infection and promotes the highest well-being of residents. The findings include: On 02/14/2022 at 10:32 AM, Resident #4's and #59's room (#102) was observed. Enteral food product was splattered on the feeding pump, IV pole, walls, mattress, bed frame and floor. A brown biological substance was smeared on the wall near the closet over garbage can. Plastic tubing caps were on the floor. A metal screw, a dead roach, dust, and debris were on the floor under the bed. Pieces of bread were on the floor next to the garbage can. (Photographic evidence obtained) During an interview with Resident #59 on 02/15/2022 at 7:15 AM, she stated that the housekeeping staff only clean the room every other day. They mop the dirt into the corners and that's why there is a buildup of dried dirt and debris in the corners of the bathroom. The floor of the bathroom is sticky too. She stated that there are live roaches in her room at night and she if very afraid of roaches. She stated her roommate, Resident #4, cannot talk so she tries to watch out for her. The buildup of dirt and debris and the sticky floor in the bathroom were observed. (Photographic evidence obtained) On 02/15/2022 at 10:35 AM, Resident #4 was observed lying in bed, covered with a sheet and a blanket. The enteral food product had not been cleaned up. The dried on brown biological substance smeared (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 5 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the wall near closet over garbage can had not been wiped off. Plastic tubing caps were on the floor. A metal screw, a dead roach, dust, and debris were under the bed. (Photographic evidence obtained) On 02/16/2022 at 9:02 AM, Resident #4 was observed lying in bed, covered with a sheet and a blanket. The enteral food product had not been cleaned up yet. The dried on brown biological substance smeared on the wall had not been wiped off. Plastic tubing caps were on the floor. A metal screw, the dead roach, dust, and debris were under the bed. (Photographic evidence obtained) During an interview with Employee A, Unit Manager on 02/16/2022 at 12:10 PM, she stated, she is very new to her position and does not know Resident #4 well. She was asked to come to the resident's room and see that it had not been cleaned appropriately. She was shown the debris on the floor and the walls, the food product on the wall, pump, pole, and floor. While in the residents' restroom, she stated that the floor in the bathroom was sticky. She agreed that it appeared the dirt and debris had been mopped into the corners. She stated that she was not sure who was responsible for cleaning up the food product, but she would let housekeeping know that they needed to come clean her room. During an interview with the Corporate Environmental Services Director on 02/17/2022 at 11:56 AM, he stated they were still cleaning Resident #4's and #59's room. He acknowledged the room needed a deep cleaning. During an interview with the [NAME] President of Clinical Services (VP) and the Director of Nursing (DON) on 02/17/2022 at 02:55 PM, the VP stated that any staff can clean the IV pole and pump for g-tube feedings. He stated, Our policy is if you see it, you should clean it. He informed that department heads round in the resident rooms every morning. He stated Clearly, there is room for growth, and acknowledged that room [ROOM NUMBER] was not being cleaned each day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 6 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview with Resident #47 on 02/14/2022 at 1:02 PM, she reported that the facility had delivered her mail open and empty of contents. She stated that she ordered ruby earrings for her granddaughter from a department store for Christmas, and that they were delivered to the facility the first week of December. She could not remember if it was the 12/06/2021 or 12/07/2021, but she did not receive the package until 12/12/2021. However, when it arrived it was open and the only thing in the package was a shipping receipt. She mentioned that she filed a grievance on 12/13/2021 with the Social Service Director (SSD) and the facility said they would investigate it. She stated that she had not received the reimbursement she was promised yet. A record review for Resident #47 revealed she was admitted on [DATE] with diagnoses that included cerebrovascular disease, pain in right and left shoulders, and assistance with personal care. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the grievance logs provided for December 2021 and January 2022 did not list a grievance filed by Resident #47 for missing items, or any documentation of any form of resolution. The provided documentation revealed that the facility had properly reported the misappropriation of property on 12/13/2021 and did not substantiate the allegation of misappropriation of property. The investigation was closed without informing the resident of the outcome of the investigation. In an additional interview with Resident #47 on 02/15/2022 at 8:40 AM, she stated that she had not been reimbursed for her missing earrings, and she had to buy her granddaughter a different present last minute because she did not get the earrings she ordered. During an interview on 02/15/2022 at 10:20 AM with the SSD, she stated that resident mail was delivered daily and unopened unless the resident requested help to open their mail. The Executive Director (ED), also present, explained that the mail was delivered to the receptionist daily and she gave it to the Activity Department for delivery. An interview was conducted on 02/15/2022 at 11:12 AM with the Executive Director (ED) and Social Services Director (SSD), regarding the status of the grievance that Resident #47 reported she filed on 12/13/2021. The ED stated that the facility had completed their investigation and were unable to substantiate the claim, and that Resident #47 was aware of the findings. The facility did not provide any documentation showing Resident #47's grievance was resolved. Review of the policy and procedure titled Clinical Guidelines-Complaint/Grievance Document Name: N-1042, revised on 08/09/2018 read: The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with whom grievances may be file (State agency, Ombudsman, Quality Improvement Organization). The grievance officer/designee shall act on the grievance and begin follow up of the concern or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 7 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0585 Level of Harm - Minimal harm or potential for actual harm submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame: this should not exceed 14 days. The findings of the grievance shall be recorded on the complaint/grievance form or electronic equivalent. Once the follow up is complete, the results should be forwarded to the executive director for review and filing. The Executive Director/Designee will log complaint/grievance in Monthly Grievance log or electronic equivalent. (Copy obtained) Residents Affected - Few Based on interviews, record review and facility policy and procedure review, the facility failed to adequately investigate grievances to ensure satisfaction with the resolution for two (Residents #59 and #47) of two residents reviewed for grievances, related to staff behavior and missing items, out of a total of 41 residents in the sample. The findings include: 1. During an interview on 02/15/2022 at 7:15 AM, Resident #59 stated that the Employee F, Certified Nursing Assistant (CNA) is rude. Resident #59 stated the CNA had worked with her 2-3 times and she is always hateful to her. Employee F was assigned to Resident #59 on the overnight shift last night 7 PM to 7 AM. She had put her call light on and when the CNA entered the room, she asked her why she had her light on. Resident #59 stated that she asked her Why are you so hateful to me? The CNA replied, Excuse me? So, she asked her Why are you mad at me? The CNA told her, I don't want to be an enabler. You ask for help for things you know you can do. Resident #59 stated she reported the CNA's rude behavior to the nurse on duty, Employee H, LPN last night. She was asked what happened after she reported it and she stated, I don't know. It won't do any good. A review of the facility grievance log revealed Resident #59 filed a grievance on 01/25/2022 related to dietary concerns and wanting nicotine supplies. Nursing and Dietary conducted a follow up. Nicotine patches were provided to the resident. Resident #59 was notified on 01/25/2022 and she was satisfied with the outcome. No other grievances from Resident #59 were on the log. A review of the clinical record for Resident #59 revealed she was admitted on [DATE]. Her diagnoses included: polyneuropathy, chronic obstructive pulmonary disease, apraxia following unspecified cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, lack of coordination, need for assistance with personal care, low back pain, chest pain, hypothyroidism, anxiety disorder, depressive episodes, schizoaffective disorder, bipolar type, idiopathic progressive neuropathy, hyperlipidemia, and heart failure (Copy obtained). A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating no cognitive impairment. She had no mood problems, no delusions, no hallucinations, no behaviors directed at others or herself. Her preferences were very important to her. She required limited assistance of one person for activities of daily living or supervision only. No impairment in her upper or lower extremities. She was diagnosed with schizophrenia, depression and anxiety and restraints were not used for her. (Copy obtained) A review of the resident's care plan dated 02/17/2022 revealed a focus area that read: The resident has an ADL self-care performance deficit related to activity intolerance and fatigue. The interventions included: Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use bell to call for assistance. Praise all efforts at self-care. Another focus area read: Resident is at risk for falls related to deconditioning, psychoactive drug (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 8 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few use. Interventions included: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. (Copy obtained) During a phone interview with Employee H, LPN at 7:55 AM, she confirmed that Resident #59 did report to her that Employee F was rude and disrespectful to her on Monday, February 14th on the 7p-7a shift. The resident told her that she was in the restroom and needed assistance, so she put her call light on. The CNA came and asked her why she keeps putting her call light on when she can do it herself. The resident asked her why she was hateful to her, and the CNA told her that she feels she is enabling her when she can do it. She stated the resident was upset when she was telling her. Employee H stated that she has been a nurse for 3 years. She has had training through her agency on how to report a grievance. She stated she reported it to who she thought was the Unit Manager (UM). She does not know all the names of the nurses at the facility. She described the UM and stated she reported it verbally to her but did not fill out a grievance form. During an interview on 02/17/2022 at 8:49 AM with Resident #59, she confirmed that when Employee F was rude to her it was around 11:00 PM on Monday, February 14th, 2022. It happened in her restroom. She was using the toilet. She explained that she is not able to change her brief when needed. She can pull it up by herself but if it is soiled then she needs help with it. She confirmed that she had told a nurse about a week earlier about Employee F's rude behavior, but she was not sure who it was. She went to the nurse's station and told someone. She knows that it did not get reported because Employee F came in and worked with her again the next night and she acted the same way. During an interview on 02/17/2022 at 9:24 AM with Employee A, UM, she stated she has not had concerns brought to her about Resident #59. When informed of Resident #59's concerns she stated Oh, I would have remembered that and filled out a form for it. During an interview on 02/17/2022 at 9:30 AM with the Social Services Director. She stated that she had not received a grievance form or any verbal reports regarding Resident #59. Review of the nursing progress notes from 01/08/2022 through 02/17/2022 revealed no notes regarding the resident's concerns about Employee F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 9 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A clinical record review for Resident #59 revealed the State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) form dated 04/07/21. The Level I, Section II indicated the resident has had serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation or requires intervention by the mental health or judicial system. There was an indication the resident had received recent treatment of a mental illness with an indication that the individual has experienced at least one of the following. Both A. psychiatric treatment more intensive than outpatient care (e.g., partial hospitalization or inpatient hospitalization) and B. Due to the mental illness, the individual has experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home or in a residential treatment environment or which resulted in interventions by housing or law enforcement officials. The PASRR was not a provisional admission. Section IV indicated no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Residents Affected - Few A record review revealed Resident #59's was admitted to the facility on [DATE]. Her diagnoses included: polyneuropathy, chronic obstructive pulmonary disease, apraxia following unspecified cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, lack of coordination, need for assistance with personal care, low back pain, chest pain, hypothyroidism, anxiety disorder, depressive episodes, schizoaffective disorder, bipolar type, idiopathic progressive neuropathy, hyperlipidemia, and heart failure. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating no cognitive impairment. She had no mood problems, no delusions, no hallucinations, no behaviors directed at others or herself. Her preferences were very important to her. She required limited assistance of one person for activities of daily living or supervision only. No impairment in her upper or lower extremities. She was diagnosed with schizophrenia, depression and anxiety and restraints were not used for her. During an interview on 02/17/22 at 2:47 PM with the [NAME] President of Clinical Services (VP) and the Director of Nursing (DON), the VP confirmed that there should have been a referral for a Level II done when she was admitted . Based on medical record reviews, interviews and facility policy and procedure for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure that three (Residents #9, #59 and #73) out of a total of 41 residents in the sample, were screened for a Level II. The findings include: 1. A review of the medical record for Resident #9 revealed a PASRR dated 10/16/20 was completed and required a Level II be initiated. Resident #9 was admitted on [DATE] with a diagnosis of paranoid personality disorder, anxiety, bipolar disorder, schizoaffective disorder, and major depressive disorder. The PASSAR noted depressive disorder and schizophrenia and has a hospital discharge exemption which noted a Level II was needed no later than 40th day of admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 10 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/16/22 at 10:06 AM, an interview was conducted with the Social Service Director (SSD). She brought the level 1 for resident and reported, she could not find a Level II was conducted. The form was reviewed which indicated a 30-day exemption from the hospital and on the 40th day a Level II should be started. The form was signed 10/16/20. (Photographic evidence obtained) On 02/16/22 at 10:18 AM, an interview was conducted with the Administrator and SSD. The Administrator confirmed the resident should have had a level II and it was not done. She reached out to someone else to clarify, and is asking Kepro to come in and do some training for staff. 3. A clinical record review revealed that Resident #73 was admitted to the facility on [DATE] with primary diagnosis of Parkinson disease. Other diagnoses include anxiety disorder, depressive episodes, schizophrenia. Physician orders included Clozaril 250 mg every 12 hours for schizophrenia, Mirtazapine (Remeron)15 mg at bedtime for depression, and buspirone 10 mg three times a day for anxiety. The admission MDS dated [DATE], indicated the resident had a BIMS score of 14, indicating no cognitive impairment. Resident required supervision for bed mobility, transfer, toilet use and eating. Active psychiatric/mood disorders include anxiety, depression, and schizophrenia. Resident received antipsychotic, antianxiety, and antidepressants. Resident #73's PASRR dated 01/10/22 revealed diagnoses of anxiety disorder, schizophrenia and major depressive disorder. Resident was assessed as a hospital discharge exemption which noted a Level II was needed no later than 40th day of admission. During an interview with the DON on 02/17/22 at 1:08 PM, she confirmed that Resident #73 did not have a level II PASRR. She added that she was not familiar with the PASRR process, and the facility had requested Kepro to conduct training to the facility staff. A review of the facility's policy and procedure titled, Preadmission Screening and Resident Review (PASRR), Document Name: SS-402 Revised on 11/08/2021 revealed that the facility will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre- admission screening according to Federal /State guidelines. The Purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. If an individual is declared exempt from a PASRR screening, the Center should male sure that appropriate documentation is on the chart upon admission. Individuals who are exempt from this assessment include: a. Those who are admitted after a release from an acute care hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery. If it is learned after admission that a PASRR level II screening is indicated, it will be the reasonability of social services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 11 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interviews, the facility failed to provide appropriate services and communication devices for one (Resident #4) out of two residents sampled for communication, out of a total of 41 residents in the sample. The resident's communication board was stapled to the bulletin board in her room under an activities department calendar. Failure to provide a communication device for a resident whose ability to communicate is impaired could potentially affect the resident's ability to communicate in an emergency and negatively affect his/her health outcome. Residents Affected - Few The findings include: A review of the clinical record for Resident #4 revealed she was admitted to the facility on [DATE]. Her diagnoses included: Aphasia following unspecified cerebrovascular disease, unspecified dementia without behavioral disturbances, acquired absence of unspecified leg above knee, contracture unspecified hand, unspecified lack of coordination, anxiety disorder, other depressive episodes, cognitive communication deficit, respiratory failure, chronic obstructive pulmonary disease, dysphagia oropharyngeal phase, stiffness of right hand, need for assistance with personal care. On 02/14/22 at 10:32 AM, Resident #4 was observed lying in her bed with her eyes shut. She did not arouse when her name was called. The room was dark, and the blinds were closed on the window. A bulletin board was observed on the wall next to her bed. Stapled to the bulletin board was a manilla folder that read, Resident #4's Communication Board. Stapled on top of the folder was an activities calendar for the month. When the activities calendar was pulled back, the communication board could be seen inside the pocket of the manilla folder. (Photographic evidence obtained) On 02/15/22 at 10:35 AM, Resident #4 was observed lying in bed covered with a sheet and a blanket. Her head was elevated. She appeared alert and attempted to communicate with this surveyor. She was non-verbal but could make some sounds. She began pointing to her right leg. The leg was amputated at the knee. She was not able to make her need known. She appeared to understand questions asked of her but could only point and make grunting sounds. She did not appear in distress. When asked if the staff use a communication board with her, she shrugged and nodded yes. When asked where it was, she shrugged her shoulders. The communication board was observed in the manilla folder stapled to the bulletin board. The activities calendar was stapled over it. It did not appear to have been moved/used since the prior observation. A review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented her Brief Interview for Mental Status (BIMS) score as 12 out of a possible 15 points, indicating moderate cognitive impairment. The assessment indicated adequate hearing, unclear speech, not comatose, usually understood and usually understands. She had no disorganized thinking or difficulty focusing attention. Her functional status was assessed as requiring extensive assist of one person or total dependence on one person for all activities of daily living. She did not walk or locomote, move on or off toilet or turn around. She had impairment on one side in her upper extremities. Impairment on both sides on lower extremities. She used a wheelchair for a mobility device. A review of the resident's annual MDS assessment dated [DATE] revealed her personal preferences were assessed as being very important to: choose clothes, take care of personal belongings, choose between shower, bed bath, tub, or sponge bath, choose bedtime, have books, newspapers, and magazines to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 12 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0676 read, listen to music she likes, keep up with the news, do her favorite activities. Level of Harm - Minimal harm or potential for actual harm A review of the care plan for Resident #4 dated 07/14/21 revealed she has a communication problem related to cerebrovascular accident, aphasia, and convulsions. With goal to maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately using communication board, writing messages through the next review date. Interventions included: Staff will utilize patient's communication board when patient is experiencing difficulty communicating her wants/needs. Monitor/document for physical /nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document resident's ability to express and comprehend language memory, reason ability, problem solving ability and ability to attend. Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express. Residents Affected - Few During an interview with Employee C, Certified Nursing Assistant on 02/16/22 at 9:42 AM, she stated she has worked here 4 years. She stated that she can figure out what Resident #4 wants but sometimes it's like charades trying to figure out what she's trying to tell me. She is not aware of a communication board for her. She stated, If there is one, I don't know where it is or what it looks like. She confirmed that the facility does not have an electronic device to use to communicate with her. On 02/16/22 at 9:02 AM, Resident #4 was observed lying in bed. The communication board was observed to be in the manilla folder stapled to the bulletin board. It did not appear to have been moved/used since the prior observation. (Photographic evidence obtained) During an interview with Employee D, CNA on 02/16/22 at 10:06 AM, he stated he has worked at this facility for the past 6 months. He stated he understands Resident #4's hand gestures and can figure out what she wants. He has never seen a communication board for her. He stated, She just points, and I can figure it out, eventually. He confirmed that there is no electronic device used to communicate with her. She likes her window blinds closed and the room dark. she is very specific about what she will tolerate. During an interview with Employees A and B, Unit Managers (UM)/Licensed Practical Nurses (LPN) on 02/16/22 at 12:10 PM, Employee B stated that she thought there was one resident on the long-term care side of the building that had a paper communication form, but she did not know where it was. She stated that Resident #4 is non-verbal, and she thinks it might be her. They both went to Resident #4's room and looked for it. They did not see it and left the room. They walked back down the hall and stopped Employee E, CNA and asked her if Resident #4 had a communication board. The CNA stated no, the staff use hand gestures to communicate with her. She stated the resident will tell them if she wants her hair combed or a clean brief or whatever she wants. They have no trouble understanding her. She just points to what she wants. Employee A, UM stated she is very new to her position and does not know Resident #4 well. She was asked to come back to the resident's room and see the communication board. She was informed that the use of the communication board is in the resident's care plan. She was shown the communication board that was stapled to the bulletin board underneath the activities calendar. She started to remove the staples and stated That needs be taken down out of there. No one can use it stuck up in there. She proceeded to remove the staples from the board and put the manila folder back up on the bulletin board. Resident #4 was shown the board and asked if the staff use it with her. She shook her head no. The UM stated she would use it to train the staff to communicate with the resident. She stated they have a lot of new and agency staff that do not know the resident and would need to use the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 13 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0676 communication board to communicate with her. Level of Harm - Minimal harm or potential for actual harm Review of the communication board for Resident #4 revealed two double-sided 8-inch by 11-inch forms that had been laminated with pictures on the forms that indicated pictures of needs the resident might have that she could point to in an effort to make her needs known. (Photographic evidence obtained) Residents Affected - Few On 02/17/22 at 9:35 AM, Resident #4 was observed to be seated in a Geri-chair covered with a blanket in the common area of the long-term care unit. She began to point across the room and make sounds. She was pointing to her leg and then across the room to the hallway in front of the nurse's station. Assistance was requested of the direct care staff to see if they could understand what it was, she wanted. A nurse and two CNAs went to the resident and started asking her questions, trying to guess at what she wanted. They kept asking her questions and she kept pointing at different things. A fourth CNA also tried. These attempts went on for 3 minutes. When asked if they wanted to use her communication board one of the CNAs stated, Does she have one? She was informed that it is in her room on the bulletin board. The CNA went and retrieved it. The staff then started pointing at the board and asking her questions. The resident pointed at the pictures and the staff were then able to find out what she wanted. During an interview with the [NAME] President of Clinical Services (VP) and the Director of Nursing (DON) on 02/17/22 at 2:55 PM, the VP stated that the Therapy Department instructs CNAs on the use of the communication boards. He confirmed that Resident #4 has a communication board, and it is to be used with the resident. He looked for a policy and procedure but could not find one specific to the use of a communication device. He provided progress notes from the therapy department. A review of the Speech Therapy discharge summary for Resident #4 dated 11/22/21, read: Patient demonstrates independently how to use her board to communicate specific wants/needs. Recommend staff continue to use communication board as taught to facilitate patient's expression of wants/needs when experiencing difficulty. Team Communication/Collaboration: Team communication/collaboration included correspondence with primary caregivers to facilitate development and follow-through of patient's plan of treatment and reviewed patient's plan of treatment and treatment services with interdisciplinary team members. Transition/Discharge Planning Process: Patient will remain a long-term care resident of this facility. Caregiver training will be completed to facilitate use of communication board. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 14 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure physician's orders for oxygen were in place prior to administering oxygen for two (Residents #301 and #453) of eight residents receiving treatment for respiratory care, out of a total of 41 residents sampled. This could result in the resident not receiving appropriate care and/or clinical complications. Residents Affected - Some The findings include: 1. A review of Resident #301's clinical record revealed she was admitted to the facility on [DATE] with primary diagnosis of Parkinson's disease. Secondary diagnoses included, but not limited to malignant neoplasm of unspecified of bronchus or lung, chronic obstructive pulmonary organism (COPD), malignant neoplasm of the lung, and pneumonia. On 02/14/22 at 11:03 AM, Resident #301 was observed in her room receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 Liters per minute (L/Min). The oxygen tubing was not properly connected to the concentrator and the resident was not receiving oxygen. Resident #301 denied having any difficulty with breathing. There were no signs of respiratory distress observed. (Photographic evidence obtained) The Minimum Data Set (MDS) assessment for Resident #301 was being completed by the facility and was unavailable for review. A review of the baseline care plan for Resident #301 did not indicate any oxygen use. A review of current physician's orders for Resident #301 revealed no oxygen order. On 02/15/22 at 1:05 PM, Resident #301 was observed in her room receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 L/min. During an interview with Employee U, Licensed Practical Nurse (LPN) on 02/17/22 at 10:54 AM, she confirmed that the concentrator for Resident #301 was not connected correctly, and the resident was not getting any oxygen. She stated the oxygen concentrator was set at 2.5 L/min. She was then asked to confirm Resident #301's oxygen orders. After reviewing the resident's orders, she stated, Resident #301 did not have any oxygen orders. She then notified the unit manager. (Copy obtained) During an interview with Employee B, LPN/Unit Manager on 02/17/22 at 11:00 AM, she confirmed that Resident #301 had no orders for oxygen. She added that the resident was admitted with 3 L/min oxygen, however, the orders were not entered into point click care (PCC - facility electronic medical record). She then went to the resident's room and adjusted the oxygen setting to 3 L/min. and added the oxygen orders to the medication administration record. 2. On 02/14/22 at 11:28 AM, Resident #453 was observed resting on bed receiving oxygen therapy via nasal cannula. When she was asked what her oxygen concentrator was supposed to be set, she responded, I'm unsure at what level I'm supposed to be on. The oxygen concentrator was set at 3.5 L/min. A review of Resident #453's clinical record revealed she was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 15 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0695 Further record review for Resident #453 revealed no physician orders for oxygen. Level of Harm - Minimal harm or potential for actual harm On 02/15/22 at 01:32 PM, Resident 453 was observed sleeping in bed wearing nasal cannula. The oxygen concentrator was set at 3 L/min. Residents Affected - Some On 02/16/22 at 11:17 AM, Resident 453 was observed in her room wearing her nasal cannula. The oxygen concentrator was set a 3 L/min. (Photographic evidence obtained) Skilled note dated 02/12/22 was entered at 14:26 read, Respiratory status is clear no SOB noted. Lung sounds are clear no cough noted. Oxygen is used via nasal cannula 2.5 litres/minute (l/min). On 02/17/22 at 9:28 AM, an interview was conducted with Resident #453's assigned nurse, Employee O, LPN. When she was asked to confirm Resident #453's current oxygen orders, she stated, I think she is on two liters (O2 flow), let me check. I believe it's two liters. After looking in PCC and hard chart, Employee O, LPN stated, I do not see any orders for O2. She explained that the nurses gets the orders of what the resident needs from the medication administrative record (MAR). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 16 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, interviews, and facility policy and procedure review, the facility failed to ensure that two (Residents #300 and #452) of six residents receiving antibiotics, out of a total of 41 residents in the sample, remained free of significant medication errors by failing to administer antibiotic medication as ordered. Residents Affected - Few The findings include: 1. A review of clinical records for Resident #300 revealed she was admitted to the facility on [DATE] with primary diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery. Other secondary diagnoses included Type II diabetes mellitus, pressure ulcer of right heel, encounter for change or removal surgical wound. A review of Resident #300's physician's orders revealed an order for vancomycin trough one time every Monday for osteomyelitis with start date of 02/14/22 and vancomycin HCL (antibiotic administered for bacterial infection) in dextrose solution 1-5 Gram /200 ML - use 200 ml intravenously at bedtime for infection infuse entire content of BAG IV over 180 minutes at 166 ml/hr. every 24 hour for 31 days - start date 01/26/2022- 02/26/22. A review of the care plan for Resident #300 revealed she was on antibiotic therapy Vancomycin related to (r/t) MRSA infection with goal for resident to be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included administer antibiotic medications as ordered by physician, monitor/document side effects and effectiveness every shift, and report pertinent lab results to MD. (Copy obtained) On 02/14/22 at 10:40 AM, a bag of vancomycin was observed hanging at the bedside of Resident #300. (Photographic evidence obtained) During an interview with Resident #300 on 02/14/22 at 10:42 AM, she stated, she was not sure why the medication was there. When asked if she had received any medication via the intravenous (IV) line she stated, No. She added that the nurse had left it there the previous night and never returned. On 02/14/22 at 11:15 AM, an interview was conducted with Employee O, Licensed Practical Nurse (LPN). She stated that Resident #300's (IV) medication was due at night and therefore, did not hang the medication. When asked if the resident had received the medication, she checked the medication administration record (MAR) and stated it was checked as given. She mentioned that the night nurse might have thought the resident took medication twice a day and took the medication out of the refrigerator for the day nurse since the medication needed some time to warm up. When asked what time the night shift nurse left the facility, she stated 7:00 AM. When asked when medication Administration was due, she said, 9:00 AM. She was then asked how long IV medication should be taken from the refrigerator, she stated, 30 minutes and confirmed the IV medication should not be left at the bedside. A review of Resident #30's medication administration record (MAR) for February 2022 revealed that the medications vancomycin HCL in dextrose solution 1-5 Gram/200 was not administered on 02/01/22, 02/02/22, and 02/03/22, and mark as held on 02/07/22, 02/08/22, 02/09/22, and 02/10/22. (Copy obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 17 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #300's laboratory results for vancomycin trough revealed the following: on 01/25/22, 02/07/22 levels were less than 1.4 micrograms per milliliters (mcg/ml); on 02/12/22 Vancomycin trough was 2.5 mcg/mL and on 02/14/22 the level was at 5.4 mcg/mL. The Normal range for vancomycin trough is 10.0-20.0 mcg/mL. (Copy obtained) 2. A review of clinical records for Resident #452 revealed he was admitted to the facility on [DATE] with primary diagnosis of acute respiratory failure. Other secondary diagnoses included cellulitis of right lower limb, infection, and inflammatory reaction due to unspecified deep veins of right lower extremity, encounter for other specified surgical aftercare. A review of physician's orders for Resident #452 revealed cefepime HCL solution reconstituted 2 grams (gm) intravenously two times a day for right hip infection until 3/07/22, with start date of 01/26/22. Vancomycin trough, creatine to be done twice a week every Monday and Thursday for monitoring until 03/8/22, with start date of 02/10/22. Vancomycin HCL solution 1 gm intravenously two times a day for infection until 03/07/22. (Copy obtained) A review of the care plan for Resident #452 revealed he was on antibiotic therapy (vancomycin and cefepime) r/t to right hip infection with goal for resident to be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included administer antibiotic medications as ordered by physician, monitor/document side effects and effectiveness every shift, and report pertinent lab results to MD. (Copy obtained) A review of the February 2022 MAR for Resident #452 revealed the medication cefepime was not administered on 02/05/22 in the morning and vancomycin was not administered on 02/11/22 and 02/14/22. (Copy obtained) During an interview with Employee K, Registered Nurse (RN)/Vice President of Clinical Services on 02/17/22 at 3:00 PM, he confirmed that Resident #300 and Resident #452 did not receive their antibiotics as prescribed. When he was asked why Resident #300 vancomycin was withheld despite low laboratory levels of vancomycin trough, he said he could not find any documentation why it was withheld. He also confirmed that he had contacted the pharmacy and resident's physician and they all denied giving orders to withhold the medication. He added that the infectious disease physician was contacted, and the resident stopped date was pushed back to cover the missed doses. When asked about antibiotics monitoring, he stated that he was training the Director of Nursing (DON) to cover the position. He also mentioned that the person designated for the infection control had resigned. A review of the facility's policy and procedure, titled: Antibiotic Stewardship, revised in December 2016 revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic stewardship. The policy interpretation and implementation read, The Purpose of antibiotic stewardship program is to monitor the uses of antibiotics in the residents. Orientation, training, and education of staff will emphasize the importance of antibiotics and will include how inappropriate use of antibiotics affects individual residents and the overall community. Training and education will include emphasis on the relationship between antibiotic use and: Gastrointestinal disorders; opportunist infections; medication interactions; and the evolution of drug- resident pathogens. According to the Mayo Clinic https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-20045720.(Accessed on 02/17/22 at 3:00 p.m.): Antibiotics are strong medications designed to kill bacteria or stop their growth. The misuse and overuse of antibiotics can lead to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 18 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 0760 Level of Harm - Minimal harm or potential for actual harm growth and spread of antibiotic-resistant bacteria. This may lead to infections that are resistant to antibiotic treatment. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 19 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, record review and facility policy and procedure review, the facility failed to ensure nutritional supplements kept in 2 of 2 nourishment refrigerators were stored in accordance with professional standards for food service saftey and failed to ensure equipment in the nourishment rooms were clean and free of debris. The findings include: During an observation of the two-nourishment rooms in the facility on 02/16/22 at 12:21 PM revealed the following: Each refrigerator had a container of Med Pass which were expired (expiration dates of 01/13/22 and 01/27/22). A review of the Medpass shake instructions revealed, use within 4 days of opening. (Photographic evidence obtained) The freezer in the nourishment room on hall 200 contained a dried brownish stain in it. (Photographic evidence obtained) Microwaves in the nourishment rooms were not clean. One microwave had dried reddish stain in it and the other had a dried whitish stain in it. (Photographic evidence obtained) On 02/17/22 at 10:14 AM, a second observation of nourishment room on hall 200 revealed the same results as the observation on 02/16/22. Refrigerator had a container of Med Pass which was expired (expiration date of 01/13/22). The freezer in the nourishment room on hall 200 contained a dried brownish stain in it. (Photographic evidence obtained) One microwave had dried reddish stain in it. (Photographic evidence obtained) An interview was conducted with Employee M, Certified Nursing Assistant (CNA) on 02/17/22 at 10:30 AM. Employee M stated that the CNAs pass snacks and drinks from nourishment room. An interview conducted with Employee N, Licensed Practical Nurse (LPN) on 02/17/22 at 10:24 am. Employee N, LPN stated that the nurses check refrigerator temperatures and housekeeping cleans the microwave and refrigerator. The CNAs try to keep the counters clean, and the dietary staff checks the refrigerator for expired items. An interview was conducted with Director of Nursing (DON) on 02/17/22 at 2:45 PM. The DON stated that CNAs, unit manager, and dietary staff keep nourishment rooms clean. She stated that CNAs clean inside the refrigerator. During an interview with the Certified Dietary Manager (CDM) on 02/17/22 at 3:25 PM, he confirmed the dietary staff was responsible for cleaning the refrigerators and bringing snacks to nourishment room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 20 of 21 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 105917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216 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 A review of the facility's policy for Safe Handling for Foods from Visitors, dated 7/2019, stated #5. Refrigerators/freezers for storage of foods brought in by visitors will be properly maintained and have temperature monitored daily. Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more than seven days and cleaned weekly. Residents Affected - Some . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 21 of 21