Health inspection·June 14, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to store all drugs in locked compartments for one (Resident #4) of four sampled residents. Specifically, an expired Albuterol inhaler, not ordered by the physician, was found on the resident's bedside tray table. Failure to ensure safe and secure storage of all resident medications, can result in resident access to medications that are not their own among other potential concerns. The findings include: On [DATE] at 11:30 a.m., Licensed Practical Nurse (LPN) A was observed checking Resident #4's blood glucose level. An Albuterol inhaler was observed on the resident's bedside tray table. It was not labeled and the nurse did not remove it from the resident's room. On [DATE] at 11:35 a.m., Resident #4 was asked if she used this inhaler. She stated, Yes, I use it if I get short of breath. She was asked if she let staff know when she used the inhaler. She stated, No, should I be telling them? The inhaler was noted to have an expiration date of [DATE]. She stated she last used the inhaler yesterday (6/13). When she was asked if she was aware that the inhaler had expired in [DATE], she replied, No, I can't read that small writing. (Photographic evidence obtained) On [DATE] at 11:40 a.m., LPN A was asked if she was aware that Resident #4 had an Albuterol inhaler in her room on her bedside table. She stated, I didn't notice it. She was asked if Resident #4 had an order for an Albuterol Inhaler. She stated, Let me check and then stated, No, not an Albuterol inhaler, but an Albuterol nebulizer. She was asked if medications should be left in residents' rooms. She replied, No, they should be locked in the med cart unless they have an order to keep them in their room. She was asked if this resident had an order to keep medications in her room. She stated no. She was asked if she had checked the expiration date on the inhaler. She stated no, and then checked and stated, Oh, this expired in January of 23. On [DATE] at 11:50 a.m., in an interview with Registered Nurse (RN) B, she was asked if residents were permitted to have inhalers in their rooms. She stated, If they have an order and a self-administration evaluation. She was asked if she was familiar with Resident #4. She stated yes. She was asked if this resident had an order to keep any medications in her room. She stated, I had a long discussion about her inhaler with her the other day. She was asking for a long-acting inhaler but her doctor didn't want to order that. She was asked if the resident had the Albuterol inhaler in her room when she spoke with her. She stated yes. She was asked if she left the inhaler in the room when they (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105917 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 06/14/2023 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)