Inspection·October 10, 2023

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reach out to the Director of Nursing (DON) and Medical Director (MD) to discuss this. (Photographic evidence was obtained) The Psychiatric NP saw Resident #1 on 10/3/23 for a psychiatric evaluation. The report said the Medical NP had asked she be seen and was very concerned about the resident wanting to go home. [Resident #1] often states she will become problematic and anxious if she can't go home. When seen today, [Resident #1] was conversing with staff, laughing, cutting up and having a great day. The Psychiatric NP assessed Resident #1 as disjointed at times and with difficulty with recall. She had poor memory, insight, and judgement. Diagnoses were major depressive disorder, recurrent, and anxiety due to her medical condition. Recommendations were to continue current medications, encourage activities, orient as needed, and acknowledge the resident's feelings. There was no mention of whether Resident #1 had the capacity to discharge and live on her own. (Photographic evidence was obtained) Resident #1's PCP saw her on 10/4/23 and noted the patient was looking forward to going home. He mentions she has underlying dementia and had transitioned to long term care. Diagnoses included hypertension, hyperlipidemia, chronic kidney disease and unspecified dementia without behavioral disturbance. The PCP noted he discussed this with the Executive Director, and that [Resident #1] will need a psych eval for competency to make her own decision. (Photographic evidence was obtained) Further review of Resident #1's record found no assessment was completed of her competency or capacity to live independently. There was no evidence the interdisciplinary team (ID Team) discussed Resident #1's capacity to discharge home. Per a nursing progress note dated 10/5/23, Resident #1 discharged at 1300 (1:00 pm) that day. Her medications were sent with her. She was alert and walked out of the facility alone for transport. A Functional Status Evaluation for Discharge dated 10/5/23 noted Resident #1 was independent with eating, oral care, toileting hygiene, bathing, dressing upper and lower body, putting on her shoes, bed mobility, sitting, sit to stand, and transfers. Resident #1 could walk 150 feet independently. A Discharge Plan/Instruction document dated 10/5/23 reported Resident #1 discharged after reaching the optimum level of stay. She discharged home alone and was transported by car. The physician's order for Resident #1's discharge with home health services was dated 10/5/23 and ordered by her PCP. The order was taken off by Licensed Practical Nurse (LPN)/Unit Manager (UM) A and electronically signed on 10/6/23 by the Medical Director. (Photographic evidence obtained) A telephone interview was conducted with Resident #1's PCP on 10/9/23 at 1:33 pm. He said he was shocked when he heard Resident #1 was allowed to go home. Resident #1's sister called him a few days ago and told him. He recalled seeing Resident #1 (on 10/4/23) but said he did not order the discharge; she needed a psych evaluation first, due to underlying dementia. The PCP explained Resident #1 was elderly, and he was not ready to let her go home. The PCP was told that her physician's order to discharge on [DATE] was ordered by him. He said he did not order her discharge; he did not know who did. The PCP said he just spoke with the ED and told her he was shocked over the discharge. The ED had no explanation and said she didn't know what happened, as she was out for a wedding. She knew nothing. Resident #1's Psychiatric NP was interviewed via telephone on 10/9/23 at 1:35 pm. She confirmed she saw Resident #1 last week and that the Medical NP had expressed concern about her potential to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 2 of 5 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 10/10/2023 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)

F 0660 Level of Harm - Minimal harm or potential for actual harm discharge. However, nobody reported to her that a discharge was scheduled. Resident #1's cognitive status was the biggest barrier to her living independently. She has told the facility this in the past and has documented that Resident #1 was not appropriate for discharge home with no caregiver. The Psychiatric NP was asked if anyone contacted her to assess Resident #1's capacity, per the PCP's recommendation on 10/4/23. She stated, No. She further stated, This resident lacks capacity to reside on her own. Residents Affected - Few The Social Services Director (SSD) was interviewed on 10/9/23 at 2:08 pm. She stated she only recently started working in the facility, but then went on leave for a week and a half. She returned on the day of Resident #1's discharge (10/5/23). During the morning meeting that day, she learned the Medical NP had been in to see the resident. Being as independent as she was, and having a BIMS of 14, they felt she was ready to discharge home. However, the SSD had not been involved in Resident #1's discharge planning since she was on leave. Her assumption was that Resident #1 had already been deemed safe to go home. On 10/9/23 at 2:20 pm, the Unit Manager (UM) was asked about Resident #1's discharge order. She replied on the day of discharge, Resident #1's PCP was in the building. He walked past her (the UM's) office and asked her, Why is she (Resident #1) here? She can discharge, get her out of here! The UM insisted the Medical NP also said Resident #1 was okay to discharge. The UM did not know Resident #1 well enough to question the discharge, as she only worked in the facility for 3 weeks. She admits to taking off the physician's order to discharge under the PCP's verbal directive. She confirmed it was the Medical Director, not the PCP, who reviewed the order, set up home health, and signed off on the order. The UM was told Resident #1's PCP had recommended a psych evaluation the day before discharge to determine capacity prior to going home, but it was never completed. The UM said she did not know if the Psychiatric NP had reviewed his note/recommendation that a capacity evaluation was needed. The Medical Director (MD) was interviewed on 10/9/23 at 2:30 pm. He said he did not know Resident #1 well; she was [PCP's] patient. The MD confirmed signing Resident #1's discharge order on 10/6/23. As he recalled, staff could not get hold of the PCP that day to do so, so he signed. He would assume everything would be in place for discharge. When advised of the PCP's recommendation for a psych evaluation prior to discharge, the MD said he had no awareness of any follow-up evaluation. He had no explanation why Resident #1 was not evaluated for capacity and asked, What can I do to fix this? The MD said, moving forward, he would consider a different approach. The DON was interviewed on 10/9/23 at 3:15 pm. She explained Resident #1 did not come in for long term care. Later, Resident #1's representative asked the facility to keep her and not let her go home. The DON explained Resident #1 has BIMS 14 and always wanted to go home. They say sometimes she can be confused, but she never saw that. The Tuesday before discharge (103/23), the DON received a message from the Medical NP saying she wanted to talk about Resident #1. The NP told her Resident #1 wants to go home and needs to be discharged . The NP recommended she be discharged , as she has a BIMS of 14; she felt she should be allowed to go home. The NP was concerned, so we made sure everything was checked before she went home (electricity on, etc .). Everybody else said they had talked to the PCP, and he was ok with discharge. When asked who everybody else was, she said she could not recall. The DON continued, saying Resident #1's representative called Saturday and was upset because she didn't want Resident #1 at home. Resident #1's neighbors had concerns about her ability to live alone without someone to watch her. This surveyor advised the DON of the PCP and NP's documented concerns and recommendations, and of the contradicting interviews related to this resident's discharge. The DON replied by insisting that the Medical NP felt Resident #1 shouldn't be here. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 3 of 5 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 10/10/2023 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)

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ED was interviewed on 10/9/23 at 3:34 pm. She explained Resident #1 asked multiple times why she couldn't go home and didn't understand how her representative obtained that authority to keep her in the facility. The ED was not aware there were discrepancies or concerns about Resident #1 going home among ID Team members. The ED explained she was on leave when the discharge happened. When advised of the contradicting record reviews and interviews, and failure to obtain a capacity determination prior to discharge, the ED acknowledged the concern and the contradictory information. The ED expressed awareness that without a cohesive ID Team determination, it was not possible to verify Resident #1 was safe to discharge. On 10/9/23 at 3:48 pm, the DON requested the Medical NP who saw Resident #1 on 10/3/23 be called. She insisted the Medical NP told her Resident #1 should go home! The Medical NP said Resident #1 shouldn't be here. The Medical NP will tell you, call her. A telephone interview was conducted with the Medical NP at this time (she was on speakerphone and the DON and ED were both in the room). The NP said she spoke with the Psychiatric NP, and they both agreed Resident #1 did not have capacity to live on her own and should not be discharged . (The DON's head abruptly dropped to the desk and she rested her forehead on her folded forearms). The NP didn't know Resident #1 had been allowed to discharge; the Psychiatric NP said Resident #1 wasn't competent. The Medical NP explained it was her impression everyone (in the facility) said Resident #1 couldn't discharge without 24-hour care. She even talked to the DON about this resident's need for 24-hour care. No official evaluation was done for capacity, but I can tell you now, I do not feel she was competent. The Medical NP did admit this was her first time seeing Resident #1, as she was covering for another practitioner that day. She said the Psychiatric NP told her Resident #1 gets confused, although seems alert and oriented. When asked if she or the Psychiatric NP documented their determination that Resident #1 was unsafe for discharge, she said, That is why I asked the Psych NP. She looked through the record and confirmed no capacity evaluation was completed prior to discharge. A review of the facility's policy titled Interdisciplinary Discharge Planning (Document SS-195 effective 11/30/13) revealed the following: Policy: Discharge Planning begins on the day of admission. The process involves the resident and family, Care Management/Social Services, and those members of the clinical team involved in the resident's care. Procedure: 1. A discharge goal and estimated length of stay will be established upon admission and reviewed/revised at the resident's first and subsequent team conference(s). The goal is based upon clinical findings, available community and family resources, and resident and family goals. 2. Discharge plans are adjusted, as appropriate, at subsequent team conferences . 6. If the Interdisciplinary Team determines the resident is at risk regarding discharge, Social Services is to notify a local agency for at risk persons in the community. (Copy obtained) A review of SS-197 Attachment A - Social Services -- Discharge Planning Checklist (Eff. 01/10) revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 4 of 5 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 10/10/2023 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)

F 0660 -Discharge plan and home care services confirmed by team. Level of Harm - Minimal harm or potential for actual harm -Discharge planning conference held and/or offered to resident/family. (Copy obtained) Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 5 of 5