Inspection·December 13, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/11/23 at 8:35 a.m., Resident #3 was observed lying in bed, awake. Her bedside unit was observed to be a treatment cart type of unit. Beige/brown debris remained on the outside of the unit, on each of the drawers. (Photographic evidence obtained0 On 12/12/23 at 9:40 a.m., Resident #3 was observed lying in bed, awake. Her bedside unit was observed to be a treatment cart type of unit. Beige/brown debris remained on the outside of the unit, on each of the drawers. (Photographic evidence obtained) The resident's privacy curtain was open between the two resident's beds. Pink/light red splatters were observed on the bottom right portion of the curtain. (Photographic evidence obtained) On 12/13/23 at 8:25 a.m., Resident #3 was observed lying in bed, awake. Her bedside unit was observed to be a treatment cart type of unit. Beige/brown debris remained on the outside of the unit, on each of the drawers. On 12/13/23 at 8:55 a.m., in an interview with the Housekeeping Director, he was asked to describe the cleaning process for resident rooms. He stated, One of the first steps we take is for regular room cleaning. We go in and empty the waste basket and put a new liner in the basket. We disinfect anything, like pictures, dressers and the drawers on the outside, the bedside table, the bed rails, the window sills, the outside surface of the air conditioner unit, the door knobs, then into the bathrooms to clean and disinfect that area. The floor is the last thing done for mopping. He was asked how often that type of cleaning was done for each resident room. He replied daily. He was asked how often the privacy curtains were inspected and cleaned. He stated, With privacy curtains we do an inspection, if we can spot clean it, we will do that. If it requires a whole cleaning, we will take the curtain down and I will take it to the laundry for cleaning. We usually let them air dry and put up a different curtain while that's drying. We do have extra curtains. He was asked again how often the privacy curtains were inspected. He stated, That's a routine inspection for the housekeeper during QCI (Quality Control Inspection), so on a daily basis. He was asked to view the bedside units for Residents #208 and #3, and the privacy curtain for Resident #3. On 12/13/23 at 9:05 a.m., the bedside unit and privacy curtain for Resident #3 were observed with the Housekeeping Director. He was asked if he could see the pink/light red splatters on the privacy curtain. He stated yes. He was asked if the curtain should have been inspected daily. He stated yes. He was asked to observe the resident's bedside unit. He observed the unit and touched the brown/beige splatters on the front of the drawers. He stated he'd need to get a wet rag to wipe it off and see what was on the unit. He was asked if that should be inspected and cleaned daily. He stated yes. At 9:10 a.m., the bedside unit for Resident #208 was observed by the Housekeeping Director. He was asked if the red splatters observed on the bedside unit and in the bedside units drawers and on the floor around the unit were expected to have been cleaned on a daily basis. He stated yes. He was asked why these bedside units were observed in this state for the past four days. He stated they must have been overlooked. A review of a facility policy titled: Daily Patient Cleaning (Revised 9/5/2017) revealed: Every room to be cleaned is that of a resident's home - treat it as such. 2: Horizontal dusting. With a cloth and disinfectant wipe all horizontal (flat) surfaces. 3: Spot clean. With a cloth and disinfectant spray clean all vertical services. 5: Damp mop floor with germicidal solution, damp mop floor working from back corner to to door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 2 of 14 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 12/13/2023 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 0584 A review of a facility policy titled: Cleaning Cubicle Curtains (Revised 9/5/2017) revealed: Level of Harm - Minimal harm or potential for actual harm Examine curtains while doing QCI or at discharge. If curtain is stained, remove immediately. Have spare curtains on hand to immediately replace dirty or torn curtains. Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 3 of 14 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 12/13/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to provide two (Resident #90 and Resident #84) residents who were unable to carry out activities of daily living, from a total sample of 30 residents, the necessary services to maintain personal hygiene (fingernail care). Residents Affected - Few The findings include: 1. On 12/10/23 at 12:30 p.m., Resident #90 was observed in his room with elongated/jagged fingernails with brown debris under each nail on both hands. Right hand fingernails were in contact with the palm of his hand due to a hand contraction. The resident was asked if he was satisfied with the state of his fingernails. He shook his head no. He was asked if staff cleaned and trimmed his fingernails. He clicked his tongue and shook his head no. He was asked if he had asked staff to clean and trim his fingernails. He nodded yes. (Photographic evidence obtained) On 12/11/23 at 1:45 p.m., Resident #90 was observed self-propelling in a wheelchair in the hallway, headed toward his unit. He was dressed in day clothes. The fingernails on all of his fingers were elongated/jagged with brown debris under each nail, just as they ha dbeen observed on 12/10/23 at 12;30 p.m. On 12/12/23 at 9:20 a.m., Resident #90 was observed sitting on the side of his bed dressed for the day. His fingernails remained elongated and jagged with brown debris observed under each nail on both hands. A medical record review revealed diagnoses which included cerebral vascular accident (CVA - stroke), aphasia, contracture of the right shoulder, weakness, anxiety disorder, major depressive disorder, lack of coordination, and muscle weakness (generalized). A review of the quarterly Minimum Data Set (MDS) assessment, dated 10/19/23, revealed the resident had no behaviors exhibited and had not refused care during the look back period. A review of the person-centered care plan created for Resident #90 revealed the following: Focus Area (8/3/23, revised 8/24/23) Resident has an activities of daily living (ADL) self-care deficit performance related to CVA with hemiplegia, contracted right shoulder. Goal: Resident will improve current level of function in his activities of daily living (ADLs) through the review date. Interventions: Bathing/showering: check nail length and trim and clean nails on bath day an as necessary. Report any changes to the nurse. A review of the certified nursing assistants (CNAs) Tasks/Kardex (Photographic evidence obtained) revealed the following: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 12/12/23 at 9:50 a.m., in an interview with Licensed practical Nurse (LPN) A, she was asked who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 4 of 14 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 12/13/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provided fingernail care to residents (trimming and cleaning their fingernails). She stated, Activities staff does fingernails and manicures. CNAs provide fingernail care. Nursing can do it too. Nurses provide the fingernail care if the resident is a diabetic. I'll trim and clean residents' nails as I see them, or I'll ask a CNA to do it. She was asked if there was a specific timeframe/time of day that fingernails should be trimmed and cleaned other than as needed. She stated, Well, they should be done on shower days because it's easier to trim and clean the nails when they are soft. She was asked if CNAs were trained to alert nursing staff if a resident refused nail care. She stated yes. She was asked what was done if a resident refused fingernail care. She stated, I would see if they would allow me to do it and try to attempt it. She was asked where the refusal would be documented if they also refused her attempt. She stated, It should be documented right in the nurses' notes. In an interview with Certified Nursing Assistant (CNA) D on 12/13/23 at 8:35 a.m., she was asked if she was caring for Resident #90 today. She stated yes. She was asked who trimmed and cleaned his fingernails. She stated, We do, the CNAs. She was asked when residents received fingernail trimming and cleaning. She stated, It should be on their shower days. She was asked what shift Resident #90 received his showers. She stated day shift. She was asked if Resident #90 had displayed behaviors of refusing nail care. She stated no. She was asked if she had ever trimmed and cleaned Resident #90s fingernails. She stated yes. She was asked for the last time she had performed nail care for Resident #90. She stated, I'm not sure, but he does allow me to trim and clean them. A review of the facility's policy titled Care of Nails (revised 9/1/17) revealed: Procedure: Explain the procedure to the resident and bring the following equipment to resident's bedside: Basin (optional) Towel Emery Board Orange Stick Nail Clippers May soak hand in basin half full with warm water if needed. Trim fingernails. Clean nails. A review of the facility's policy titled Bathing/Showering (revised 9/1/17) revealed: Policy: Assistance with showering and bathing will be provided at least twice a week and as needed to cleanse and refresh the resident. 2. On 12/10/23 at 12:07 p.m., Resident #84 was observed with elongated fingernails on both hands with brown matter under his fingernails. He was asked when he last had his fingernails cleaned and trimmed. He stated, My nails grow fast. They just cut them about 3-4 weeks ago. He expressed his desire to have his fingernails trimmed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 5 of 14 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 12/13/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/11/23 at 9:55 a.m., Resident #84 was observed with elongated fingernails on both hands with brown matter under his fingernails. (Photographic evidence obtained) On 12/12/23 at 9:35 a.m., Resident #84 was observed lying in bed with both hands underneath the bed covers. When he was asked whether the staff had cut or cleaned his fingernails, he pulled his hands out from under the bed covers. His fingernails remained elongated with brown matter underneath the nails. On 12/12/23 at 10:05 a.m., CNA G was interviewed and stated she had been employed by the facility for one year. CNA G stated she had taken care of or had been assigned to care for and was familiar with all of the residents on the unit where Resident #84 lived. She was asked who was tasked to provide fingernail care for these residents. She stated the CNAs provided fingernail care on shower days and as needed, and the Activities staff also provided fingernail care. She was asked what she did if a resident refused fingernail care. She stated, I respect their right to refuse or sometimes I may go back and ask again later. I also report to the nurse that the resident refused. A medical record review revealed that Resident #84 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, a need for assistance with personal care, contracture of the left knee, protein-calorie malnutrition, contracture of the left hip, epilepsy, and heart failure. A review of the Annual Minimum Data Set (MDS) assessment, dated 8/24/23, revealed that Resident #84 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. He was also documented as dependent on staff for bed mobility, transfers, toilet hygiene, personal hygiene, and indicated no refusal of care behaviors during the lookback period. A review of his patient centered care plan, dated 11/24/23, revealed: FOCUS: Resident has activities of daily living (ADL) self-care performance deficit related to mobility problem, paraplegia, arthritis. Goal: Resident will maintain current level of function in his ADLs through the review date. Intervention: BATHING/SHOWERING: Check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. A review of the resident's progress notes revealed no documentation indicating refusal of care or a preference to wear his fingernails long. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 6 of 14 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 12/13/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, record review, and facility policy review, the facility failed to implement interventions, including monitoring placement and function of wander-alarm devices, consistent with a resident's needs, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident for one (Resident #93) of 30 residents sampled. Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning. The findings include: On 12/10/23 at 12:45 p.m., in an interview with Resident #93's spouse, he stated, They put that bracelet thing on her ankle and the door locks when I take her outside. He stated his wife did not wander or walk around, that she used a wheelchair. He further stated staff did not tell him why she had the device on her ankle. Resident #93 presented as pleasantly confused when interviewed. She was unable to answer simple questions accurately. A Wanderguard device was observed on her right ankle. On 12/11/23 at 8:30 a.m., Resident #93 was observed lying in bed, awake. A Wanderguard device was observed on her right ankle. She was asked if she minded having the Wanderguard device on her ankle. She was pleasantly confused and answered, smiling and laughing, Oh, I meant to give that back to them haha. On 12/12/23 at 9:40 a.m., Resident #93 was observed in a Fall Focus program, in her wheelchair and dressed for the day. She was well groomed. She was one of five residents and one staff member, Certified Nursing Assistant (CNA) B, who was asked asked if Resident #93 wore a Wanderguard device and if so, what the reason was for the device. CNA B stated, Yes, she used to wander all the time when she was first here, back in June. She was always looking to get outside. CNA B was asked if the resident was still exit seeking. She stated, Not so much now. She's calmer but she can still get around in her wheelchair, so the possibility is there. She's confused so we can't explain to her in a way she would understand and remember why she can't leave the building. On 12/12/23 at 9:50 a.m., during an interview with Licensed Practical Nurse (LPN) A, she was asked if she was caring for Resident #93 today. She confirmed that she was. She was asked if the resident wore a Wanderguard device, and if so, why. She replied, When she first came here, that was back in June of this year, all she wanted to do was leave. She wanted to go find her husband. She's very confused. She would try all the doors to go look for him. She doesn't seem to do that so much anymore, but she can self propel in her wheelchair. LPN A was asked if the resident had the Wanderguard device since admission. She stated, Yes, I think she was identified as exit seeking right from admission. On 12/12/23 at 1:37 p.m., in a follow-up interview with LPN A, she was asked where she documented the resident's Wanderguard placement and function. She stated, In the eMAR (Electronic Medication Administration Record). She was asked to show where she documented that. She pulled up Resident #93's eMAR on her medication cart computer, but was unable to find anywhere in the resident's record where this was documented. She stated, This is where it's supposed to be. I don't know. It's not here, but I do check it each shift. On 12/12/23 at 1:50 p.m., in an interview with Registered Nurse (RN) H, she was asked why a focus area for Elopement/Wandering was added to Resident #93's care plan on 9/22/23. She stated, She was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 7 of 14 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 12/13/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few trying to leave. She was wandering down the hallway in her wheelchair looking for an exit to leave. The staff on the 400 hall witnessed her exit-seeking behavior and I witnessed her looking for an exit. She was asked if the resident had an elopement risk assessment completed at that time. She stated, Yes, she did. The nurses will do the elopement risk assessment in the computer. She was asked if she could provide a copy of that elopement risk assessment. She stated, Yes, I will find it for you. On 12/12/23 at 3:40 p.m., RN H stated she was unable to provide any elopement risk assessments completed after 6/9/23, the resident's admission assessment. She was asked to describe the resident's wandering and/or elopement risk behaviors that she witnessed. She stated, There were no behaviors of exit seeking prior to that day. She was wheeling up to the doors saying I gotta get out of here. RN H was asked if the resident ever eloped from the building. She replied no. She was asked if the resident had an order to place a Wanderguard device. She stated, Yes she did, and we added her to the elopement risk sheet and the elopement risk books. The nurse placed the Wanderguard on her. I remember she had some edema on her ankles. She was asked where the Wanderguard device monitoring documentation was located. She stated, It should be in the care plan. The signing off would be on the nursing documentation. She was asked if there was any documentation of the Wanderguard device being signed off as monitored for placement and function each shift or day. She left to retrieve information and upon return stated there was no documentation to show the Wanderguard device was being signed off as having been checked for placement and/or functionality each shift or day. A medical record review for Resident #93 revealed diagnoses which included unspecified dementia; attention and concentration disorder, and anxiety disorder. A review of the active physician's orders for Resident #93 revealed no order for Wanderguard use, placement or monitoring. A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from September 1, 2023 through December 12, 2023, revealed no orders related to a Wanderguard device for checking placement or function of the device. Further review of the medical record revealed no behavior log for wandering or attempted diversional activities. A review of the person centered Care Plan revealed: Focus Area (9/22/23) Resident is an elopement risk/wanderer related to dementia, cognitive loss, impaired safety awareness, has episodes of wandering at times. Goal: Residents safety will be maintained through the review date. Resident will not leave the facility unattended through the review date. Interventions: Electronic monitoring (Wanderguard) device as ordered; identify pattern of wandering; is wandering purposeful, aimless, or escapist? Is resident looking for something? Monitor location frequently. Document wandering behavior and attempted diversional activities in behavior log. A review of the admission Elopement Risk Evaluation for Resident #93, dated 6/6/23, revealed the resident was not at risk for elopement. An second Elopement Risk Evaluation, documented in medical record on 6/9/23, revealed a score of 0.0, indicating no elopement risk. No Elopement Risk Evaluations were found during a medical record review as having been completed after 6/9/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 8 of 14 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 12/13/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of an Elopement Book at the facility's reception desk revealed that Resident #93's information and photograph were included. A review of the facility's policy titled Elopement/Wandering Risk Guideline (revised 8/1/20) revealed: Overview: To evaluate and identify patients/residents that are at risk for elopement and develop individualized interventions. Process: Patients/residents to be evaluated on admission, re-admission, seven days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If utilizing a wander monitoring system device, check placement of the device every shift and functionality daily. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 9 of 14 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 12/13/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, received that care as ordered and consistent with professional standards of practice, for one (Resident #35) of a total sample of 30 residents. Residents Affected - Few The findings include: On 12/10/23 at 2:21 p.m., Resident #35 was observed lying in bed receiving oxygen via a nasal cannula. Her oxygen concentrator, located at bedside, was set at a flow rate of 3L/min. (3 liters of oxygen per minute) (Photographic evidence obtained) On 12/11/23 at 9:33 a.m., a second observation was made of Resident #35 lying in bed receiving oxygen via a nasal cannula. Her oxygen concentrator was set with a flow rate of 3L/min. (Photographic evidence obtained) On 12/13/23 at 9:47 a.m., a third observation was made of Resident #35 lying in bed wearing a nasal cannula with her oxygen concentrator flow rate set at 3L/min. (Photographic evidence obtained) A review of the medical record revealed no active physician's orders for oxygen therapy. Further review of the active physician's orders revealed: ProAir HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 MCG (micrograms)/ACT, 2 puffs inhale orally every 12 hours as needed for Chronic Obstructive Pulmonary Disease (COPD). The order was dated 11/30/23. Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT, 1 puff inhale orally in the morning for COPD, dated 12/1/2023, Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3ml (milligrams per milliliter) 0.083%, 1 dose inhale orally via nebulizer every 6 hours for SOB (shortness of breath), wheezing for 5 days, dated 12/11/23, and Medrol 2 tabs therapy pack 4 mg po every morning and at bedtime for SOB, wheezing for 1 day then give 1 tab PO BID (by mouth twice daily) for SOB, wheezing for 2 days then give 2 tabs PO at bedtime for SOB, wheezing for 1 day then give 1 tab PO in the morning for SOB, wheezing for 5 days then give 1 tab PO at bedtime for SOB, wheezing for 3 days, dated 12/11/23 to 12/25/23. Respiratory Oxygen 2L/min (2 liters per minute) via nasal cannula PRN (as needed) for shortness of breath was discontinued on 10/7/23. Further review of the record revealed an admission date of 11/30/23 with an initial admission date of 3/5/2018. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), shortness of breath; repeated falls; other lack of coordination; difficulty in walking, not elsewhere classified; major depressive disorder, recurrent, unspecified; anxiety disorder, unspecified; schizoaffective disorder, depressive type; unspecified lack of coordination; depression, unspecified; bipolar II disorder; opioid dependence, uncomplicated; other bipolar disorder; heart failure, unspecified; anemia, unspecified, and Cerebral Ischemia. A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2023 revealed nothing about oxygen therapy. All other medications were documented as having been provided as ordered by the physician. (Copy obtained) A review of Resident #35's Care Plan, revised 7/7/23, revealed a focus area for oxygen therapy related to ineffective gas exchange/COPD. Interventions included oxygen settings as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 10 of 14 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 12/13/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #35's hospital Patient Transfer form, dated 11/30/23 (her date of admission to the nursing home), revealed oxygen at 3L/min continuous via nasal cannula. On 12/13/23 at 11:47 a.m., Licensed Practical Nurse (LPN) E confirmed that Resident #35 was receiving oxygen and the oxygen order was not in the Electronic Medical Record (EMR). She stated the admitting nurse or any nurse could add the order. When asked who provided ongoing monitoring of the resident's oxygen therapy, she replied, the nurse. She stated the nurse was also responsible for assuring that the resident was receiving the correct oxygen flow rate per the order. Correct oxygen settings were identified by checking the 3008 form (Hospital transfer form) on admission, and thereafter checking orders in the EMR. Night shift nursing staff were responsible for changing the resident's oxygen tubing. Correct settings were communicated from one staff person to another through verbal communication. On 12/13/23 at 11:57 p.m., the Director of Nursing (DON) was asked how correct oxygen settings were communicated from one staff person to another. She replied, by checking the order in the computer. A review of the facility's policy and procedure titled Oxygen Therapy (revised: 08/28/2017) revealed: Procedure: Review physician's order . monitor respiratory rate and heart rate . document initiation of therapy in the resident's chart. . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 11 of 14 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 12/13/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medication error rates were not 5% or greater. Two errors were identified out of 32 opportunities for error, resulting in a medication error rate of 6.25% and affecting two (Residents #64 and #33) of five residents observed during medication administration, from a total of 30 residents in the sample. Residents Affected - Few The findings include: On 12/11/23 at 11:36 a.m., Licensed Practical Nurse (LPN) I was observed checking Resident #64's blood glucose level. The resident was observed eating lunch and had already consumed more than 50% of the meal at the time of the blood glucose testing. LPN I then proceeded to administer Aspart Sliding Scale insulin to Resident #64 according to his blood glucose level. At this time the resident had consumed all of his lunch meal. An interview was conducted with Licensed Practical Nurse (LPN) I on 12/11/23 at 11:48 a.m. She was asked to review the orders for blood glucose monitoring and Aspart insulin administration. She pulled the order up on her medication cart computer and stated, Glucometer checks before meals and at bedtime. Administer Aspart Insulin U-100/ml (milliliter) per sliding scale before meals and at bedtime. She was asked why she had checked the resident's blood glucose level while he was eating, and why she had administered his insulin after he had completed his meal. She stated, I saw the trays come up and I told him to wait for me, but he didn't. On 12/13/23 at 9:17 a.m., LPN F prepared medications to administer to Resident #33. After the nurse prepared the medications, she picked up the cup that held the medications and a pre-dosed syringe of Trulicity (Type II diabetes medication), which was observed to be Trulicity 0.75/0.5ml. She locked her medication cart and proceeded to enter the resident's room. She was stopped and asked if she was going to administer the medications she had prepared. She responded yes. She was asked to check the dosage of the Trulicity she was going to administer against the physician's order. LPN F checked the medication order and compared the dosage of the Trulicity that she had prepared to the dosage that was currently ordered on the Electronic Medical Administration Record (EMAR). LPN F then stated, Oh no, I'm not going to give this, it's not the right dose. A medical record review for Resident #64 revealed an active physician's order which stated: Glucometer checks before meals and at bedtime, Administer Aspart Insulin U-100/ml per sliding scale before meals and at bedtime. A medical record review for Resident #33 revealed an order which stated: Trulicity- subcutaneous, Inject 1.5mg/0.5ml weekly. A review the facility's policy titled Medication-Oral Administration of (revision date 08/15/2019) revealed: Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 12 of 14 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 12/13/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Review MAR or EMAR; should there be any uncertainties, verify the MAR or EMAR with the Physician's Order Sheet (POS) and seek clarification as indicated. Compare the medication unit/dose label against the MAR or EMAR prior to supporting the resident to accept and ingest the medication. Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 13 of 14 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 12/13/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and facility policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections, by inappropriately storing and disposing of used sharps. Residents Affected - Few The findings include: On 12/11/23 at 11:36 a.m., Licensed Practical Nurse (LPN) I was observed checking Resident #64's blood glucose level. When she was finished, she placed the used lancet in her jacket pocket and not in the sharps container. After administering Aspart sliding scale insulin to Resident #64, she disposed of the lancet and the KwikPen insulin needle, wrapped in her used gloves, into the trash can in the resident's room. An interview was conducted with LPN I on 12/11/23 at 11:48 a.m. She was asked to explain the procedure for disposal of sharps. She stated, Sharps material is disposed of in the sharps container, but this (referring to a new KwikPen insulin needle that she retrieved from the medication cart) is not a sharps. LPN I confirmed that the lancet she disposed of in the trash can should have been disposed of in the sharps container. A review of the facility's policy titled Insulin Administration-Injection Pens (revision date 10/10/2017) revealed: Procedure: Assemble the equipment, including disposable safety needle. Check eMAR for order three times, remove and discard the needle per manufacturer's instruction in an approved sharps container. A review of the facility's policy titled Insulin Administration (revision date 11/04/2020) revealed: Obtain physician's order, utilizing the medication card, medication sheet or electronic equivalent, check the label of medication three times. Do not recap the needle; engage safety sheath per manufacturer's instruction, dispose of needle and syringe in sharps container. A review of the facility's policy titled Sharps Disposal (revised January 2012) revealed: Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105917 If continuation sheet Page 14 of 14