Health inspection·December 11, 2025

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. Based on interviews and record reviews, the facility failed to document and respond appropriately to resident grievances regarding missing clothing items for 1 out of 5 residents reviewed. (Resident #46)The findings include:During an interview on 12/9/2025 at 2:45pm, Resident #46 reported missing two pairs of pants. She said, I told [Environmental Services Account Manager] about it, but nothing ever got done.Review of the grievance log for the previous 12 months did not reveal a grievance filed by the resident.During an interview on 12/11/2025 at 10:30am, the Environmental Services Account Manager stated, I remember she [Resident #46] said something to me about a pair of pants a few months ago, but like I tell them, I check the inventory and if it's listed on the inventory, then I look for it. The ES Account Manager was asked if he initiated a grievance for all reported missing items. He stated, Not until I see if I can find it, then I let Social Services know either I found it, or I didn't. When asked how he kept track of residents' verbal reports of missing items, he replied, It's discussed in the morning meeting. He indicated that the information is on the daily report, but was unable to provide the report for review.Review of Resident #46's inventory sheet showed one pair of black sweatpants on June 13, 2025. Review of the facility Policy and Procedure entitled Personal Property-Loss or theft (N-1037, revision date 7/24/2017) revealed, Process: An employee receiving a concern regarding lost or missing item(s) from a resident or resident representative will initiate a Complaint/Grievance form or electronic equivalent.Review of the facility Policy and Procedure entitled Complaint/Grievance (Revision Date 10/24/2022) revealed, Procedure: An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. Page 1 of 7 105917 105917 12/11/2025 Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record reviews and interviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately to the administrator and to other officials in one of one identified occurrence. (Resident #118)The findings include:Review of the grievances for dining complaints revealed a grievance filed by Resident #118 on August 25, 2025. The grievance stated, Kitchen staff told me he could make my life harder. I don't understand what I actually did. I was talking to the nurse . The documentation section of the grievance form revealed that the Certified Dietary Manager (CDM) documented, Spoke with [identified employee name] about abuse towards residents. [Identified employee name] has been issued an ECA [Employee Corrective Action]. It is documented that the complaint is resolved and that the complainant is satisfied with the resolution.During an interview on 12/11/2025 at 10:00 am, Resident #118 stated, The deal was he [identified employee name] wasn't supposed to leave the kitchen anymore. That's what I was told. Well, he's leaving the kitchen. He just sort of stands around and smirks. I'll be honest, I check out the windows for his car. If he's here, I don't eat out of the kitchen. I was just telling the guy I'd move out of the way, and that's when he came at me with, I can make your life harder than it already is. During an interview on 12/11/2025 at 10:30 am, the Executive Director (ED) stated, I'm aware of other issues with this employee, but I was not aware that this had happened. The ED added that the Social Services employee that was identified as addressing the original complaint was no longer employed at the facility. The ED confirmed that this allegation had not been reported as required.During an interview on 12/11/2025 at 10:50 am, the Certified Dietary Manager (CDM) stated, I spoke with him [identified employee] and provided him [identified employee] abuse training. When asked if the employee was to remain in the kitchen, the CDM replied, Yes, he is doing dishes and trays. He is not to leave the kitchen. The CDM denied awareness that the employee was leaving the kitchen during his scheduled work hours. When asked why the ED was not notified of the occurrence, CDM stated, I thought Social Services would tell her.Review of the facility policy entitled Abuse, Neglect, Exploitation & Misappropriation, with an annual review date of January 2025, revealed, 7. Reporting /Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, are not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials in accordance with state law. 105917 Page 2 of 7 105917 12/11/2025 Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, interviews, and policy and procedure review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. The findings include: Observations of the tray line on 12/10/2025 at 10:55 am revealed the Dietary Aide (Caller) calls the diet, the cook prepares and plates the food, and the Manager in Training checks tickets to ensure items match, then load the meal trays on the cart. Observations revealed meal tickets not matching the meal plated/inaccurate protein portions or meal tray placed in the cart for distribution with missed food item/apple/cranberry order/preference not provided per meal ticket; nectar shake not provided per meal ticket; bread not followed by order/preference on meal ticket; and gravy not provided per meal ticket. All items were pulled from the meal cart and corrected. An additional complaint from Resident #118 included that the resident does not eat pork, but continues to receive pork items. There was no attempted resolution for the resident's issue with food. An interview was conducted on 12/11/2025 at 8:50 am with Employee A, Dietary Aide, who explained the tray line process and who was responsible for what task. She stated, the A1/Dietary Aide was responsible for placing drinks, dessert, cold cereal, condiments on each tray and call the tickets. The A2 staff was responsible for adding hot plates, juice and milk, tray accuracy, lids, and placing trays on cart. The cook was responsible for food temperatures, food accuracy, and placing plates on top of the tray line for the A2 staff to receive. When asked, how does the kitchen determine how much food to prepare for each meal she replied, The CDM provides prep guide daily for every food item needed; it states the need for the day. When asked to explain the process for measuring protein/meat, she responded she was unsure of the cook's duty. She reported a 3-ounce (oz) protein is required for a regular diet tray; 6-oz was considered a double protein; 2 scoops of all food items were considered a double portion; 1 1/2 protein was a large portion of protein; and 4-oz was considered a large protein. When asked how often are meal substitutions provided she replied, Not very often but it does happen sometime. When it happens, the CDM will add the substitute to the bottom of the ticket and 'please accept this item'. Substitutions are tracked on the prep guide. An interview was conducted on 12/11/2025 at 9:16 am with Employee B, Manager in Training, who was asked to explain the tray line process and who was responsible for what task. She stated the lead calls tickets, places condiments, drinks, and desserts on the tray; the cook prepares the plate, and the catcher reviews tickets and plates for accuracy, then places the meal tray in the cart. When asked how the kitchen determines how much food to prepare for each meal she replied, Use of the production sheet tells how many regular, mechanical, puree, and fortified meals to prepare. When asked to explain the process for measuring protein/meat, she stated most of the food comes proportioned to 3 oz or 6 oz. She reported a 3-ounce (oz) protein was required for a regular diet tray; 2 servings of the meat/protein was considered a double protein; and double everything/plate was considered a double portion. She stated she was very new to the position and was unsure of what a 1 1/2 was considered. A large protein was considered a large meat portion. She also was not sure how often meal substitutions were provided. An interview was conducted on 12/11/2025 at 9:30 am with [NAME] C, who explained the tray line process and who was responsible for what task. He stated, the lead reads the ticket, calls the diet, adds condiments and desserts to the tray; the [NAME] responds to the ticket and plates the food, places the food/plate on top of the tray line; the catcher 105917 Page 3 of 7 105917 12/11/2025 Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few adds beverages, ensures plate accuracy, then places the meal tray in the cart. When asked0 how the kitchen determines how much food to prepare for each meal he replied, Follow recipe; use scale to measure protein. He noticed the scale was broken during lunch on 12/10/2025. He notified the CDM and was told another scale was ordered and should arrive on 12/11/2025. The [NAME] confirmed he used eyeballs to portion the pork roast served at lunch during the time of the survey. When asked to explain the process for measuring protein/meat he replied, Slice a few pieces of the protein, then measure on the scale. He reported a 4-oz protein was required for a regular diet tray; 4-oz x 2 was considered a double protein; 2 separate plates were considered a double portion; 1 1/2 protein is 6-oz protein; and 1 1/2 protein was considered a large protein. When asked how often are meal substitutions provided he replied, It has happened but very rare. The CDM will inform staff of menu changes, verbally and document on the production sheet. An interview was conducted on 12/11/2025 at 9:53 am with the CDM who confirmed the first person will call tickets, set up trays with condiments and drinks, the cook prepares the meal to specification of the ticket, and the last staff pull plates, ensure the plate matches the meal ticket, place lid on the plate, add supplements/thickened drinks, and place the meal tray on the cart. When asked how the kitchen determines how much food to prepare for each meal he replied, The CDM provides a production sheet daily that includes recipes. When asked to explain the process for measuring protein/meat he replied, Ounces have been visual; pieces are the actual count. I ordered a scale yesterday and should arrive today. There was no scale in the past. Most meals have been pieces opposed to weight. He reported a 3-oz protein was required for a regular diet tray; 6-oz was considered a double protein; 1 protein and 1/2 protein: 4 oz; 6 oz was considered a double portion; 1 1/2 protein is 4-oz protein; and 1 1/2/4 oz protein was considered a large protein. When asked how often are meal substitutions provided he replied, Very rare. Substitutions are tracked on the substitution and production sheets, each unit is notified, and menu boards are changed. Review of the facility's policy and procedure: Menus revised: 10/2022 revealed Policy Statement: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures.4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition for the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2020-2025 edition. Policy and Procedure Food Quality and Palatability revised: 2/2023 revealed Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are pared and served in a manner, form, and texture to meet resident's needs. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. (Copy obtained). 105917 Page 4 of 7 105917 12/11/2025 Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and policy and procedure review, the facility failed to ensure food served was prepared by methods that conserve nutritive value and appearance by failing to provide appetizing and appealing food in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting on their ability to heal, and possibly resulting in an overall health status decline. The findings include: During a tour of the kitchen on 12/10/2025 at 10:55 am, carrots served on the tray line were observed to be discolored with black spots making them unsuitable for consumption, leading to five bowls being pulled and discarded to ensure food safety and quality. During the facility survey, additional complaints received included: Resident #11 reported her grilled cheese sandwich was too hard to consume; Resident #64 reported receiving black broccoli, It was rotten, they took it out of the bag like that and steamed it and served it. They overcook everything. The grilled cheese was hard as a rock.; Resident #73 reported issues with overcooked food, most recently the grilled cheese and tater tots; Resident #84 reported overcooked grilled cheese, tater tots, and peas. (Photographic Evidence Obtained) On 12/10/2025 at 10:55 am, Employee A, Dietary Aide, was asked during tray line service who was responsible for ensuring food components were appealing and suitable for meal consumption. She stated all staff working on the tray line. During the same tray line service, Employee C, Cook, was asked who was responsible for ensuring food components were appealing and suitable for meal consumption. He stated the cook. He also stated he did not notice the number of carrots that were discolored right away, but began removing them from the tray line and pan. The Certified Dietary Manager (CDM) was informed that the carrots were discolored with black spots. An interview was conducted on 12/11/2025 at 9:53 am with the CDM, who confirmed that the cook was responsible for ensuring meals were prepared by methods that conserve nutritive value and appearance and for following recipes when preparing meals. He was unaware of the black spots on the carrots prior to meal service, but stated carrots identified with the dark spots were to be discarded. Review of the facility's policy and procedure: Food Quality and Palatability revised: 2/2023 revealed Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. (Copy obtained). (Copy obtained). Residents Affected - Few 105917 Page 5 of 7 105917 12/11/2025 Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to clean one of two microwaves located in a unit nourishment room. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: Observations of the nourishment rooms were conducted during the follow-up tour on 12/10/2025 at 10:55 am. During the tour, the unit microwave in one of two nourishment rooms located on the 100-300 unit was observed to have black substances of unknown origin resembling fungal growth on the inside ceiling. Another observation was made on 12/11/2025 at 11:42 am of the same black substances on the inside ceiling of the microwave. (Photographic evidence obtained) During the follow-up tour in the kitchen, the Certified Dietary Manager (CDM) reported the facility had two nourishment rooms and Environmental Services (EVS) was responsible for cleaning the microwaves in nourishment rooms. An interview was conducted on 12/11/2025 at 8:50 am with Employee A, Dietary Aide, who reported the CDM cleans the refrigerator, but was unsure who was responsible for cleaning the nourishment room microwaves. An interview was conducted on 12/11/2025 at 9:16 am with Employee B, Manager in Training, who reported she was unsure who cleaned the microwave in nourishment rooms. An interview was conducted on 12/11/2025 at 9:30 am with [NAME] C, stated he was not sure who cleaned microwaves in the nourishment rooms. An interview was conducted on 12/11/2025 at 9:53 am with the CDM, who confirmed that [NAME]/CNA staff were responsible for cleaning the nourishment room microwave. A review of the facility's policy and procedure entitled Equipment, revised 9/2017 revealed: Policy Statement: All food service equipment will be clean, sanitary, and in proper working order. Procedures: 1 All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023) Annex 4. Equipment, Utensils, and Linens. 4-602.12. Cooking and Baking Equipment. Page 129. (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 4-602.13 Nonfood-Contact Surfaces. Nonfood-Contact Surfaces of Equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues 105917 Page 6 of 7 105917 12/11/2025 Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record reviews and interviews, the facility failed to appropriately document side effects and behaviors for psychotropic medications, in accordance with the corresponding key on the Medication Administration Record for two of five residents reviewed for psychotropic medications. (Residents #15 & #72)The findings include:1. Review of Resident #15's medical record revealed a physician's order for behavior monitoring every shift for antipsychotics agents with a start date of January 24, 2022. Data entry for corresponding codes included; 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress note. Review of Resident #15's medication administration records for November 2025 revealed that NA [Not Applicable] was documented on the following dates: 11/1/2025, 11/2/2025, 11/3/2025, 11/5/2025, 11/10/2025, 11/16/2025, 11/17/2025, 11/19/2025, 11/26/2025, 11/27/2025, 11/29/2025, and 11/30/2025. Review of Resident #15's medication administration record for December 2025 revealed that NA [Not Applicable] was documented on the following dates: 12/3/2025, 12/8/2025, and 12/10/2025. 2. Review of Resident #72's medical record revealed a physician's order for behavior monitoring every shift for antipsychotics agents with a start date of July 26, 2025. Data entry for corresponding codes included; 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress note.Review of Resident #72's medication administration record for November 2025 revealed a check mark only on the following dates: November 1, 2025-November 30, 2025.Review of Resident #72's medication administration record for December 2025 revealed a check mark only on the following dates: December 1, 2025-December 10, 2025. During an interview on 12/11/2025 at 6:45pm, Staff A, Licensed Practical Nurse (LPN), stated, We monitor for behaviors on the MAR [Medication Administration Record] and if there are any behaviors, you document the number and there should be a corresponding progress note.During an interview on 12/11/2025 at 6:55pm, Staff B, Licensed Practical Nurse (LPN), stated, It gives you a code on the MAR. If there aren't any behaviors, you document a zero, if not, there is a corresponding number that matches a behavior and there should be a progress note. During an interview on 12/11/2025 at 7:20pm, the Director of Nursing (DON) stated, I expect the staff to document any behaviors in accordance with the corresponding key. 105917 Page 7 of 7