Inspection·June 23, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm On 6/23/21 at 3:30 p.m. a telephone message was left for the POA in an attempt to identify whether or not the written notifications had been received. No return phone calls were received. A review of the facility policy titled, Transfer/Discharge Notification and Right to Appeal, with an effective date of 9/23/2017 and a revision date of 3/26/2018, indicated the following: Residents Affected - Few Policy: Transfer and discharges of residents, initiated by the center will be conducted according to Federal and/or State regulatory requirements. Procedure: Notice before Transfer: Before a center transfers or discharges a resident, the center must: Notify the resident and resident representative of the transfer or discharge and the reasons for the move in writing (in a language and manner they understand) Timing of the Notice: Notice of transfer or discharge must be made 30 days prior to resident is transferred or discharged except when: An immediate transfer or discharge is required by the resident's urgent medical needs. Notice must be made as soon as practicable before transfer or discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide written notification of bed hold to the resident representative for one resident (#3) of one sampled resident for hospitalizations. Findings included: A review of the admission Record for Resident #3 indicated the resident was admitted to the facility on [DATE] with diagnoses of non-traumatic intracerebral hemorrhage, monoplegia of upper limb affecting left nondominant side, speech and language deficits following cerebrovascular disease, and gastrostomy. A review of the nursing progress notes indicated on 4/27/2021 at 5:27 p.m. the nurse noted Resident #3 had a dislodged gastrostomy tube with the tip of the tube deflated and torn. The note indicated the resident was having discomfort and an 18 French, 10 milliliter Foley was inserted as a nursing intervention. The health care provider was notified, and the resident was sent to the hospital for care. The POA was notified by the nurse at the time. On 4/28/2021 at 12:27 a.m. the nursing note indicated Resident #3 returned to the facility with a gastrostomy tube in place. A review of the Bed Hold Authorization form dated 4/27/21 indicated the POA for Resident #3 was given a phone consent form and no signature for the POA was present on the form. On 6/20/21 at 11:01 a.m. an interview was conducted with the Power of Attorney (POA) for Resident #3. The POA stated she was responsible for all medical and financial decisions for the resident due to a stroke that had left the resident unable to speak and care for herself. On 6/23/21 at 3:06 p.m. an interview was conducted with Staff C, Social Services and Business Development Coordinator. The Coordinator stated the Bed Hold Policy form is filled in at the time of the transfer by nursing. She stated nursing notifies the POA verbally by telephone at the time of the transfer. She stated a written copy of the form is not sent out to the POA. She stated the facility was implementing the process currently. She stated she had just heard a couple of weeks ago about the requirement to notify the POA in writing by mail. She stated the process had not been done at the facility prior to this time. The Coordinator stated she was going to be making sure the notices go out in writing because checking them and following up on transfers is her responsibility. On 6/23/21 at 3:30 p.m. a telephone message was left for the POA in an attempt to identify whether or not the written notifications had been received. No return phone calls were received. A review of the facility policy titled, Transfer/Discharge Notification and Right to Appeal, with an effective date of 9/23/2017 and a revision date of 3/26/2018, indicated the following: Policy: Transfer and discharges of residents, initiated by the center will be conducted according to Federal and/or State regulatory requirements. Procedure: Notice before Transfer: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0625 Before a center transfers or discharges a resident, the center must: Level of Harm - Minimal harm or potential for actual harm Notify the resident and resident representative of the transfer or discharge and the reasons for the move in writing (in a language and manner they understand) Residents Affected - Few Timing of the Notice: Notice of transfer or discharge must be made 30 days prior to resident is transferred or discharged except when: An immediate transfer or discharge is required by the resident's urgent medical needs. Notice must be made as soon as practicable before transfer or discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure implementation of the plan of care related to fluid restriction for one resident (#24) out of 29 sampled residents. Findings included: On 06/22/21 at 11:00 a.m. a cup of water, 1/4 full was observed on Resident #24's bedside tray table. The resident was observed in bed. The cup was labeled with the resident's room number and the date of 06/22. (Photographic evidence obtained) Staff J, Certified Nursing Assistant (CNA) was interviewed immediately following the observation and said she was not assigned to the resident that day, but knew her and knew she was not supposed to have water. Staff K, CNA was interviewed, confirmed she was assigned to the resident that shift, and confirmed she (Resident #24) was not supposed to have water. Staff K, CNA, and Staff P, CNA went to Resident #24's room during the interview and confirmed there was a cup of water at her bedside. They said they had not put it there and that it must have been put there by the 11 p.m. to a.m. shift staff. Staff K confirmed that information about fluid restrictions should be in the resident's [NAME] so that any CNA caring for the resident would know not to provide water. Staff K revealed the [NAME] for Resident #24 which contained the following instruction: No water in room, fluids on tray not restricted, water with medication is allowed. An interview was conducted with Staff M, Licensed Practical Nurse (LPN) on 06/23/21 at 11:38 a.m. She confirmed she had been told that Resident #24 was not to have water at bedside. Review of Resident #24's medical record revealed an initial admission date of 07/03/29. Diagnoses included hypo-osmolality (lower than normal levels of electrolytes/protein/nutrients in the blood), hyponatremia (sodium levels in blood are too low), and dementia. Physician orders for June 2021 revealed fluid restriction: no fluids at bedside. Her care plan, initiated 4/12/21, revealed a focus area for fluid overload related to hypo-osmolality and hyponatremia which included the intervention, no water in room. Review of the facility policy titled, Plans of Care, revised 09/25/21, revealed that a comprehensive plan of care must be developed for each resident to meet their medical and nursing needs. The policy revealed that all care providers responsible for any area of a resident's care had responsibility to implement the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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, and record review the facility failed to ensure that activities of daily living related to nail care were provided for two residents (#36, #30), and failed to provide oral care for one resident (#30), out of four sampled residents. Residents Affected - Few Findings included: 1. An observation of Resident #36 was conducted on 06/21/21 at 9:48 a.m. He was observed in bed, wearing a gown, and there was crust around his eyes, his neck had flaking skin and what appeared to be food crumbs, his fingernails were long past his fingertips with black matter under the nails, and his hands appeared unwashed and had food residue on them. The resident engaged freely and said his fingernails used to be worse and that they were still too long and caused him to scratch himself. An observation was conducted on 06/22/21 at 8:54 a.m. and Resident #36's nails were in the same state as previously observed on 6/21/21, long past his fingertips with black matter lodged underneath, and hands unwashed with food residue on them. On 06/22/21 at 11:08 a.m. the resident was observed in bed wearing a clean gown and said he had received a bed bath. His fingernails were observed still long past his fingertips with black matter under the nails, dried skin on backs of hands, and food residue on his fingers. He again confirmed he felt his nails were too long and said, I scratch myself with them. An interview was conducted with Staff P, Certified Nursing Assistant (CNA) on 06/22/21 at 11:15 a.m. She confirmed she had given the resident a full bath that morning and said he got one every day. She said she cleaned and cut his nails as part of care but said, he digs all day in his privates, and that was how his nails got dirty. Review of the medical record for Resident #36 revealed an original admission date of 8/27/20. Diagnoses included type 2 diabetes with complications, bilateral below knee amputations, cognitive communication deficit, and visual impairment. The Minimum Data Set (MDS) completed 05/27/21 revealed a Brief Interview for Mental Status (BIMS) score of 12 which meant the resident had moderate cognitive impairment. The MDS revealed the resident required extensive assistant for dressing, was dependent for toileting, and required extensive assistance for personal hygiene. His care plan revealed a focus area for self-care performance deficit, initiated on 8/28/20 and revised on 5/27/21 and included the intervention, Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. The intervention was assigned to the positions of Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN). The CNA daily task list for Resident #36 included personal hygiene every day every shift and the directive to check nails on bath day and as necessary, perform trimming & cleaning, and report changes to the nurse. On 06/23/21 at 11:32 a.m. Resident #36's nails were observed still long past fingertips with black matter underneath nails. An interview was conducted on 06/23/21 at 11:36 a.m. with Staff M, LPN who confirmed she was the resident's nurse that day. She said she was from a staffing agency, and it was her first shift working in the facility. She said she did not know anything about the showering routine or nail care for residents and had not received any specific orientation from the facility. She said she had not done a head-to-toe observation of Resident #36 and had not noticed his nails. During the interview Staff M observed the resident's nails and said, Yes his nails are too long and dirty, should not be that way. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 An interview was conducted with Staff K, CNA on 06/23/21 at 11:51 a.m. She said she was from a staffing agency and had worked on and off in the facility for three months. She said she was not assigned to Resident #36 that day but said the general process for nail care was to perform as part of ADL (activities of daily living) care. She said there were no nail clippers in the facility, and she did not know if she could cut a resident's nails and said she thought it was the activities person who did that. Staff K said she had not received any training from the facility about nail care and said her practice was to use a washcloth to get dirt out from under fingernails. An interview was conducted with the facility Administrator (NHA) on 06/23/21 at 12:03 p.m. She said the expectation for nail care for residents was that they be kept trimmed and cleaned if a resident allowed it. She said that if nails were long and dirty the expectation was, they would be cleaned. She said for diabetic residents, a nurse was required to cut fingernails and a CNA should notify a nurse of the need. She said she expected that nurses would perform a head-to-toe assessment when providing care. An interview was conducted with the facility Director of Nursing (DON) on 06/23/21 at 1:07 p.m. She said the expectation for resident nail care was that they be kept trimmed and clean if the resident allowed it. Review of facility procedure titled, Care of Nails, revised 09/01/17 revealed the following: *Perform hand hygiene. *Explain procedure to resident and bring following equipment to the resident's bedside: basin, towel, emery board, orange stick, nail clippers. *Trim fingernails. *Clean nails . 2. During multiple facility tours conducted on 06/20/21 at 9:35 a.m., and 3:29 p.m., 06/21/21 at 4:46 p.m. and 6/22/21 at 11:04 a.m., Resident #30 was observed with teeth noted to have food caked in after meals. Resident #30 reported that she has not had her teeth brushed in a while. Resident #30 was noted with long fingernails and stated she prefers them short. A review of the admission Record revealed that Resident #30 was re-admitted to the facility on [DATE] with diagnoses to include Parkinson's mononeuropathy, other polyneuropathies, multi degeneration of autonomic nervous system, other seizures, muscle weakness, joint pain, cognitive communication deficit, generalized anxiety disorder, and altered mental status. An annual MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognition impairment. Section F of the MDS under personal preferences, it showed that Resident #30 states it is very important to make ADL (activity of daily living) choices. In Section G, Functional status, Resident #30 was shown as totally dependent on staff for all ADLS due to impairment on both sides. Resident has upper extremities impairment on shoulder, wrists, and hand. It also showed that Resident #30 is totally dependent for personal hygiene including combing hair, brushing teeth, shaving, make up, wash face, drying and hand washing. On 06/22/21 at 11:07 a.m., an interview was conducted with Staff J, CNA related to oral care. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 J stated that sometimes Resident #30 refuses care according to some staff. When asked if the refusals were care planned or documented, Staff J, CNA stated she did not know. When asked if Resident #30 had refused to get her teeth brushed or nails trimmed today, Staff J, CNA stated that Resident #30 had not refused. Staff J, CNA looked at Resident #30's teeth and noted that her teeth had not been brushed, and food remains were caked in her teeth. Staff J stated that she was assigned to Resident #30 today and will make sure she gets cleaned up. Staff J, CNA was asked if Resident #30 had a toothbrush. Staff J, CNA stated that Resident #30 still had her own teeth, and it was important they keep them clean. A review of an annual care plan dated 05/20/21 revealed that Resident #30 has an ADL self-care performance deficit related to limited use of upper and lower extremities due to spasticity related to Parkinson's disease. Resident #30 has impaired strength neuromuscular deficit to upper and lower extremities and tremors and requires extensive total assistance with ADLs. The interventions indicated to: Check nail length and trim and clean on bath day and as necessary. An oral care routine (AM, PM, HS [night time]- hours of sleep) brush teeth, clean gums with toothette, rinse mouth with wash. On personal hygiene and oral care, Resident #30 is totally dependent on one staff. The resident requires staff assistance for her personal hygiene needs. Focus: The resident has oral / dental health Assist with oral hygiene and mouth care potential for mouth pain. Goal, resident will be free from infection. Resident will comply with mouth care daily. Interventions included to coordinate arrangements for dental care, transportation as needed, diet as ordered. Provide mouth care as per ADL personal hygiene. Apply lip balm ointment as needed. On 06/22/21 at 3:11 p.m., an interview was conducted with Staff K, CNA. Staff K stated that she was an agency employee. When asked if she had taken care of Resident #30, Staff K, CNA stated that she had, a few times. When asked if she had noticed Resident #30's long nails, Staff K, CNA stated that she had not. When asked if she assists the residents with nail care, Staff K stated that she does not. When asked if she reviewed care plans for resident's ADL needs, Staff K, CNA stated she did not know about nail care. A follow up was conducted with Staff L, LPN on 06/22/21 at 3:25 p.m. Staff L, LPN stated that she was a regular employee and knows the residents well. Staff L, LPN stated that if a resident is diabetic, they do not trim their nails and that they wait for the podiatrist. Staff L, LPN confirmed that Resident #30 was not diabetic. She stated that Resident #30 had not asked for them (nails) to be trimmed. When asked if it was the expectation that residents should initiate care, Staff L, LPN said, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Yes, if they are alert and oriented. For residents with moderate impairment or low cognition, Staff L, LPN stated she would understand why staff should initiate the care and ask for resident preferences. Staff L, LPN confirmed that the care plan should be followed. Staff L, LPN stated that activities staff or CNAs do it (nail care) and that CNAs should assist with oral care after meals. An interview was conducted with NHA and DON on 06/22/21 at 4:37 p.m. The DON stated that all staff, agency or not, should be familiar with resident's care needs. The DON confirmed that nursing staff should be completing all aspects of care, oral care, or nail care and emptying catheters as noted on the residents' care plans. When asked how staff should handle residents who refuse care, the DON stated that staff should let management know if there are any concerns. Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations were made of Resident #6 from 06/21/21 - 06/22/21 in the morning hours and afternoon hours. Resident #6 was always observed in bed in his room and was often covered completely by a sheet including over his head and face. No stimulation was noted in his room, and no staff were noted providing stimulation to the resident. There was an audio book player observed in a plastic bag on the floor and a blank calendar posted on the wall. On 06/21/21 at 3:55 p.m. the resident was observed in bed with his head uncovered, eyes open and alert, no television on in room, no staff in room. On 6/22/21 at 9:02 a.m. the resident was observed asleep in bed, at 11:30 a.m. he was observed awake with eyes open in bed, at 4:00 p.m. he was observed asleep in bed. There was no stimulation observed in room, on television, or provided by staff during these observations. Residents Affected - Few Review of Resident #6's medical record revealed an initial admission date of 04/02/19. Diagnoses included cerebral palsy and microcephaly (smaller head often due to abnormal brain development). The MDS completed on 06/12/21, revealed severe cognitive impairment, extensive assist required for bed mobility, and totally dependent for other mobility and self-care performance. The MDS revealed a staff assessment of daily activity preferences: listening to music and spending time outdoors were selected as interests. A psychosocial evaluation dated 04/08/21 revealed that the resident was non-verbal and the following preferences were reported by family: liked cartoons and was shy. No other interests or preferences were selected. His care plan revealed a focus area for dependence on staff for meeting emotional, intellectual, physical, and social needs. The care plan revealed that the resident enjoyed teddy bears, cartoons, certain movies, holding a washcloth, family visits and Motown music. The resident was care-planned for 1:1 visit 2-3 times per week. The daily task list report for Resident #6 revealed that one to one activities and group activities were to be provided as needed from 7:00 a.m. to 7:00 p.m. by Community Life Aide and Community Life Director. Review of the one-on-one activities binder provided by the facility revealed Resident #6 was listed to receive one-on one activity Monday, Wednesday, and Friday. There was no documentation in the binder of one-on-one visits completed for the resident. Residents #12, #9, and #19 were interviewed during a Resident Council meeting on 06/22/21 at 1:45 p.m. They confirmed that the Activities Director had resigned from the facility about a month ago and said that nobody had been doing the job since. They said that Staff I held bingo on Monday about two or three weeks ago, but no other activities were held. They said they used to have a variety of group activities including fishing and arts and crafts. They confirmed that blank activities calendars were posted in their rooms. An interview was conducted on 06/23/21 at 2:34 p.m. with Staff I. She confirmed she knew Resident #6 and said, He likes to watch tv (television) and the talking books .he likes cartoons .black and white films. Regarding the audio book player observed on the floor in a plastic bag she said, Someone probably bagged [it] up during a room check. Staff I confirmed that the Activities Director had resigned and said, Ever since [Activities Director] left it hasn't been any one person in activities .hasn't been any one set person. Regarding one-on-one activities with Resident #6 she said, Last time I did with him I don't even remember, but it was with talking book and watching cartoon. Staff I confirmed there was no documentation of the one-on-one activity with Resident #6. She said, I do sixteen hours a week activities, mix of one on one and group. She said if there were not enough floor staff for CNA duties then she got pulled from activities and the department heads were assigned to perform the activity programming. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0679 Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to implement an on-going activities program consistently based on the comprehensive assessment and preferences of two residents (#193, and #6) out of 29 sampled residents to support the physical, mental and psychosocial well-being of each resident Residents Affected - Few Findings included: 1. During multiple tours throughout the day on 06/20/21 and 06/21/21, Resident #193 was noted wandering the hallways and going in and out of the building to the courtyard throughout the day. Resident #193 was not observed interacting with staff with activity related activities. A review of the admission Record revealed that Resident #193 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diffuse TBI (traumatic brain injury) without loss of consciousness, unspecified TBI with loss of consciousness, greater than 24 hours, hemiplegia and hemiparesis, muscle weakness, cerebral infarction, contracture of muscle, intentional self-harm shot gun discharge, and generalized anxiety. An MDS, dated [DATE], revealed Resident #193 is rarely or never understood, and his BIMS could not be completed. Resident #193's care plan, initiated 1/14/21 and revised 4/15/21, revealed interventions to invite the resident to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility. On 06/21/21 at 10:05 a.m., an interview was conducted with Resident #193's representative who confirmed that Resident #193 used to enjoy fishing, but they have not taken him lately. Fishing was the only activity that calms him down. The Resident Representative confirmed that Resident #193's activities are not reviewed or discussed with her. Review of Resident #193's EMR (electronic medical record) did not show any documentation or attendance to activities of preference. The Activities Task Log was used to document group activities and or 1:1 activities attendance revealed no documentation of activities offered or participation thereof. An interview was conducted with Resident #193 on 06/22/21 at 4:06 p.m. He was asked if he enjoyed participating in activities. Resident smiled and showed a thumbs up sign. Resident #193 was asked what activities he enjoyed. He pointed to his phone. Resident #193 mumbled in an audible way stating, Yes, I do, when asked if he enjoyed music as noted on the MDS dated [DATE]. When asked if he enjoyed any outdoor activities, Resident #193 motioned fishing gestures and smoking. Resident was asked if he had gone fishing lately. Resident expressed no, by shaking his head and verbalizing no. On 06/21/21 at 4:57 p.m., an interview was conducted with Staff H, Certified Nursing Assistant (CNA). Staff H stated it had been a while since she saw residents in an activity. On 06/22/21 at 3:20 p.m. an interview was conducted with the Nursing Home Administrator (NHA) regarding Resident #193 and preferred activities. The NHA stated that the physician order for one to one activities is a PRN (as needed) order. It was put in place to assist him to calm down related to behavior monitoring. Staff should engage him in an activity of his choice when he is frustrated. In addition, the NHA stated that they did not have an activities director, but that the department heads (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0679 were assisting with activities. Level of Harm - Minimal harm or potential for actual harm On 06/21/21 at 4:40 p.m., an interview was conducted with Resident #19, the Resident Council President. Resident #19 stated that the facility offers bingo twice a week, and some other activity once a week like Waffles Wednesday. Resident #19 confirmed the activities director left at the end of May (2021) and that other staff take turns to facilitate activities including the Admissions Director. Resident #19 was asked about the blank calendar for June 2021 in her room and how she knows what activity to expect. Resident #19 stated that it is empty right now because there was no Activities Director. Resident #19 said there is no consistent activity scheduling at this time. Residents Affected - Few On 06/21/21 at 4:47 p.m. an observation was made of the June 2021 activity calendars posted on the walls in the resident's rooms. All the calendars were noted blank in resident rooms #1 to #10. An interview was conducted on 06/22/21 at 10:15 a.m. with Staff I, CNA. Staff I stated she had been assisting with activities since the Activities Director left the end of May 2021. Staff I, CNA stated that she had been working as a central supply aide along with the activities aide. Staff I, CNA stated that she did not have any certification related to activities training but has experience from a previous job. Staff I, CNA said she had not received any training for this role at this facility. Staff I, CNA stated that various, department heads assist in providing activities at least two days a week. Staff I, CNA stated that she goes by the calendar to determine what activities to facilitate. Staff I, CNA confirmed she facilitated coffee club and bingo. Staff I, CNA stated that the Activity Director typically creates the calendar but at this time no one was in the position. Staff I, CNA said she had not completed any documentation related to tracking of activities attendance, but that there was a task log in the electronic medical record software for activities documentation. Staff I stated that there was a 1:1 activities book for residents who have designated 1:1 activities. Staff I, CNA said an activities calendar is supposed to be posted in the rooms (resident) and in the hallway by the dining room. A review of the handwritten June 2021 activities calendar posted outside of the dining area, revealed no activities scheduled for the weekends. The calendar also showed the following activities scheduled repetitively that consisted of: trivia, movies, music on the patio, arts and crafts, Waffle Wednesdays at 11 a.m., bingo at 2 p.m. and 1:1 visits every Thursday, and shopping every Friday. The activities scheduled for Monday 6/21/21 and Tuesday 6/22/21 at 11:00 a.m. for music on the patio and 2:00 p.m. for Arts & Crafts were not observed to occur on 06/21/21 or 06/22/21. An interview was conducted with the NHA on 06/23/21 at 3:00 p.m. The NHA stated that the Resident Council President assists in facilitating activities. The NHA stated that the facility did not have an Activities Director and that [Staff I, CNA], HR (human resources), Director of Social Services, and all department heads take turns. The NHA stated that the Activities Director's last day was 05/24/21. She stated that they use a census sheet to track attendance for the day. The NHA stated that the 1:1 activities are lacking. The NHA confirmed that the activities area is lacking since they lost the Director. The NHA stated that the Manager on Duty should facilitate activities on the weekends and evenings. A review of the facility's policy titled, Community Resources, with a revision date of 05/29/19, documented that the use of community resources will be utilized to enhance resident's ability to be involved in community activities and continue life-long practices. Procedure #2 states that the community life department will maintain a community contact file (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0679 pertaining to education, entertainment, services, resources, spiritual contacts, and program leaders. Level of Harm - Minimal harm or potential for actual harm A review of the facility's job description titled, Director of Therapeutic and Recreational services (Activity Director), last updated 01/2018, reveals a primary purpose to plan, organize, develop, and direct the overall activity department in accordance with current regulations . to ensure that an on-going program of activities is designed to meet in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a restorative nursing program (RNP) was available as a service for 7 residents (#18, #34, #37, #13, #193, #22, #32) identified by facility personnel as candidates for RNP, out of a total sample of 29 residents. Due to the absence of an RNP program, residents who had been recommended for those services to prevent avoidable reduction of range of motion (ROM) or mobility, increase ROM or mobility status, or maintain or improve ROM or mobility, did not receive those services. Findings included: Review of the Facility Assessment Tool last updated 12/16/20 revealed the restorative nursing had been identified as a service and specific practice that the facility needed to offer based on their residents' needs. On 06/21/21 at 12:37 p.m., a resting hand splint was observed on Resident #18's bedside table underneath a pile of personal items. (Photographic Evidence Obtained) The resident's hands were observed contracted and the left hand was in a fisted position. Resident #18 confirmed that she had contractures and limited range of motion in both of her hands, was unable to use her left hand, and had significant difficulty using her right. An interview was conducted on 06/22/21 at 8:58 a.m. with Resident#18 and she said she had tried to feed herself oatmeal that morning because, I don't want to lose my abilities, and after her trial a staff member had to come and feed her. An interview was conducted on 06/22/21 at 11:15 a.m. with Staff P, Certified Nursing Assistant (CNA). She confirmed that Resident #18 had difficulty using her hands and at mealtimes she preferred to try feeding herself first and then get help to finish. Staff P did not have any information about the resting hand splint observed in Resident #18's room. She said the resident had one (a splint) with a therapist at one time, but it was too painful for the resident to wear it. She said she did not know anything about restorative services for Resident #18. A review of Resident #18's the admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE], and the diagnoses included multiple sclerosis, osteoarthritis, lack of coordination, and contractures of both hands that were present on admission. The Minimum Data Set (MDS) completed 05/09/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, which meant that the resident was not cognitively impaired. The MDS revealed an impaired range of motion for both upper and lower extremities (arms/legs/hands/feet). Her care plan, initiated on 2/10/21 and revised on 5/12/21, revealed, The resident has contractures of the upper and lower extremities. Occupational Therapy (OT) and Physical Therapy (PT) Discharge Summaries revealed that she had received treatment from OT from 04/21/21-06/18/21, and PT from 04/21/21-05/28/21. The PT Discharge Summary, signed on 5/28/21, revealed diagnoses that included multiple sclerosis, osteoarthritis, and generalized muscle weakness. The PT treatment goals had included working to increase ROM in both hips and knees. PT discharge recommendations included referred for RNP .continue ROM with nursing staff daily. The OT Discharge Summary, signed 6/18/21, revealed diagnoses that included multiple sclerosis, generalized weakness, contractures both hands, and unspecified lack of coordination. The OT treatment goals had included improved range of motion and motor control. The OT discharge recommendations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0688 included referred for RNP. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 06/22/21 at 3:15 p.m. with the Director of Rehabilitation (DOR). He confirmed that Resident #18 had been treated by OT and discharged on 06/18/21. He reported that the resident was discharged until a custom splint could be ordered from a vendor. He said the resident would be picked up again by OT once the splint was received. He revealed the OT Discharge Summary documentation revealed, maximum potential achieved, referred for RNP/FMP (functional maintenance program). The DOR said he did not know if Resident #18 had received any restorative nursing services and did not know if the facility had an active RNP. Residents Affected - Some An interview was conducted on 06/22/21 at 6:12 p.m. with Staff N, OT. He reported that the ring finger and pinky finger of Resident #18's right hand are a little too contracted for that resting hand splint; so rather than keep her on [caseload] while we figure that out, I want to bring someone in to assess for that for something more custom. He said that the resident's left hand was too contracted for a splint, but not contracted to the point of risking the palm, and therefore did not require a palm protector. He confirmed he had signed off on the OT Discharge Summary, that it had been written by the treating therapist who was a Certified Occupational Therapy Assist (COTA), and said she should have entered anticipate resumption rather than refer to RNP/FMP. Related to the facility's RNP he said, to the best of my knowledge there is no certified nurse's aide following through on a restorative program .I'm guessing it's due to staffing shortage. An interview was conducted on 06/23/21 at 12:18 p.m. with the facility Administrator (NHA). She said, When I first started [Staff J, CNA] was doing restorative .I don't think she does it every day .will have to check with [DON] or [DOR]. The NHA left the interview and returned along with Staff J and said, I was wrong .the DON had told me we had a restorative program. Staff J confirmed that she had been a restorative nursing aide and had carried out the RNP at the facility. Staff J confirmed the facility's RNP/services had ended in December 2020 because the facility needed more floor staff. Staff J said that in December I got pulled to be a floor CNA. She said, Floor staff don't do anything that would be considered restorative .if we notice that someone needs range of motion or shows a decline, we'll let the therapists know and they'll pick them up. An interview was conducted with the DOR on 06/23/21 at 12:45 p.m. He said the facility, used to have a great restorative program. He said he felt like everyone needed restorative services. A census list of the current facility residents was provided to him to identify who out of the current residents should be receiving restorative nursing services. He identified the following residents: Resident #18 for ROM Resident #34 for range of motion Resident #37 for ambulation and mobility Resident #13 for positioning Resident #193 for ROM Resident #22 for leg exercises Resident #32 for ROM and positioning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DOR said that as therapists, we can only recommend restorative but not tell them (the facility) they have to .that's the facility's responsibility. An interview was conducted on 06/23/21 at 12:59 p.m. with the DON. She said, I was hired into a decision that CNAs could provide range of motion and ambulation during regular care which would count as restorative. She could not provide any details or documentation on those services or how the CNAs had been trained to perform the service. She said that when she physically began as the DON in the facility on 12/3/20 her focus was on stabilizing basic nursing. The DON confirmed that there was a need for a restorative nursing program at the facility. She identified one of the current residents that should be receiving restorative nursing services as Resident #32. Medical record review was completed for the residents identified by the DOR and DON as needing the RNP services and revealed the following: A review of the admission Record for Resident #34 revealed the resident was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, dementia, lack of coordination, difficulty walking, history of falling, and polyarthritis. The MDS completed 05/11/21 revealed that the resident required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Her care plan revealed limitations in physical mobility. The PT Discharge Summary, signed on 4/15/21, revealed the most recent services were from 02/23/21-04/15/21 and the discharge recommendations included, referred for RNP. The OT Discharge Summary, signed 6/16/21, revealed that services had begun on 06/15/21 and included goals for improved range of motion and mobility. A review of the admission Record for Resident #37 revealed the resident was admitted to the facility on [DATE] and the diagnoses included incomplete paraplegia (incomplete paralysis of legs and lower body) and generalized muscle weakness. The MDS completed 05/24/21 revealed the resident required extensive assistance for transfers, dressing, toilet use, and personal hygiene. The PT Discharge Summary, signed 1/1/21, revealed the most recent services were from 12/01/20-12/31/20 and had included goals and interventions related to ROM and mobility. The discharge recommendations were for RNP .referred for RNP. The admission Record for Resident #13 revealed the resident was admitted to the facility on [DATE] and the d Diagnoses included stroke, contracture both hips and both knees, Alzheimer's disease, lack of coordination. The MDS completed 05/03/21 revealed impaired range of motion both lower extremities (hip/knee/ankle/foot). PT documentation revealed most recent services from 11/04/20-01/04/20, goals and interventions included ROM goals related to contractures, and discharge recommendations were for RNP. OT documentation revealed most recent services from 04/02/21-05/28/21 and discharge recommendations revealed, referred for RNP. A review of the admission Record for Resident #193 revealed the resident was admitted initially to the facility on [DATE], and the diagnoses included traumatic brain injury, stroke, hemiplegia (paralysis of one side of the body) affecting right dominant side, and contracture right hand. The MDS completed 4/5/21 revealed impaired range of motion upper and lower extremity on one side. His care plan, initiated on 1/14/21 and revised on 4/15/21, revealed a focus area for contractures. The OT Discharge Summary, signed on 5/19/21, revealed the most recent services from 03/24/21-05/19/21. The PT Discharge Summary, signed on 5/12/21, revealed the most recent services from 03/19/21-05/12/21 and the discharge recommendations were for referral to RNP. The admission Record for Resident #22 revealed the resident was initially admitted to the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on [DATE], and the diagnoses included osteoarthritis, generalized muscle weakness, right hand contracture, and traumatic brain injury. The MDS completed 05/17/21 revealed range of motion impairment for both lower extremities (hip/knee/ankle/foot) that interfered with daily functions or placed the resident at risk of injury. Her care plan, initiated on 5/27/21 and revised on 6/7/21, revealed a self-care deficit related to the right-hand contracture. The OT Discharge Summary, signed 3/24/21, revealed the most recent services from 01/29/21-03/23/21 and the discharge recommendations were, referred for RNP. The PT Discharge Summary, signed on 3/31/21, revealed the most recent services from 02/17/21-03/31/21 and the discharge recommendations were, referred for RNP. The admission Record for Resident #32 revealed the resident was admitted to the facility on [DATE], and the diagnoses included Parkinson's disease, generalized muscle weakness, difficulty walking, and lack of coordination. The MDS completed on 05/23/21 revealed limitations in range of motion both upper and lower extremities (shoulder/elbow/hand/wrist/hip/knee/ankle/foot) that interfered with daily functions or placed resident at risk of injury. His care plan, initiated on 5/7/19 and revised on 3/25/21, revealed a focus area for stiffness of joints (dated 3/18/21), more difficult to move due to the progression of Parkinson's disease. The OT Discharge Summary, signed 5/17/21, revealed the most recent services from 03/05/21-05/17/21 with the discharge recommendation referred for RNP. The PT Discharge Summary, signed 5/21/21, revealed the most recent services from 03/29/21-05/21/21 with the discharge recommendation referred for RNP. The policies and/or procedures for the facility's restorative nursing program and services was requested but not provided by the exit of the survey on 6/23/21. Review of the facility's job description for the Restorative Nursing Aide revealed the duties and responsibilities that included the following: 1. Provide direct care to residents receiving restorative nursing to promote the resident's ability to attain and maintain their maximum function potential and minimize functional decline. 2. Provide direct restorative care; restorative dining, splints, ADL's (activities of daily living), bowel and bladder management, passive and active range of motion, ambulation and transfers. 4. Maintains documentation on each resident participating in Restorative Program: Daily Note Weekly Summary. 6. Maintains documentation of completion of residents specific/individualized Restorative Care. 9. Provides Restorative care/program as designated by the Restorative Nurse Manager (RNM) and therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure supervision was provided for one (#144) of two residents sampled for smoking. Findings included: On 06/21/21 at 09:33 a.m., an observation was made of Resident #144 lighting a cigarette off another resident. A review of the clinical record for Resident #144 showed admission to the facility on [DATE] with a diagnosis to include Hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side. An initial Minimum Data Set (MDS) dated [DATE] revealed a BIMS (brief interview for mental status) score of 05, indicating severe mental impairment. A review of a care plan dated 06/20/21 revealed Resident #144 is a cigarette smoker who is not compliant with smoking restrictions. A goal revealed that Resident #144 will not smoke without supervision through the review date. Goal 2 states that the resident will not suffer injury from unsafe smoking practices through the review date. Interventions included to instruct resident about smoking hazards, the facility's policy on smoking, locations, times and safety concerns. Notify charge nurse of violations. Resident #144 requires smoking supervision. Resident #144's smoking supplies are stored. On 06/21/21 at 11:13 a.m., an interview was conducted with Staff Q, Human Resources (HR). Staff Q stated that she was providing supervision because the Patient Care Aide (PCA) who covers the smoking duty was not available. Staff Q stated that she knows the expectations when providing smoking supervision and said they usually lock up all cigarettes and lighters. Staff Q stated that residents are not allowed to hold their own cigarettes and lighters and further stated residents should be supervised, and they should not be lighting cigarettes off other residents. An observation was made of Resident #144 on 06/22/21 at 11:17 a.m. Resident #144 stood up from his wheelchair and pulled out cigarettes and lighters from his back pocket. Resident #144 was observed lighting his own cigarette and proceeded to smoke. Resident #144 was observed throwing his cigarette butt on the ground. An interview was conducted with Staff D, Certified Nursing Assistant (CNA) who was in the courtyard on 06/22/21 at 11.25 a.m. Staff D was observed on her cell phone sitting at the table by herself. Staff D was not interacting with the four residents observed in the courtyard area. Staff D confirmed she was providing smoking supervision at the time. Staff D confirmed she was agency staff and had not provided smoking supervision before, further stating her typical duty is to take care of residents. Staff D confirmed she had not received any training for this role, and she had not reviewed smoking assessments or resident's care plans; she further stated this was her first day at this facility. Staff D stated that Resident #144 was independent, and she was not providing smoking supervision to that resident. Staff D further stated Resident #144 refuses to surrender his cigarettes, and she had let the Nursing Home Administrator (NHA) know. Staff D stated she did not know which residents were allowed to hold their own cigarette and further stated she thought Resident #144 was allowed to keep his lighter. On 06/22/21 at 11:43 a.m., an interview with Director of Nursing (DON) was conducted. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 stated that there is a binder that contains the smoking assessments in the black box where the cigarettes and lighters are locked up. The DON was notified that Staff D, CNA was not aware of the assessments or where to find them. On 06/22/21 04:43 p.m. Resident #144 was observed smoking unsupervised. No staff was observed in the courtyard. Resident #144 was observed throwing his cigarette butt on the ground after smoking. A follow up interview was conducted with the DON on 06/22/21 at 05:01 p.m. The DON confirmed that residents are not supposed to smoke without supervision and also stated residents should not be carrying lighters. On 06/23/21 08:49 a.m., Resident #144 was observed in the Courtyard smoking without staff supervision. A review of Resident #144 smoking evaluation dated 06/08/21 showed that resident the assessment was not updated following care plan updates on 06/20/21. The evaluation showed Resident #144 is not able to recall information and his decision-making skills are not reasonable and consistent. A summary of the evaluation revealed that Resident #144 needed constant supervision while smoking. Resident #144 should be supervised per facility policy. An interview with Minimum Data Set (MDS) nurse on 06/23/21 at 01:30 p.m. The MDS nurse stated care plans and smoking assessments should match and remain updated accordingly. The MDS nurse stated that these documents should always be accessible to the staff assigned smoking supervision. On 06/23/21 at 3:00 p.m., an interview was conducted with the NHA regarding smoking supervision. NHA confirmed that residents must always be supervised while smoking per their policy. A review of the facility's policy subject titled, smoking - supervised with a revision date, 02/07/20, states that the center will provide a safe designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. (4) During designated smoking times staff will be assigned to assist or supervised residence whose care plans indicate assistance all supervision is required while smoking (5) The center will retain, and store matches and lighters for all residents. (6) All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were not left unattended by nursing, at the bedside, during medication administration for one (Resident #29) of 29 sampled residents. Findings included: On 6/20/21 at 12:27 p.m., during an interview with Resident #29, two medications cups with pills in each cup were noted sitting on the overbed table in front of the resident. Resident #29 indicated he had been given the pills to take by the nurse a few minutes ago and the nurse usually leaves them for him to take. Resident #29 stated it took him a little while to take his pills because he has difficulty getting them all down at once. Resident #29 proceeded to take the two medicine cups of pills slowly. The nurse was not in the room at the time to witness the pills Resident #29 was taking. On 6/20/21 at 12:31 p.m. Staff B, Registered Nurse (RN) entered the room for Resident #29. Staff B, RN stated she had left the pills at the bedside for Resident #29 because he was alert and she had stepped out of the room to go and get insulin for the resident. Staff B, RN stated she was only gone for 30 seconds. Staff B, RN proceeded to give Resident #29 his insulin injection. A review of the admission Record for Resident #29 indicated an admission date of 8/18/2020 and a diagnosis of cerebrovascular disease, major depressive disorder, type 2 Diabetes Mellitus, alcoholic cirrhosis of liver, encephalopathy and altered mental status. A review of the Medication Administration Record (MAR) for Resident #29 revealed Staff B, RN had administered following medications: Humalog insulin 2 units subcutaneously before meals scheduled for 11:30 a.m., Tessalon [NAME] 200 milligrams scheduled for 1:00 p.m., Humalog insulin 6 units subcutaneously for sliding scale scheduled at 11:00 a.m., Guaifenesin 400 milligrams scheduled for 12:00 p.m., and Percocet 7.5/325 milligrams as needed for pain given at 12:22 p.m. On 6/20/2021 at 2:40 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the nurse should not leave a resident unattended to take their pulls at any time. The DON stated it was the expectation of the nurses to watch each resident take their pills regardless of their cognitive abilities. She stated the nurse would be counseled regarding the policy for medication administration. A review of the facility policy entitled General Dose Preparation and Medication Administration with an effective date of 12/02/2007 and a revision date of 01/011/2013 indicated the following: Applicability: This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. Procedure: 1-Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3-Dose preparation: Facility should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.9-Facility staff should not leave medications or chemicals unattended. 5-During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.9-Observe the resident's consumption of the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 21 of 21