Inspection·February 2, 2023

F 0584 A facility policy titled Maintenance, dated 11/30/14 was reviewed. The policy stated the following: Level of Harm - Minimal harm or potential for actual harm The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Residents Affected - Few Procedure: The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 2 of 29 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 02/02/2023 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to file and resolve a grievance for one (Resident #32) of thirty-one sampled residents. Findings included: A review of the Transfer/Discharge Report indicated Resident #32 was admitted into the facility on [DATE]. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. On 01/30/23 at 9:55 a.m., Resident #32 reported Staff K, Certified Nursing Assistant (CNA), yelled at him and told him to mind his own [expletive] business because he told her his roommate had been sitting in a dirty brief for hours. He reported his roommate was eighty something years old and could not change himself and he was looking out for him. Resident #32 reported an agency nurse came in because they were screaming at each other so loud. The resident reported Staff K, CNA, would see his call light on and ignore it. According to the resident, this incident happened about one week ago, and he reported this to the Director of Nursing (DON). The DON stated to him that she would deal with it. A review of the Monthly Grievance Log for January 2023 did not reflect a grievance related to this incident. On 01/31/23 at 11:27 a.m., the DON stated Resident #32 reported the incident to her a week and a half ago. He came to her and told her that one of the CNAs was being rude to his roommate. The roommate had ALS (Amyotrophic Lateral Sclerosis). She interviewed the roommate, and he was not upset. Staff K, CNA, told Resident #32 she was taking care of his roommate and the resident reported to the DON she was being rude. The DON immediately interviewed both the resident and the CNA. On 01/31/23 at 11:29 a.m., Staff K, CNA, reported she went in the room because both residents had their call lights on. Resident #32 asked for a gown and his roommate wanted a brief change. She went to get a gown and came back to change the roommate's brief. She was explaining to the roommate that she was going to pull him up and that he needed to keep the bed steady. Resident #32 yelled and said don't talk to him like that, he was an eighty-year-old man. Another nurse then entered the room and stated she heard yelling. On 01/31/23 at 11:35 a.m., the DON said the roommate reported he did not have any issues. She explained to Staff K, CNA, that they must use customer service skills. The DON said Resident #32 did not report to her that Staff K, CNA, used profanity. He only stated that she was rude. On 01/31/23 at 11:40 a.m., Staff K, CNA, stated she did not use profanity when she spoke to the resident. She stated Resident #32 was being rude and was trying to tell her how to take care of his roommate. She reported he was always complaining about things. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 3 of 29 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 02/02/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/31/23 at 11:42 a.m., the DON reported she did not do a grievance. She only did verbal education with the CNA. She reported to the Administrator and said she would follow up with Resident #32. On 02/01/23 at 1:35 p.m., the Administrator reported she heard about the incident yesterday, 01/31/23. She was told by Resident #32 the CNA went to provide care to his roommate, he had concerns that he voiced to the CNA, and she said to mind his [expletive] business. The Administrator reported she submitted a one day report, got a statement from the CNA, and contacted law enforcement. The initial conversation about the incident did not include verbal abuse and it was not interpreted as verbal abuse. She said [Resident #32] made that comment yesterday, 01/31/23. She would expect to see some type of coaching, teachable moment, in-service, and a grievance. The policies and procedures provided by the facility Complaint/Grievances with an effective date of 11/30/2014 revealed the following: The residence shall ensure investigation and resolution of complaints. A log will be kept of all complaints and outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 4 of 29 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 02/02/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, facility documentation review and photographic evidence the facility failed to thoroughly and accurately investigate an allegation of sexual abuse for one (Resident #33) of one sampled resident. Residents Affected - Few Findings included: During an interview on 01/20/23 at 12:15 p.m., Resident #33 stated on 12/08/22 a physical therapist made her feel uncomfortable. Resident #33 stated that a grievance and witness statement was completed and turned into the Administrator. Resident #33 stated the Administrator gave back Resident #33's grievance and witness statement and stated the sexual abuse incident would be an internal matter only. The grievance dated 12/08/22 provided by Resident #33 showed no investigation or resolution was completed. Photographic evidence of the grievance and witness statement were obtained. A record review of Resident #33's medical record showed an admission date of 11/05/22. Resident #33 had a primary diagnosis of multiple sclerosis. A care plan revealed a focus of Resident #33's limited physical mobility with neurological deficits and weakness. A goal stated Resident #33 would remain free of complications related to immobility. Interventions included: Bed mobility, provide supportive care, assist with mobility with physical and occupational referrals as ordered. An admission minimum data set (MDS) dated [DATE], showed the resident needed limited assistance with a one (1) person assist for transfers, walking did not occur and had a brief interview for mental states (BIMS) of 15, which indicated intact cognition. A review of the grievance dated 12/08/22 stated, I'm very concerned about my physical therapist inappropriate behavior, physical touching, going threw[sic] my personal belongings and coming to me and my room. The grievance was signed and dated by Resident #33. There was no investigation or resolution completed for the grievance. Photographic evidence obtained. A review of the witness statement dated 12/09/22 stated, On Monday Therapist rubbed biofreeze on my legs and I felt it was inappropriately done. The witness statement also stated the Physical Therapy Assistant (PTA) went to Resident #33's room to find the foot pedal to the wheelchair and saw coffee cakes. He would not stop asking for one until Resident #33 gave him one. Resident #33 stated in the witness statement, I feel like he goes out of his way to find me and touches me (rubs back/arm) inappropriately. The witness statement was signed and dated by both the Resident #33 and a Registered Nurse (RN) on 12/09/22. Photographic evidence was obtained. A review of the reportable event documentation dated 12/09/22 revealed, Resident #33 stated that during therapy the PTA made a comment about the contents of her drawer and the coffee cakes. 'I love those coffee cakes.' She claims that while he was adjusting her gait belt that he was too close to her, and it made her uncomfortable. The allegation was not substantiated. During an interview on 02/02/23 at 9:15 a.m., the administrator stated she was familiar with the incident of sexual abuse regarding Resident #33 and stated a reportable was completed with an investigation. The administrator was shown the incomplete grievance dated 12/08/22. The administrator replied, I am the grievance offer and I have never seen that grievance before, and that grievance was never signed off by a nurse. The administrator stated grievance forms could be picked up by the front desk by anyone. The administrator stated Resident # 33 had a blue copy of the grievance which she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 5 of 29 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 02/02/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete should not have had. If the grievance had been turned in, Resident #33 would have received a yellow copy for her records. The administrator was shown a witness statement dated 12/09/22 with both a nurse and Resident #33's signatures. The administrator responded that the witness statement was from the investigation dated for 12/09/22, not a grievance that was never seen. The administrator was shown the witness statement written by Resident #33 that stated, PTA rubbed biofreeze on my legs and I felt it was inappropriately done. The investigation report indicated, she claims that while adjusting a gait belt that he was too close to her and it made her feel uncomfortable. The administrator was asked why the inappropriate touching statement was not documented on the investigation report from the witness statement. The administrator stated the PTA was asking for Resident #33's coffee cakes and was too close to Resident # 33 making her uncomfortable. The administrator was again asked why the inappropriate touching statement was not documented in the investigation report from the witness statement. The administrator stated, that was my bad and I can see how that would have been important to put on the reportable. The administrator was asked if the PTA was still working for the facility and administrator responded No. Administrator stated the investigation of the allegation of sexual abuse was not substantiated. Event ID: Facility ID: 105012 If continuation sheet Page 6 of 29 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 02/02/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete a baseline care plan upon admission for one (Resident #46) of three sampled closed records. Findings included: A record review of Resident #46's medical record showed an admission date of 11/18/22. Resident #46 had diagnoses of Asthma, Hyperthyroid and Hypertension. A progress note dated 11/23/22 stated, Received new orders from physician to discharge back to [name of the facility]. PICC (Peripherally Inserted Central Catheter) removed per orders. Paperwork sent with resident. Daughter and receiving facility aware resident is on her way back to room [ROOM NUMBER]. Resident #46 had a discharge date of 11/23/22. No care plan was available in the medical record. During an interview on 02/01/23 at 9:45 a.m., Staff C, Regional Nurse stated there was no baseline care plan available for Resident #46. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 7 of 29 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 02/02/2023 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 observations, staff and resident interviews, and medical record review, the facility failed to implement care plan interventions for safe smoking for three (Residents #99, #44, #42) of twenty-one sampled residents. Findings included: On 1/30/2023 at 8:55 a.m., prior to entering the building for the first day of survey, Resident #99 was observed at the fence line at the side of facility's parking lot and seated in a chair, along with three other residents next to her. She was observed smoking and had her own cigarettes and lighter on her person. She, along with the other residents revealed that the facility did not follow the smoking schedule and did not let them out on the back porch area where the designated smoking area was located. She said, the back porch entrance/exit doors were locked and staff had to let them in and out. Staff were not available to let them out in that area, especially during posted smoking times. Resident #99 revealed the back porch area was beautiful and they could sit and watch the water and the dolphins swimming by. She revealed she had only been at the facility for about three weeks and had not been able to go outside on the back porch, during smoking hours, for most of her days here. She revealed she had to resort to checking herself out Leave of Absence and walk over to the facility parking lot fence line, near the park to smoke. The area where the residents were smoking in the parking lot was on the facility side of the fence and not the side of the fence next to the park. Resident #99 and three others were smoking and seated on facility property. Photographic evidence was obtained. On 1/30/2023 at 8:55 a.m., prior to entering the building for first day of survey, Resident #44 was observed at the fence line at the side of facility's parking lot and standing up next to three other residents. She was observed smoking and had her own cigarettes and lighter on her person. She was smoking in the parking lot just at the fence line leading into the neighboring park. Resident #44 was interviewed and said staff did not honor the posted smoking times and the residents could not smoke on the facility's back porch designated smoking area due to no one assisting them. She further revealed that it was hard to find staff to let them outside onto the back porch area just to lounge and watch the water, sunset, and dolphins. She confirmed she and other residents who smoke, had to resort to checking themselves out of the facility to smoke. Resident #44 said the residents should have access to the back porch area whenever they wanted to go out there, even without smoking. Resident #44 and #99, who were near each other, said when they asked staff to let them out to the back porch, staff would tell them they did not have enough staff to go out and supervise them, even if they were not smoking. Resident #44 said she kept her own cigarettes and lighting devices because nobody would help her with those things if they had them locked up. Resident #44 and #99 did not remember being provided with a smoking policy and smoking rules for signature. There were no staff in the area, or outside in the parking lot, supervising the residents while they smoked. On 1/30/2023 at 3:10 p.m., Resident #42 was observed self propelling while in her wheelchair through the back dining room to the doors that lead to the back porch/patio area. She reached the doors where there was an electronic key pad and entered a code. She opened the doors and self propelled outside to the porch. She was observed to stay on either side of the ramps leading down and began to light her cigarette with her own personal lighter. There were no staff outside. Approximately ten minutes later, the resident self propelled herself to the key pad, entered a code, and opened the doors to let herself back inside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 8 of 29 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 02/02/2023 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 On 1/30/2023 at 3:30 p.m. an interview with the NHA and DON revealed residents who were assessed as safe smokers were allowed to keep their own packs of cigarettes, but were not allowed to keep their own lighting devices. The NHA revealed that many residents checked themselves out on Leave of Absence and sneak lighters back in the facility and she did not know how to catch or monitor that. The NHA and DON further confirmed the policy and normal practice for residents to smoke, were to check out a lighter at either the front desk for ask their nurse. Once the residents were done using the lighters they were to check the lighters back in. On 1/31/2023 at 6:04 a.m., Resident #42 and Resident #44 were observed on the front porch area just outside the main lobby doors. Resident #44 was standing up with a lit cigarette in her mouth. She was observed pressing the door bell to the front lobby doors several times and said, Nobody will answer the door and let me in. I have been trying to push the door bell for about fifteen minutes now. Resident #42 was seated on the front porch by the doors with Resident #44. Both residents revealed a staff member let them outside earlier so they could smoke. Both of them revealed they had their own cigarettes and own lighting devices and came outside in this non designated smoking area to smoke. Both residents said they could not go down to the parking lot to the fence line near the park to smoke because it was pitch black outside and they could not see. Both confirmed they were in a non-designated smoking area. Resident #44 said there was a designated smoking area out on the back porch area, that overlooked the water, but that area was never open and staff did not assist them during the scheduled smoking times. A review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed the resident was her own responsibility to make her care and medical decisions. A review of the current Physician's Order Sheet dated for the month 1/2023 revealed orders to include but not limited to: May go on LOA (Leave of Absence) with no further instruction. A review of the current admission MDS assessment, dated 11/25/2022, revealed the following(Cognition/BIMS score 15 of 15, which indicated intact cognition. A review of the most current smoking assessment, dated 11/18/2022 revealed the resident was a smoker and deemed/assessed as a safe smoker with no further notes. A review of the Smoking agreement/notice of policy was signed by the resident on 1/31/2023, one day after the smoking concern was brought to the attention to the Nursing Home Administrator and Director of Nursing. The Nursing Home Administrator confirmed there was no previous notice of smoking policies signed by the resident. Review of the current care plans with next review date 3/12/2023 revealed the following: (a.) Resident #44 is a smoker with interventions in place and to include: 1. Instruct resident about the facility policy on smoking: locations, times, safety concerns; 2. Notify charge nurse if it is suspected resident has violated facility smoking policy; 3. The resident requires SUPERVISION while smoking. A review of the medical record revealed Resident #42 was admitted at the facility on 11/12/2022 and readmitted on [DATE]. Review of the advance directives revealed resident was her own responsible party. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 9 of 29 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 02/02/2023 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 A review of the current Physician's Order Sheet dated for month 1/2023 revealed an order to include but not limited to: May go out with responsible party. A review of the current admission MDS assessment, dated 11/19/2022 revealed: (Cognition/Brief Interview Mental Status or BIMS score 15 of 15, which indicated the resident was able to make her daily and medical decisions). A review of the most current smoking assessment, dated 11/12/2022 revealed the resident was deemed/assessed as a safe smoker and goes on smoke breaks with staff and other residents. A review of the Smoking agreement/notice of policy was signed by the resident on 2/1/2023, two day after the smoking concern was brought to the attention to the Nursing Home Administrator and Director of Nursing. The Nursing Home Administrator confirmed there was no previous notice of smoking policies signed by the resident. A review of the current care plans with next review date 2/8/2023 revealed the following but not limited areas: (a.) Resident #42 is a smoker with interventions in place to include: 1. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; 2. Instruct the resident about the facility policy on smoking: locations, times, safety concerns; 3. Observe clothing and skin for signs of cigarette burns; 4. The resident requires SUPERVISION while smoking. On 1/31/2023 at 9:45 a.m. and 2:00 p.m., an interview with Resident #99 revealed she would like to smoke out on the back porch where the designated smoking area was but staff never let them out there, especially during the scheduled smoking times. She revealed she had not seen anyone out in the smoking area, and therefore most of the residents who smoke, had to check themselves out and go out to the parking lot fence area. A review of the medical record for Resident #99 revealed she was admitted to the facility on [DATE]. She was her own responsible party related to her care and medical decisions. A review of the current Physician's Order Sheet dated for the month of 1/2023, revealed orders for: May go on LOA with no further instruction. A review of the current admission Minimum Data Set (MDS) assessment, dated 1/15/2023, revealed the following: Cognition/Brief Interview Mental Status or BIMS score of 14 of 15, which indicated intact cognition. A review of the most current smoking assessment, dated 1/9/2023, revealed Resident #99 was a smoker and was deemed/assessed as a safe smoker with no further notes. A review the Smoking agreement/notice of policy was signed by Resident #99 on 1/31/2023, one day after the smoking concern was brought to the attention of the Nursing Home Administrator and Director of Nursing. The Nursing Home Administrator confirmed there was no previous notice of smoking policies signed by the resident. A review of the current care plans with next review date 4/23/2023, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 10 of 29 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 02/02/2023 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 (a.) Resident #99 is a smoker with interventions in place to include: 1. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; 2. Instruct resident about the facility policy on smoking with relation to locations, times, safety concerns; 3. Notify the charge nurse immediately if it is suspected resident has violated facility smoking policy; 4. Observe clothing and skin for signs of cigarette burns; 5. The resident requires SUPERVISION while smoking. Residents Affected - Few An interview on 1/31/2023 at 1:00 p.m., with the Nursing Home Administrator revealed residents who were assessed as safe smokers, were to be supervised by staff when smoking. A visiting Nursing Home Administrator, Staff B indicated once the residents check themselves out by Leave of Absence, they [the facility] were no longer responsible for where the resident's smoke, as long as it was off the facility property. The Nursing Home Administrator and Staff B both confirmed the front lobby doors and front porch area, the fence line on the facility part of the parking lot, and all areas on the back porch minus the designated smoking area, were on facility property and residents should not be smoking in those areas. On 1/31/2022 at 10:00 a.m., during an interview with the NHA, Staff B, and Staff C, Regional Nurse Consultant, they revealed the facility had residents in the facility that were assessed as safe smokers. Staff B revealed the facility did have a designated smoking area, which was outside on the back enclosed porch, which overlooked the water. She said there were supervised smoking times and the smoking schedule was posted throughout the facility and on the doors that lead outside to the back porch, smoking area. Staff B and Staff C said they had to do a better job making sure staff were available to help residents go out on the back porch and to let them back in. She further revealed they likes to have supervision with all residents who go out in this area, whether they were their own responsible party or if they need supervision. A review of the Plans of Care policy and procedure with a revision date of 9/25/2017, revealed the following: The policy stated; An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The Procedure section revealed the following but not limited areas: 1. Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. Develop and implement an individualized Person-Centered comprehensive plan of care by the interdisciplinary team that includes but is not limited to- the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and , to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 11 of 29 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 02/02/2023 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 3. The individualized Person Centered care plan may include but is not limited to the following: Level of Harm - Minimal harm or potential for actual harm (a.) Individualized interventions that honor the resident's preference and promote achievement of the resident's goals. Residents Affected - Few (b.) Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths and desired outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 12 of 29 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 02/02/2023 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to initiate the discharge planning process for one (Resident #32) of two sampled residents. Residents Affected - Few Findings included: On 01/30/23 at 9:55 a.m., Resident #32 reported he wanted to discharge to an assisted living facility. He stated he mentioned this to administration but there had been a delay because the facility did not have a Social Services Director. A review of the Transfer/Discharge Report indicated Resident #32 was admitted into the facility on [DATE]. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. A discharge care plan initiated on 12/20/21 indicated Resident #32 wished to discharge to an assisted living facility when able. On 02/01/23 at 1:35 p.m., the Administrator reported she did not have a full time Social Services Director, but she had a Social Services Director that worked in a sister facility that came to the facility on Wednesdays. The Administrator reported Resident #32 had verbalized wanting to leave about one month ago. The Social Services Director was working down the list but she had not made it to him yet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 13 of 29 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 02/02/2023 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 - Few 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, record review, and interviews, the facility failed to ensure splints were applied per therapy discharge recommendations for one (Resident #32) of one sampled resident. Findings included: A review of the Transfer/Discharge Report indicated Resident #32 was admitted into the facility on [DATE] with a diagnosis that included but was not limited to hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting the left non-dominant side. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Section O Special Treatments, Procedures, and Programs of the MDS indicated Resident #32 did not have a splint or brace. The Order Summary Report with active orders as of 02/02/23 reflected the following order: May have restorative/maintenance programs as indicated, order date 10/15/21. The Occupational Therapy Discharge Summary revealed the following discharge recommendations: Splint/ brace and restorative nursing program, dated 9/23/2022. The resident did not have a care plan in place related to the use of a splint. On 01/30/23 at 9:55 a.m., Resident #32 reported there was not a restorative program due to staffing. He reported he had a splint but staff did not put it on and he should be wearing it. Resident #32 stated therapy told him the aides should be putting it on and the aides told him therapy should be putting it on. Resident #32 was observed not wearing a splint at this time and his left hand was severely contracted. On 02/01/23 at 3:30 p.m., Resident #32 was observed not wearing a splint on the severely contracted left hand. On 02/02/23 at 9:39 a.m., Resident #32 was observed not wearing a splint on the severely contracted left hand. The splint was observed on the resident's dresser. The resident stated there's no way he could put the splint on himself. On 02/02/23 at 9:35 a.m., Staff M, Certified Nursing Assistant (CNA), reported she was assigned to Resident #32. Staff M, CNA reported she did not apply the splint and she thought he applied it himself. She stated he could put the splint on himself and never asked her to put it on. Staff M, CNA, stated she cleaned under his arm, but he did most of his care himself. On 02/02/23 at 9:45 a.m., Staff O, Occupational Therapy Assistant (OTA), reported the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 14 of 29 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 02/02/2023 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 initially on his case load for splinting on the left hand. He was not currently on the case load. Staff O, OTA, reported Resident #32 should be wearing the splint and the aides should be putting it on. On 02/02/23 at 10:13 a.m., the Director of Nursing (DON) stated if therapy was not applying the splints, then nurses and CNAs should put them on. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 15 of 29 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 02/02/2023 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 - Some 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, staff and resident interviews, and medical record review, the facility failed to 1. ensure safety and supervision for smoking for five (Residents (#42, #98, #44, #99, and #38) of twenty-one sampled residents and 2. failed to ensure fifteen minute checks were performed and a toileting program was implemented to prevent falls for one (Resident #6) of one sampled resident. Findings included: 1. On 1/30/2023 at 8:55 a.m. prior to entering the building for first day of survey, Resident #99 was observed on the fence line of the side parking lot and seated in a chair, along with three other residents next to her. She was observed smoking and had her own cigarettes and lighter on her person. She, along with the other residents, revealed the facility did not follow the smoking schedule and did not let them out on the back porch area where the designated smoking area was located. She said the back porch entrance/exit doors were locked and staff were never available to let them out in that area. She said it was beautiful and they could sit and watch the water and the dolphins swimming by. Resident #99 revealed she had to resort to checking herself out by Leave of Absence and walking over to the parking lot fence line to smoke. She confirmed she kept her lighter with her at all times. A review of Resident #99's medical record revealed she was admitted to the facility on [DATE] and her own responsible party. A review of the current Physician's Order Sheet dated for the month of 1/2023 revealed orders for: May go on LOA (Leave of Absence) with no further instruction. A review of the current admission Minimum Data set (MDS) assessment dated [DATE], revealed the following: Cognition/Brief Interview for Mental Status (BIMS) score 14 of 15, indicated intact cognition. A review of the most current smoking assessment, dated 1/9/2023 revealed the resident was a smoker and was deemed/assessed as a safe smoker with no further notes. A review of the Smoking agreement/notice of policy was signed by the resident on 1/31/2023, one day after this was brought to the attention to the NHA and DON. The policy was not provided to the resident upon her admission and during the time she was assessed as a smoker. Review of the current care plans with next review date 4/23/2023 revealed the following but not limited to areas: (a.) Resident is a smoker with interventions in place to include: 1. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; 2. Instruct resident about the facility policy on smoking: locations, times, safety concerns; 3. Notify the charge nurse immediately if it is suspected resident has violated facility smoking policy; 4. Observe clothing and skin for signs of cigarette burns; 5. The resident requires SUPERVISION while smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 16 of 29 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 02/02/2023 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 - Some On 1/30/2023 at 2:00 p.m., Resident #98 was in his room when this surveyor walked by and heard the resident yell out for help. Upon entering his room, Resident #98 observed seating upright in his bed with over ten packs of cigarettes emptied on the bed. He said he smoked and the facility did not follow the smoking times as posted. He said he and other residents would go to the back doors that lead to the smoking porch and the porch right off the water during the posted smoking times. Staff never came to open the locked door for them. He said this had been an ongoing issue and there had been a lot of complaints from others as well. He said he had to resort to checking himself out by Leave of Absence and go on the side of the parking lot near the fence line to smoke. He said at times he would smoke on the front porch. He confirmed this was not a designated smoking area, but as far as he knew, the only designated smoking area was on the back porch, which the resident's could never get to. Further observations revealed back behind him on his bed was a blue plastic lighter. He said it was his and he kept it with him. He revealed he was unaware what the policy was for holding a lighter on his person. A review of the medical record revealed Resident #98 was admitted to the facility on [DATE]. He was his own responsible party to make his daily and medical decisions. A review of the current Physician's Order Sheet dated for month 1/2023 revealed an order for: May go out with responsible party. A review of the Admission/readmission data collection -INR assessment, dated 1/19/2023, revealed in Section B: Cognition - Resident #99 was alert to person, place and time and with OK memory. Section C. Communication - Hearing adequate, Vision adequate, Speech clear, makes self understood, and understands others. This assessment revealed that the resident was able to make his daily decisions. A review of the current smoking assessment, dated 1/20/2023 revealed the resident was not a smoker. The rest of the assessment was not completed as a result of being checked a Non smoker. Further review of the medical record did not contain a more current smoking assessment and did not contain an assessment to reflect the resident was currently a smoker. A review of the Smoking agreement/notice of policy revealed the agreement/notice was signed by the resident on 2/1/2023, two days after this was brought to the attention of the Nursing Home Administrator and Director of Nursing. There were no other smoking agreement policies prior to the 2/1/2023 notice. A review of the current care plans with next review date of 4/25/2023, and still in the completion process, did not indicate Resident #98 was a smoker. There were no interim care plans that focused on Resident #98 smoking since his admission date. On 2/1/2023 at 1:00 p.m. an interview with the Staff C, Regional Nurse Consultant confirmed the facility had not completed the care plans to reflect Resident #98 was a smoker. There were no smoking assessments to reflect if he was a safe or unsafe smoker. She confirmed the resident was a smoker via review of the Resident Smokers list that was provided by the Nursing Home Administrator on 1/30/2023. Staff C confirmed the facility should have completed a smoking assessment on this resident by now. On 1/30/2023 at 3:10 p.m., during an observation of Resident #42, she propelled her wheelchair to the back patio area door. She entered a security code to open the door. Once outside, she put a cigarette in her mouth, used a lighter to light the cigarette and began to smoke. She was in an area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 17 of 29 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 02/02/2023 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 - Some where there was no smoking receptacles. There was a smoking area with receptacles and smoking blankets, chairs, etc. about twenty feet away from where she was smoking. There were no staff at or around the area, she was smoking unsupervised. On 1/31/2023 at 6:04 a.m., before sunrise, Resident #42 and Resident #44 were on the front porch area just outside the main lobby doors. Resident #44 was observed standing up with a lit cigarette in her mouth. She was observed pressing the door bell to the front lobby doors several times and told this surveyor, nobody will answer the door and let me in. I have been pushing the door bell for about fifteen minutes now. Both residents revealed they had their own cigarettes and own lighting devices. Both said they could not go down to the parking lot to the fence line near the park to smoke because it was pitch black outside and they could not see. Both confirmed they were currently in a non-designated smoking area. Resident #42 was seated in her wheelchair holding a lit cigarette up to her mouth with her right hand. She was observed with a plastic lighter in her left hand. Resident #42 revealed she had the code to get outside on the back porch and she would smoke out there as well, but said staff did not follow the scheduled smoking times, as listed. Resident #42 confirmed she signed herself out of the facility or had staff open the front doors so she could smoke on the front porch area. She said if staff were not going to follow the smoking schedules, then she would continue to go out on her own to the front porch and back porch. Resident #42 confirmed the front porch area was not a designated smoking area. A review of Resident #42's medical record revealed she was admitted to the facility on [DATE], readmitted on [DATE] and was her own responsible party. A review of the Physician's Order Sheet dated for the month of 1/2023, revealed an order for: May go out with responsible party. A review of the current admission MDS assessment, dated 11/19/2022, revealed: Cognition/Brief Interview for Mental Status (BIMS) score 15 of 15, which indicated intact cognition. A review of the most current smoking assessment, dated 11/12/2022 revealed the resident was deemed/assessed as a safe smoker and goes on smoke breaks with staff and other residents. A review of the Smoking agreement/notice of policy was signed by the resident on 2/1/2023, two days after this was brought to the attention of the Nursing Home Administrator (NHA) and the Director of Nurses (DON). Review of the current care plans with next review date 2/8/2023 revealed the following: (a.) Resident #42 is a smoker with interventions in place to include but not limited to: 1. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; 2. Instruct the resident about the facility policy on smoking: locations, times, safety concerns; 3. Observe clothing and skin for signs of cigarette burns; 4. The resident requires SUPERVISION while smoking. A review of Resident #44's medical record revealed she was admitted to the facility on [DATE] and was her own responsible party. A review of the current Physician's Order Sheet dated for the month of 1/2023, revealed orders for : May go on LOA with no further instruction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 18 of 29 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 02/02/2023 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 A review of the current admission MDS assessment dated [DATE], revealed the following: Cognition/BIMS score 15 of 15, which indicated intact cognition. A review of the most current smoking assessment, dated 11/18/2022 revealed the resident was a smoker and deemed/assessed as a safe smoker with no further notes. Residents Affected - Some A review of the Smoking agreement/notice of policy was signed by the resident on 1/31/2023, one day after this was brought to the attention to the NHA and DON. This policy was not provided to the resident upon her admission and during the time she was assessed as a smoker. Review of the current care plans with next review date 3/12/2023 revealed the following areas but not limited to: (a.) Resident is a smoker with interventions in place and to include: 1. Instruct resident about the facility policy on smoking: locations, times, safety concerns; 2. Notify charge nurse if it is suspected resident has violated facility smoking policy; 3. The resident requires SUPERVISION while smoking. On 1/30/2023 at 8:55 a.m., Resident #38 was observed smoking out in the facility parking lot fence line area next to the nearby park. He had his cigarette lighter and he indicated he kept it on his person and left it in his room when not using it. He explained the facility staff were never around to check out or check in his lighting devices. On 1/31/2023 at 10:00 a.m. Resident #38 was observed seated in a lounge chair out on the front lobby porch area, just next to the facility's entrance doors. He was noted with a cigarette in his hand and a lighting device on his lap. He confirmed again that he held his own cigarettes and lighters because if he let staff keep them, he would never be able to check them out when he wanted to smoke. He said staff did not follow the smoking schedules. He was told by the staff there were not enough staff to supervise out on back porch where the designated smoking area was located. He said instead he would check him self out by Leave of Absence and either smoke early in the morning on the front porch area or in the parking lot at the fence line. He was not sure if those areas were smoking areas, but did confirm those areas lacked any type of cigarette butt receptacle. A review of Resident #38's medical record revealed he was admitted to the facility on [DATE] and was his own responsible party. A review of the current Physician's Order Sheet for the month of 1/2023 revealed orders for : May go on LOA with meds with no further instruction. A review of the current quarterly MDS assessment dated [DATE] revealed the following: Cognition/BIMS score 15 of 15, which indicated intact cognition. A review of the smoking assessment, dated 10/13/2021 revealed the resident was a smoker and was deemed/assessed as a safe smoker with no further notes. A review of the most current smoking assessment dated [DATE], after the surveyor observed the resident smoking unsupervised on 1/30/2023 and informed administration, revealed the resident was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 19 of 29 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 02/02/2023 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 current smoker and deemed/assessed as a safe smoker and required supervision while on facility grounds. Level of Harm - Minimal harm or potential for actual harm Review of the current care plans with next review dated 4/19/2023 revealed the following: (a.) Residents Affected - Some Resident is a smoker with interventions in place to include: 1. Instruct the resident about smoking risks and hazards about smoking cessation aids that are available; 2. Instruct resident about the facility policy on smoking: locations, times, safety concerns; 3. Monitor oral hygiene; 4. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. On 1/30/2023 at 3:30 p.m. an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) both revealed residents who were assessed as safe smokers were allowed to keep their own packs of cigarettes, but were not allowed to keep their own lighting devices. The NHA revealed many residents check themselves out by Leave of Absence and they sneak lighters back in the facility. The NHA and DON further confirmed that the policy and normal practice for residents to smoke, was to check out a lighter at either the front desk for ask their nurses. Once the residents were done using the lighters and done smoking, they were to check the lighter back in. On 1/31/2023 at 9:20 a.m., during the scheduled smoking time from 9:00 a.m. to 9:30 p.m., an interview with Staff D, CNA, Staff E, CNA, and Staff F CNA was conducted. They were asked who was responsible to assist the residents who smoked with the current scheduled smoking time outside on the back porch. The CNAs said they were not assigned to do that task and did not know who was responsible for that. Staff D, E, and F revealed the residents just checked themselves out of the facility and go next door to the park and smoke. They were not aware as to why residents could not smoke out in the designated smoking area on the back porch during posted smoking times. They were not aware of who supervised the residents when they smoked or if they smoked on the back porch area. On 1/31/2023 at 10:00 a.m., an interview was conducted with the facility's Nursing Home Administrator, Staff B, a visiting Administrator, and Staff C, Regional Nurse Consultant. They revealed the facility had residents that were assessed as safe smokers. Staff B revealed most of the residents who smoked, checked themselves out by Leave of Absence and went off property to the park next door to smoke. Staff B revealed there were times they sat in the side parking lot at the fence line and smoked, but the residents were routinely educated that they could not smoke on the property. Staff B said the facility had a designated smoking area, which was outside on the back enclosed porch, which overlooked the water. The supervised smoking times and smoking schedule was posted throughout the facility to include near the nurse station, and on the doors that lead outside to the back porch, smoking area. Both Staff B and Staff C said they had to do a better job making sure there were staff available to help residents go out on the back porch area and to let them back in. Review of the facility's posted smoking times, which are posted next to the nursing station and at the door that leads to the back porch, revealed the following: SMOKING HOURS **STAFF MUST BE PRESENT (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 20 of 29 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 02/02/2023 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 9:00 a.m. - 9:30 a.m.; 11:00 a.m. - 11:30 a.m.; 1:30 p.m. - 2:00 p.m.; 3:30 p.m. - 4:00 p.m.; 6:00 p.m. - 6:30 p.m.; and 9:30 p.m. to 10:00 p.m. On 2/2/2023 at 1:00 p.m. the Director of Nursing and the Nursing Home Administrator provided the Smoking - Supervised policy and procedure, with last revision date of 2/7/2020, for review. Residents Affected - Some The policy stated; 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. Oxygen is not permitted in the designated smoking areas. The Center will have safety equipment available in designated smoking areas including: Smoking Blankets, Smoking Aprons, a Fire extinguisher, and Non-combustible self-closing ashtrays. The policy procedure section revealed the following but not limited areas: (3.) The center will establish and post designated smoking areas and times. (4.) During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. (5.) The Center will retain and store matches, lighters, etc. for all residents. (6.) All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. (7.) Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement. (9.) Metal contains with self closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 2. On 1/30/23 at 11:33 a.m. Resident #6 was observed standing from his bed. His wheelchair was approximately 3 ½ feet away from him. With straight legs the resident fell forward and caught himself on the arms of the wheelchair. He retrieved an item from the chair, repositioned himself, stood up and with straight legs fell backwards on to the bed. When the resident was beginning to throw himself backwards on the bed, a Certified Nursing Assistant (CNA) walked into the room and was trying to tell him to wait. The resident had no fall mats in place and his door was observed to be closed all morning. A bedside commode was sitting beside his bed. The resident was non-interviewable. A review of records indicated Resident #6 was admitted on [DATE] and readmitted on [DATE] with diagnoses including Hallervorden-[NAME] Disease, history of falls, Parkinson's disease, muscle weakness, unsteadiness on feet, difficulty walking, and cognitive communication deficit. A review of orders revealed an active order for 15-minute checks every shift for safety, dated 1/14/23. A review of the facility's Incident Log indicated Resident #6 had a fall on 1/4/23 at 5:38 p.m. and on 11/7/22 at 3:10 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 21 of 29 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 02/02/2023 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 - Some A review of Resident #6 Minimum Data Set (MDS,) dated 1/17/23 section G (Functional Status) indicated the resident required extensive assistance and two + person physical assist with walking in his room, extensive assistance and one person physical assist with toilet use, and limited assistance with one person physical assist with transfers. A Fall Risk Eval-CHC completed after a fall on 11/7/22, indicated a score of 90, indicating a high risk for falls. The evaluation indicated the resident had a history of falls, had an impaired gait, overestimates/forgets limitations and gets up to go to the bathroom at night. A Fall Risk Eval-CHC completed on 1/16/23, indicated a score of 64, indicating a high risk for falls. The evaluation indicated the resident had a history of falls, had a weak gait, overestimates/forget limitations, and gets up to go to the bathroom at night. A review of Resident #6's care plan shows the following care plans: Impaired physical mobility related to neurological disorder with interventions including staff assist x 1 for safety with transfer, and ambulate with staff assist x 1 and use of a walker. Risk for falls related to history of frequent falls, decline in mobility/self-care, use of psychoactive medications, unaware of self-safety/limitations with interventions including anticipate and meet the resident's needs and assist resident to bathroom before going out to smoke as tolerated. A review of progress notes revealed the following after Resident #6 had a fall on 1/4/23: 1/4/23 at 4:30 p.m. Resident was found on the floor in the bathroom. No visible injuries noted, vital signs normal. Resident denies hitting head. States I hit my knees. Doctor made aware. Resident's son made aware. Resident remains on 15-minute checks. Neuro checks started. DON and administrator made aware. Resident sitting in hallway with nurse at this time. 1/5/23 at 10:28 a.m. the Director of Nursing (DON) wrote, On 1/4/23 at approximately 16:30( 4:30 p.m.) the laundry assistant observed Resident #6 had a fall while attempting to go to the restroom. Nurse completed a full assessment on resident, resident stated he fell to his knees and did not hit his head. Neuro and safety checks initiated. Dr and son notified. Interdisciplinary Team (IDT) met to discuss this incident and decided that resident would benefit from a scheduled toileting program at the hours of 7:00 a.m., 11:00 a.m., 3:00 p.m. and 8:00 p.m. On 1/31/23 at 9:20 a.m., the resident was observed in his room with the door closed. No one entered the resident's room to check on him until 9:53 a.m. when the resident's call light was activated. An interview as conducted with Staff D, Certified Nursing Assistant (CNA) on 2/1/23 at 12:44 p.m. Staff D, CNA confirmed she was assigned to Resident #6 regularly, including that day. She stated the resident used the bedside commode by himself when he needed to go and was not on a toileting schedule. She said, he ain't on no schedule, he just goes when he has to go. Staff D said Resident #6 was not on 15-minute checks anymore; he was after his fall. She said the CNAs just randomly check on him and his door stayed closed because he liked it that way. A review of the Nurse Aide [NAME] revealed the following: Safety: Monitor the resident at least every shift and PRN for safety. Observe resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 22 of 29 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 02/02/2023 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 intermittently for his whereabouts and safety. Level of Harm - Minimal harm or potential for actual harm Toileting: Assist resident to toilet as needed. The resident requires staff assist x 1 for toileting. Transferring: Resident requires staff assist x 1 for safety with transfer. Residents Affected - Some An interview was conducted with the DON on 2/2/23 at 1:36 p.m. She stated Resident #6 was not on 15-minute checks anymore. When told the order was still in place and not being completed she was surprised and said it should have been discontinued. She stated the resident could move around with support but sometimes got up on his own. She stated she put a toileting schedule in place as an intervention after his last fall. The DON confirmed the order for 15-minute checks was still in place and the [NAME] showed the resident was to be toileted as needed. The DON was unable to find any documentation that a toileting schedule had been implemented. On 2/2/23 at 1:40 p.m., the Regional Nurse stated Resident #6 needed to go back on 15-minute checks for 72 hours so staff could determine his toileting needs, then they would base a schedule on how often he needed to use the restroom. She said this would help prevent further falls. On 2/2/23 at 2:31 p.m. the DON confirmed Resident #6 was now getting checked every 15 minutes. An interview was conducted with the Director of Rehabilitation on 2/2/23 at 2:37 p.m. He confirmed he worked with Resident #6 for physical therapy. He said the resident needed assistance with transferring to his chair and the toilet. He said he had advocated at several morning meetings for Resident #6 to be 1:1 or have more frequent checks due to him being impulsive and getting up on his own. A facility policy titled Fall Management, dated 7/29/2019 was reviewed. The policy stated the following: Purpose is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. Process: B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors. 2. Update the resident's care plan and the nurse aide [NAME] with interventions a. on admission/re-admission b. quarterly c. with a significant change in status C. Post Fall Strategies: 4. Re-evaluate fall risk utilizing post fall evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 23 of 29 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 02/02/2023 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 5. Update care plan and nurse aide [NAME] with intervention(s) Level of Harm - Minimal harm or potential for actual harm 7. Interdisciplinary team to review fall documentation and complete root cause analysis 8. Update plan of care with new interventions as appropriate. Residents Affected - Some Surveyor: [NAME], [NAME] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 24 of 29 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 02/02/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 Dialysis Communication Sheets were completed for one (Resident #22) of two sampled residents. Residents Affected - Few Findings included: On 01/30/23 at 09:44 a.m., Resident #22 was observed with her call light on asking for pain medication, Staff G, Licensed Practical Nurse (LPN) told Resident #22 she just given her a pain pill and it was not time for at least another 3 hours. Resident#22 stated she was forgetful at times and just returned from dialysis. Resident#22 stated she went to dialysis early because last time she went at 10:00 a.m. she did not return until 8:00 p.m. that night. On 02/02/23 at 09:26 a.m., in an interview with Staff L, Registered Nurse (RN), she stated Resident #22's dialysis process was to fill out the communication book, give snacks before Resident #22 left, document medications given, report the resident's condition on the dialysis communication sheet, ask the Dialysis Center for communication, and document vital signs/weights pre/post dialysis. Staff L also stated if communication was not available staff would call the Dialysis Center to fax over the form. A review of admission record revealed Resident#22 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus, Dependence on Dialysis, and End Stage Renal Disease (ESRD). A review of the DIALYSIS COMMUNICATION Record showed: 02/01/23-Dialysis Center's name and information missing, original date was not there originally but added to copy(photo was obtained prior), Dialysis Center's information and Facility information upon Resident #22's return not completed. 01/27/23-Dialysis Center information not written on top, and Facility's information upon Resident #22's return not completed. 01/20/23-Dialysis Center information not written on top of form and facility did not complete prior or return dialysis information. 01/16/23-Dialysis Center information not written on top; facility did not complete Resident #22's return information. 01/11/23-Dialysis Center facility did not complete their section and Facility did not complete their return information on Resident #22. 01/09/23- Dialysis Center facility did not complete their section and Facility did not complete their return information on Resident #22 01/06/23- Dialysis Center facility did not complete their section and Facility did not complete their return information on Resident #22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 25 of 29 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 02/02/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm 01/04/23- Dialysis Center facility did not complete their section and Facility did not complete their return information on Resident #22 01/02/23- Dialysis Center facility did not complete their section and Facility did not complete their return information on Resident #22 Residents Affected - Few A review of Physician Orders showed the following: 01/30/23- send bagged lunch with resident. 01/30/23- hemodialysis assess site right inner thigh for bruising/bleeding/symptoms of infections. 1/30/23- Hemodialysis- medication not to be given on dialysis days prior to dialysis. 11/09/22- Dialysis appointment Monday, Wednesday, and Friday. Chair time 5:30 am, return time 9:15 am to [name and location of the dialysis center] 10/27/22- CCD NAS diet, regular texture, (avoid tomato, potato, OJ citrus and banana) A review of skilled nurses' note showed: 01/31/23-noted resident admitted on [DATE], and assessment is without any issues 01/26/23- resident presented with pain scale of 6 and was medicated with relief, right anterior thigh fistula is without sign and symptoms of infection. On 02/01/2023 Dietary note from Registered Dietitian stated resident is at nutritional risk due to multiple diagnosis including ESRD (End stage Renal disease) , diabetic and dialysis dependent. Weight on 1/30/23 was 134, BMI 23.8, weight is stable past 3 months and fluid management good. Provide- CCD NAS diet, phosphate binder, liquid protein, renal vitamin and give bag lunch on dialysis days. Meal plan adjusted as needed in consultation with dialysis. A review of the Care Plan showed on 01/18/23 resident has potential for fluid deficit/overload related to ESRD: monitor vital signs & lab work & weigh at same time each day, and resident has potential for nutritional problems related to ESRD: coordinate nutritional plan with HD (hemodialysis) Center, monitor labs. A review of the [NAME] as of 02/02/23 showed to monitor post HD treatment weight as available and report significant changes to RD (registered dietician) and Medical Doctor, no Blood pressures in right arm, * special consideration* resident goes to [name of dialysis center] Monday, Wednesday, and Friday with pick-up at 5:00 a.m. and resident to have dialysis book & assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 26 of 29 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 02/02/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy reviews the facility failed to properly secure medication in one of two medication carts, in one of two treatment carts, in one of one medication refrigerator and for three (Residents #1, #10, and #21) of 31 sampled residents. Findings included: An observation was made upon entering the facility on 1/30/23 at 9:10 a.m. of a treatment cart in the south hallway. The cart was unlocked, and no nurses were in site of the cart. The cart contained prescription topical medications. (Photographic evidence obtained.) An observation was made in the room of Resident #1 on 1/30/23 at 10:34 a.m. of a bottle of Tums antacid sitting on the bedside table. The resident was out of the facility at the time and the door was open. The medication remained sitting on Resident #1's bedside table all four days of the survey, even after the resident returned to the facility. (Photographic evidence obtained.) A review of the medical records indicated Resident #1 was admitted on [DATE] with diagnoses including Diabetes Mellitus type II, Bipolar disorder, and Schizoaffective disorder. A review of the orders did not reveal an order for an antacid medication. An observation was made on 1/30/23 at 2:23 p.m. of an unlocked treatment cart in the south hallway. The treatment cart was sitting outside of a resident room facing the hallway to the side of the door. The nurse was in the room behind the curtain and no other nurse was in sight of the cart. Multiple residents were observed moving throughout the hallway past the cart. (Photographic evidence obtained.) On 2/1/23 at 12:36 p.m., an observation was completed of the medication storage refrigerator with the Director of Nursing (DON.) Inside the refrigerator there was one pitcher of ice water and one pitcher that contained an inch of juice. Neither pitcher was dated or labeled. (Photographic evidence obtained.) The DON stated there should be no drinks in the medication refrigerator and she did not know why they were there. She removed them immediately. On 2/1/23 at 12:51 p.m., an observation was made in the room of Resident #10. From the hallway a bottle of pink stomach relief medication, Bismuth Subsalicylate 525 mg, was observed sitting in the window sill. Resident #10 stated the bottle had been sitting there and she had not taken the medication in a while. She stated the lid was broken and the bottle would not close, and she did not know why it had been left there. (Photographic evidence obtained.) A review of the medical records indicated Resident #10 was re-admitted on [DATE] with diagnoses including irritable bowel syndrome and gastro-esophageal reflux disease. A review of the physician orders did not reveal any current orders for Bismuth Subsalicylate 525 mg. On 2/1/23 at 2:16 p.m., a medication cart observation was completed with Staff I, Registered Nurse (RN) of the north medication cart. In one drawer of the medication cart, 1 loose pill was found. In the narcotic box within the medication cart there was an envelope containing a resident's check (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 27 of 29 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 02/02/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm book, a set of keys, and an airpod. Staff I, RN did not know why the items were in the cart. In another drawer of the cart Glucagen 1 mg for Resident #21 was found to be expired as of 10/2022. Glucagen is for emergency use of low blood sugar. The expired medication was the only Glucagen in the north or south medication cart for Resident #21. Staff I, RN stated they cleaned their carts daily, but a deep clean was done on night shift. Residents Affected - Some A review of the medical records indicated Resident #21 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including Type II Diabetes Mellitus. A review of orders did not reveal a current order for Glucagen 1 mg. At 2:20 p.m. on 2/1/23, the DON was called to the medication cart. She observed the person items in the narcotic box and stated the items should not be in a medication cart, they should be locked in the business office. She confirmed no loose or expired medication should be in the cart. The DON also stated no medications should be in resident rooms, including over-the-counter medication such as Tums or Bismuth Subsalicylate. She confirmed there were currently no residents cleared for self-administration of medication. A facility policy titled General Dose Preparation and Medication Administration, revised 1/1/22, was reviewed. The policy stated the following: 3.10 Facility staff should not leave medications or chemicals unattended. A facility policy titled Storage and Expiration Dating of Medications, Biologicals, revised 7/21/22, was reviewed. The policy stated the following: 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 3.6 Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medication and biologicals are stored. 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 8. Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items. 13. Bedside medication storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a physician/prescriber order and approval by the Interdisciplinary Care Team and facility administration. 13.2 Facility should store bedside medications or biological in a locked compartment within the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 28 of 29 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 02/02/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and policy review the facility failed to ensure an effective pest program in two (Rooms #24 and #26) of 33 rooms for one (Resident #3) of two residents reviewed for pest control. Residents Affected - Few Findings included: An observation on 01/30/23 at 10:40 a.m., showed a bathroom that was shared by resident rooms #24 and #26. The bathroom contained many gnats flying around. The gnats were landing on the toilet, bathroom walls and flying in the air. Photographic evidence obtained. During an interview on 01/30/23 at 2:00 p.m., Resident #3 stated every time lunch or dinner came, the gnats also came and landed on food. Resident #3 stated, I had maintenance take care of these fruit flies and Maintenance said they are coming from the bathroom. The resident stated the gnats were bad for lunch today and they kept flying into my food. An observation on 01/30/23 at 2:03 p.m. showed multiple gnats flying around the bathroom and into room [ROOM NUMBER] when the bathroom door was open. Photographic evidence was obtained. During an interview on 01/31/23 at 1:50 p.m., Staff A, Environmental Services stated there were certainly a large amount of gnats in the bathroom and it appeared that it may be coming from a leaking toilet. During an interview on 01/31/23 at 1:55 PM, Staff B, visiting Nursing Home administrator stated, yes, there are lots of fruit flies in here, we will take care of them immediately. A policy review, titled Pest Control with effective date 11/30/2014 stated, The facility will maintain a pest control program, which includes inspection, reporting and prevention. Treatment will be rendered as required to control insects and vermin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 29 of 29