Inspection·May 15, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had been assigned to conduct the investigation, but, the findings of the investigation were: Money has been misplaced for year. The dentures and passport not found. Facility is scheduling appointment for resident to receive new dentures. Facility will assist resident in obtaining a new passport. Resident stated he did not want foreign currency exchange just wanted dentures and passport replaced. The form indicated the concern was not reportable to the state agency. The form indicated the grievance was resolved. The form indicated the complainant was satisfied. On 05/15/2023 at 2:39 p.m., during an interview with the NHA, she confirmed Resident #6 had come to her directly with the concerns. She stated, I know the resident, I think you would be able to speak with him. He had a passport. We believe it went through laundry. We have yet to find it. We were going through the passport portal to answer the questions. Right now, we are at a standstill on getting the passport. We were unable to answer the questions on the site and no one, family or friends to answer on his behalf. He has a Medicaid case worker. We were going to pay for the passport. Do not think he is going to China anytime soon. When asked if the latter information was documented in the resident's clinical chart, she stated, it was not really clinical; she confirmed the information was not in the clinical chart. When the NHA was asked if the facility had reported the passport as missing to the issuing agency, she stated have not reported the passport missing. When the NHA was asked who the staff members were that had searched for the passport, she stated, Certified Nursing Assistants, and laundry. No names were provided. The NHA indicated the SSD was responsible for the search. When the NHA was asked about efforts to return the resident's money, she stated she had gone to the bank, she was going to replace the money. The money had gone missing in foreign currency. She stated when she approached the resident about the money, he had told her he did not want the money, only the passport and dentures. On 05/15/2023 at approximately 4:00 p.m., an attempt to interview Resident #6 was conducted. Resident #6 was observed in his room, lying on his bed in regular clothes with his eyes closed. A 2nd attempt was conducted, with the same results, at approximately 4:45 p.m. On 05/15/2023, the facility provided a Dental Services screening attempt document, dated 05/05/2023, which documented: Patient refused screening, will attempt at next visit. On 05/15/2023, the NHA provided a screen print of the U.S. Department of State Passport Application System, print date of 05/15/2023 at 3:50 p.m. Review of the document reflected no indication that the form had been filled out prior to the print date of 05/15/2023 or that the form had been formally submitted. A review of the facility's Complaint/Grievance policy and procedures, N-1042, last revised 10/24/2022, documented the policy: the Center will support each resident's right to voice a complaint/ Grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and informed (sic) the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 2 of 12 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 05/15/2023 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 The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with whom grievances may be file (State Agency, Ombudsman, Quality Improvement Organizations). Residents Affected - Few The Executive Director will designate a Grievance Officer at the facility. Procedure 1. An employee receiving a complaint/ grievance from a resident, family member and/ or visitor will initiate a Complaint/ Grievance Form . 2. Original grievance forms are then submitted to the Grievance Officer/ designee for further action. 3. The grievance Officer/ designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint/ Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance Official will log complaints/ grievances in Monthly Grievance Log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 3 of 12 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 05/15/2023 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 interviews and record review, the facility failed to complete a thorough investigation related to an allegation of sexual abuse for one Resident (#2) out of 3 reportable incidents reviewed. Residents Affected - Few Findings included. Review of Resident #2's admission record revealed she is a [AGE] year-old female resident with an initial admission date of 11/21/2022 and readmitted on [DATE] from an acute care hospital. She was admitted with medical diagnosis which include but are not limited to type 2 diabetes mellitus, muscle weakness, unsteadiness on feet, difficulty in walking, schizoaffective disorder, and bipolar disorder. Review of the facility's Reportable list revealed an allegation of neglect for Resident #2 on 4/27/23. An interview was conducted on 5/15/23 at 1:16 p.m. with the Nursing Home Administrator (NHA). The NHA said. [Resident #2] has been here since November and she is a Psych [Psychiatry] patient and 9 out of 10 times she has refused her medications. Psych is aware of that. She has ran Psych out the building once she thinks that it's poisoning her and government conspiracy she's all over the place honestly. On 4/27/23 we became aware when Law Enforcement was next door. The resident was hilarious [sic] very emotional, distraught she said her insides are falling out through her vagina that she had glass in her shoes and based on that we explained to Law Enforcement her history and they took her to [Hospital]; she came back I believe the same day because she refused treatment there. We attempted to [NAME] Act her that day and she came back the same day. She's functioning but she could definitely benefit from a psych facility. Her allegation included glass being in her food and someone rubbed her vaginal area too hard. The Director of Nursing (DON) interviewed [Resident #3] that was [Resident #2's] roommate and has since been moved to a different room. They changed her room because I think it may have been something she mentioned. The NHA looked through her report and said let me have the DON come and talk to you about [Resident #3] . On 5/15/23 at approximately 1:30 p.m. the DON said Law Enforcement was pulling on the door so I went to answer it and they said someone is being abused in here we need to get in so I let them in. I said who is this about and they told me the name. We went to the patients room, she wasn't in her room. I asked the CNA [Certified Nursing Assistant] and Nurses where the resident was and they said she went to the park. So myself and Law Enforcement went to the park that's right next to our [the facility's] parking lot. When we got to the park Law Enforcement and EMS [emergency medical services] were at the park she [Resident #2] didn't want staff around so I stepped back and I'm not sure what they said. Law Enforcement and EMS told me they were familiar with her because they get a lot of calls from her. When I got to the park she [Resident #2] was crying and tearful. I could hear a little bit of what she was saying. I heard her telling them there was glass in her food and it was causing bleeding in her vagina and she had been bleeding for a few days and it was because we were feeding her glass. Then [NHA] came out and I came back to the building and Law Enforcement said they were going to take her to the hospital and I asked if they could bring her [Resident #2] to a psych hospital and try to [NAME] Act her and get her back on her medications and stabilized so she would continue to take her medications but that did not happen. She came right back the same day. She is alert and oriented and her own person, so she came back. The NHA said The resident didn't want to speak with me and shooed me away. She would only talk to EMS and Law Enforcement. So, I backed up and let them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 4 of 12 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 05/15/2023 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 work on her and then they told me they were going to take her to [Hospital] for the psych component of that facility. She was there for a few hours and she came back the same day.The DON said, Law Enforcement asked me 'is there something going on with her and her roommate. Can we change their rooms.' So, I interviewed [Resident #3] that morning on 4/2/23 and [Resident #3] said she did not know of anything that happened she just said that she thought [Resident #2] was talking to her and yelling at her but then she realized [Resident #2] was talking to people in her head. Not for that incidence, just overall I asked her how [Resident #2] was just in general. She also said she saw [Resident #2] at the park and she came from the building [facility] to the park crying. I talked to [Resident #2] when she came back from the hospital and she agreed to move rooms so [Resident #2] has a different room now. The NHA said . On 4/27/23, that morning, I reported it [to the state agencies] because of the vaginal rubbing. I asked my regional team if I should report it and they said yes to see if there was anything factual. She [Resident #2] came back, we did a skin assessment, and she was fine. I think it was more of an episode more than anything. Department of Children and Families [DCF] was notified on 4/27/23 they did not accept the case. Law Enforcement was on site already and they were aware. At the time of the interview the Social Services Director stated I a wrote a set of questions, do you feel safe in this building, have you felt threatened, if you have concerns do you feel like you're concerns are heard. I just picked random residents and staff. I picked 2 staff and 4 residents. There was no concerns. The NHA said the hospital records should have been provided. She confirmed Resident #2 came back from the hospital around 7 or 8 o'clock at night on the same day she went out. The DON said I think the note said 7:00p.m. The NHA said when I talked to the resident on 5/2/23 she said she had mumps and rubella so I had [Staff Z, Licensed Practical Nurse], the nurse, do a skin assessment and I'm surprised she didn't document that. The DON also confirmed there was no skin assessments documented for 5/2/23. The NHA said Psych also saw her and went over her history. Disorganized speech, delusion, aggravated factors, no history of physical or mental abuse or PTSD [Post Traumatic Stress Disorder]. General appearance is anxious. Intact speech, rate, rhythm, and tone. Schizophrenia bipolar type. Psych is recommending her to continue her psych meds and she's refusing to take those. This allegation was not substantiated based on medical record review, medical doctor, staff interviews, and patient history. The DON reviewed Resident #2's hospital records, located in her medical record, and said she confirmed she had not seen the hospital document that revealed reporting vaginal pain after roommate sexually assaulted her. Review of Resident #2's ED [emergency department] Rapid Triage dated 4/27/23 at 11:22a.m. revealed Reason for Visit Narrative: pt [patient] from [Nursing Home facility] via ems [sic] reporting vaginal pain after roommate sexually assaulted her . An interview was conducted with Resident #2 on 5/15/23 at 10:08 a.m. Resident #2 was observed to be outside of the building, in her wheelchair, dressed in day clothes, clean and well kept. She stated she is doing well . The resident stated the food is good and she enjoys it. She stated the staff at the facility are really nice and she has no concerns about the staff, and she feels safe in the facility. She stated she is not having any pain but she has redness on her thighs and the doctor ordered cream for it and the staff put that on her without any concerns. She stated sometimes she will have vaginal pain I had endometriosis a long time ago and I had surgery on it I don't know if I still have it or not. I'm not having any pain right now. A couple weeks ago I went to the hospital because they told me I can't take medications because of something with gluten they called it blade syndrome and sometimes the food makes me feel like my insides are being cut up by the blade. They also say I have diabetes, but I don't. I'm just real sensitive to medications and I'll get blisters all over me. She stated she has no concerns, and she really enjoys going outside and breathing in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 5 of 12 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 05/15/2023 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 fresh air because she has breathing problems sometimes and the fresh air helps . Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's medical record did not reveal a skin assessment conducted on 4/27/23, the day of the allegation or when Resident #2 returned back to the facility from the hospital on 4/27/23. Residents Affected - Few Resident #2's medical record was reviewed and revealed a Weekly Skin Integrity Review dated 4/29/23, which revealed .2. Skin Intact: Yes. There were no other skin assessments completed after 4/29/23 in the medical record. Review of Resident #2's Nursing Progress Note dated 4/27/23 at 7:47 p.m. revealed Returned from hospital/ER [emergency room] at 7PM. Alert, verbal responsive. Denied pain. No s/s [signs/symptoms] of distress noted. Returned with script to start new medications. Review of Resident #2's Psychiatry Advanced Registered Nurse Practitioner note dated 5/3/23 revealed Review of Systems: Psychosis: Disorganized speech, Delusions (of: Persecution, Grandeur, Jealousy, Erotogenic) and Disorganized [sic] behaviors paranoia. Onset of symptoms: Gradual. Nature of symptoms: Chronic. Progression: Variable. Aggravating factors: Ongoing medical problems and life stressors and Being [sic] in the facility. relieving factors: Emotional support and Social [sic] support. Context: age, ongoing medical issues, loss of independence and changed role Trauma History: Abuse/Neglect: There is no known history of physical, sexual, emotional abuse, or emotional neglect. Post Traumatic Stress Disorder [PTSD]: Patient denies symptoms of PTSD. Denies experiencing traumatic events that involved actual or threatened death or serious injury . A combined interview with the DON and the NHA was conducted on 5/15/23 at 4:15 p.m. the DON stated Unit Managers are responsible for reviewing hospital records when residents come back from the hospital. The Unit Manager came to me and told me she [Resident #2] has a UTI [urinary tract infection] and new antibiotics. I was aware she [Resident #2] went to the hospital for an evaluation. I was aware she was having vaginal bleeding because we were feeding her glass, I don't know where the roommate allegation came from. I was only aware that her vagina was bleeding because we put glass in her food . The DON confirmed she was the Risk Manager and the NHA was the Abuse Coordinator. The DON also stated Hospital documentation are typically reviewed the next day at the clinical meeting. If I had known there was an allegation that someone inappropriately touched her. I would want an assessment done. When she came back, I was not aware of any allegation of sexual abuse. I was only made aware that she had a UTI with antibiotics. An immediate skin assessment should be done once an allegation of sexual abuse is made. The NHA confirmed she was the Abuse Coordinator, and she did the investigation for Resident #2's sexual abuse allegation. The NHA stated I did not see or review the hospital records for [Resident #2]. The DON confirmed the facility has had the hospital records since the day Resident #2 came back. The DON and the NHA both confirmed they would be part of the clinical meeting and confirmed there was a clinical meeting the next day after Resident #2's allegation. The DON stated, post event I have received abuse and neglect training by the NHA. The NHA said I have not had training I just review the policy [abuse and neglect policy] frequently. Review of the facility's Allegation of Abuse/Neglect Investigation and Documentation Checklist with a revision date of 2/23/22 revealed complete SBAR [situation, background, assessment, recommendation] with RN [Registered Nurse] Assessment. . identify other Patients/Residents potentially affected: Complete Abuse Quality Reviews on Resident's hallway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 6 of 12 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 05/15/2023 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 .initiate Psychosocial monitoring of Patient/Resident q [every] day x 72 hours minimum. Medical Record documentation of findings. Interviews- patient/Resident Roommate Staff; interviewable [sic] Patients/Residents; other individuals who may have been in vicinity when event occurred. 'witness Statement' documentation. Residents Affected - Few .Root Cause Analysis . . Medical Record review with Corporate Leadership. Recent assessments (risk identified); IDT Progress notes; H&P [history and physical]; MARs [medication administration record]; TARs [treatment administration record]; Physician orders; Recent Labs; Activity Logs; Psych/Psycho Consults; Standards of Care/Risk Review of this Patient/Resident? .Review in Morning Clinical Meeting . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 7 of 12 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 05/15/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a 30-day discharge notice contained an explanation to support the action, and a physician signature for three (Resident #1, #3, and #5) of three residents reviewed for discharge process. In addition, the facility failed to ensure a copy of the 30-day discharge notice was placed in the clinical chart of the residents for three (Resident #1, #3, and #5) of three sampled residents reviewed for discharge process. Findings include: 1. On 05/15/2023 at 10:18 a.m., an interview was conducted with Resident #1. Resident #1 was observed independently ambulating in her room, dressed in seasonally appropriate clothing, and she agreed to be interviewed. She confirmed she had received a 30-day notice from the facility. she indicated she thought the notice had been dismissed. She said her mom was looking for an apartment in (state name) for her. Resident #1 said, the facility told her she had a back bill, since December. She stated she was currently in the middle of applying for Medicaid. She said the facility had wanted to discharge her to a tent city. She did not like this plan. She said she was trying to get assistance from a local organization. (Local Organization) for housing. A review of Resident #1's clinical record, admission Record, documented an admission in 11/2022. Her diagnosis information included: Unsteadiness on feet, difficulty in walking, major depressive disorder, [NAME]-Chair Syndrome with Hydrocephalus, Hypokalemia, generalized anxiety disorder and bipolar disorder, unspecified. Record review of Resident #1's progress notes for 03/2023, and 04/2023, reflected documentation of the Social Service Director (SSD) attempting to assist the resident with placement outside of the facility with no results. Record review of Census information reflected the resident to be Medicaid pending from 12/03/2022 through the date of survey, 05/15/2023. Record review of [NAME] notes reflected initial conversations with the resident regarding an application with DCF [department of children and families] for LTC [long term care] Medicaid. Record review of Resident #1's clinical chart revealed no copy of the 30-day notice in the chart and no mention of the 30-day notice being provided to the resident. A review of a Nursing Home Transfer and Discharge Notice, dated as given to Resident #1 on 04/12/2023 with an effective date of 05/12/2023, documented the location to which the resident would be discharged to as (Shelter name) with address and phone number. The reason for the discharge was Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay. And Your health has improved sufficiently so that you no longer need the services provided by this facility. The area for a brief explanation to support the action was blank. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 8 of 12 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 05/15/2023 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 0623 The notice was documented to be presented by the Nursing Home Administrator (NHA) on 04/12/2023 with a witness signature. Level of Harm - Minimal harm or potential for actual harm The area for the physician signature was blank. Residents Affected - Some The resident had been documented to have refused to provide a signature. The form had no documentation present on it to indicate the date the Local Long Term Care Ombudsman Council had been notified or the date the notice had been recorded in Resident #1's clinical record. 2. On 05/15/2023 at 9:55 a.m. an observation was conducted of Resident #3, in her room, dressed in seasonally appropriate clothing, and observed to independently ambulate across her bedroom floor. She agreed to be interviewed. She confirmed she had been issued a 30-day notice. She stated she needed to continue to reside at the facility. She had health issues. She said, they have not done anything but provide me a letter. No resources. No one has given a clearance for my foot. A review of Resident #3's clinical chart, admission Record, documented an admission in 11/2022. Her diagnosis information included: necrotizing fasciitis, other acute osteomyelitis, right ankle and foot, muscle weakness, difficulty in walking, and type 2 diabetes mellitus with diabetic polyneuropathy. A review of a Nursing Home Transfer and Discharge Notice, dated as given to Resident #3 on 04/24/2023 with an effective date of 05/24/2023, documented the location to which the resident would be discharged to as (Shelter name) with address and phone number. The reason for the discharge was Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay. And Your health has improved sufficiently so that you no longer need the services provided by this facility. The area for a brief explanation to support the action was blank. The notice was documented to be presented by the NHA on 04/24/2023 with a witness signature. The area for the physician signature was blank. The resident had been documented to have refused to provide a signature. The form had no documentation present on it to indicate the date the Local Long Term Care Ombudsman Council had been notified or the date the notice had been recorded in Resident #3's clinical record. A review of Census information reflected the resident to be coded as private pay from 12/28/2022 through 03/31/2023, and as of 04/01/2023, the resident was coded to be Medicaid pending. A review of physician orders reflected an order dated 01/31/2023, which indicated the resident was ok to discharge home with her medications. A review of 04/2023 and 05/2023 progress notes reflected documentation of discussions pertaining to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 9 of 12 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 05/15/2023 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 0623 discharge back to the community and assistance from programs. Level of Harm - Minimal harm or potential for actual harm A review of [NAME] notes reflected initial conversations with the resident regarding an application with a Medicaid specialist on 03/07/2023. Residents Affected - Some Record review of Resident #3's clinical chart revealed no copy of the 30-day notice in the chart and no mention of the 30-day notice being provided to the resident. Billing notes documented the resident appealed a 30-day discharge notice on 03/07/2023. 3. An observation was conducted of Resident #5 in his room, in his bed. He agreed to an interview. He confirmed he had been provided a 30-day discharge notice. He stated, it was about the money. He confirmed he had Medicaid and that he was not paying the patient liability. He said, they say they have been trying to find me another Nursing Home. They want to discharge me to a homeless shelter. A review of Resident #5's clinical chart, admission Record, documented an admission in 04/2022. His diagnosis information included: Multiple Sclerosis, muscle weakness, Ataxia, spondylolisthesis, lumbar region, idiopathic peripheral autonomic neuropathy, repeated falls, and lack of coordination. A review of Resident #5's admission Record documented an admission of 04/13/2022. A review of a Nursing Home Transfer and Discharge Notice, dated as given to Resident #5 on 03/14/2023 with an effective date of 04/14/2023, documented the location to which the resident would be discharged to as (Shelter name) with address and phone number. The reason for the discharge was Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay. The area for a brief explanation to support the action was blank. The notice was documented to be presented by the NHA on 03/14/2023 with a witness signature. The area for the physician signature was blank. The resident had been documented to have refused to provide a signature. The form had no documentation present on it to indicate the date the Local Long Term Care Ombudsman Council had been notified or the date the notice had been recorded in Resident #5's clinical record. A review of Resident #5's ACCESS eligibility profile, print date of 05/15/2023 reflected he was eligible for Nursing Home Medicaid with a patient liability of $1135.00 per month. A review of Census information reflected Resident #5 to be coded as Medicaid long term care, from 06/23/2022 on going. A review of physician orders reflected an order dated 04/23/2023, which indicated Resident #5 was ok to discharge home with his medications. A review of 04/2023 and 05/2023 progress notes reflected documentation of discussions pertaining to discharge back to the community, assistance from programs and placement suggestions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 10 of 12 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 05/15/2023 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 0623 Record review of Resident #3's clinical chart revealed no copy of the 30-day notice in the chart. Level of Harm - Minimal harm or potential for actual harm The record review of [NAME] notes reflected no documentation of Resident #5 being provided a 30-day notice. Residents Affected - Some On 05/15/2023 at 12:27 p.m., an interview was conducted with the Social Service Director (SSD). He indicated he was not involved with the issuance of a 30-day discharge notice for the residents. He stated, that comes from the Nursing Home Administrator (NHA). He indicated he was not involved in notifying the local Ombudsman or representative of the 30-day notice. He stated he was not involved with the Long-Term Care Medicaid applications. He stated, Resident #1 was initially admitted to the facility as a skilled resident. Once her skilled days ran out, there was no reason for her to be here. She was basically homeless prior to coming to the facility. We tried seeking assistance from (community programs) for placement. The programs are full and closed. He stated the 30-day discharge notice for Resident #1 was still in effect and not rescinded by the facility. He stated the 30-day notice indicated that the resident would be transferred to a shelter. He stated he was still trying to follow up with programs for assistance. He stated, Resident #2, the reason she was issued the 30-day discharge notice was that she has no clinical reason to be here. For discharge placement, the location indicated was a shelter to help her transition back to the community. He stated, Resident #5, the reason he was issued the 30-day discharge notice was this was not the level of care he needs, and he refused to pay his co-pays. The discharge plan, the option is a shelter. The reason we are down to that option is he has refused an Assisted Living Facility (ALF). He said he was willing to go to another nursing home facility. It is hard to get another facility to accept a resident that is not paying their copayments. On 05/15/2023 at 2:39 p.m. an interview was conducted with the Nursing Home Administrator (NHA). The NHA indicated the 30-day discharge notice was provided to Resident #1 because the resident was not making payments to the facility. It is no longer medically necessary for her to be in the facility. The discharge location is a shelter. The NHA confirmed the physician had not signed the 30-day discharge notice, and she stated, for her that may have been an oversight. For the clinical chart, the NHA indicated, putting the discharge notice in the clinical chart was not something she had done; but, moving forward, she would do so. When asked if the 30-day notice had been rescinded by the facility for Resident #1, the NHA stated, no formal facility document had been issued that would indicate the facility has rescinded the 30-day notice. But we are working with the resident. The NHA indicated the 30-day discharge notice was provided to Resident #3 because it was no longer medically necessary for her to be in the facility. When the discharge notice was reviewed and the Ombudsman notification was verified to be blank, the NHA stated, everything has gone to the Ombudsman, and she said she would provide receipts. The NHA confirmed Resident #3 had an unpaid bill, approximately $50,000. The NHA confirmed the signature area for the physician was blank. The NHA indicated the 30-day discharge notice was provided to Resident #5 because he was not paying his portion of the bill. The NHA confirmed she had not obtained the physician signature for the discharge notice. For the blank area that would indicate notification to the Ombudsman office, she stated a copy goes to the local Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 11 of 12 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 05/15/2023 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 0943 Level of Harm - Minimal harm or potential for actual harm Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and employee file review, the facility failed to conduct abuse and neglect training for 5 out of 5 employee files reviewed. Residents Affected - Some Findings included: On 5/15/23 at 3:00 p.m. a request was made to the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) for 5 employee files to include their abuse and neglect training. The NHA indicated she would obtain the employee files. On 5/15/23 at 5:00 p.m. the NHA provided 2 employee files and indicated the Human Resource Director was not at the facility and she was unable to obtain the other 3 employee files. All 5 of the employee files did not include abuse and neglect training and there was no evidence provided by the end of survey that the 5 employee's had received abuse and neglect training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 12 of 12