Health inspection·November 17, 2023

F 0550 The findings included: Level of Harm - Minimal harm or potential for actual harm 1) Review of the record revealed Resident #31 was admitted to the facility on [DATE] to her current room, and had not been sent out to the hospital since her admission. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident was incontinent of bowel movements and that it was very important for her to make choices regarding her activities of daily living. Review of the current care plan dated 11/01/23 documented Resident #31 needed maximum assistance from staff for toileting. Residents Affected - Some During an interview on 11/13/23 at 9:00 AM, Resident #31 stated some of the staff are questionable. When asked what she meant by that, the resident stated some staff are moody and don't show nice feelings. The resident further explained some speak in different languages in front of her while providing care. She stated at times when one staff is caring for her, another will come in speaking to the first staff in a foreign language, and it makes her uncomfortable. During an interview on 11/15/23 at 9:46 AM, Resident #31 had just finished breakfast and stated she gets tired of the same thing. When asked if she had asked for an alternate, Resident #31 stated, These CNAs will only deliver the trays and move on. You can not ask them for even an extra Sweet'N Low (artificial sugar) packet. They won't do it and they give you an attitude. Good luck asking for anything. Resident #31 was also noted to have three hospital arm bands on her right arm. One arm band documented her name, birth date, and medical record number from the hospital. The second was a bright yellow arm band with fall risk documented in large, capital, bold lettering. The third was a red band that documented the resident had allergies. When asked about the arm bands, Resident #31 stated, I would love to have them off. When asked how it makes her feel having the bands on her arm, Resident #31 stated, I feel like I have a big sign across my chest. I don't like it. (Photographic Evidence Obtained). During an interview on 11/15/23 at 10:08 AM, when shown the three arm bands on Resident #31, the [NAME] Unit Manager confirmed they were from the hospital. When asked how the facility identified a resident who was at risk for falls, the Director of Nursing (DON) stated they don't utilize any type of arm band or sign. During a supplemental interview on 11/15/23 at 10:24 AM, Resident #31 volunteered, Thank you for getting rid of these arm bands. I felt like a prisoner behind bars. An observation of personal care for Resident #31 was made on 11/15/23 at 10:25 AM. During a supplemental interview on 11/15/23 at 12:20 PM, Resident #31 volunteered, What you saw today when they cleaned me was not the norm. It was all for show. No CNA has ever asked me to test the water temperature in that basin. They come to the bed with a wet towel, dripping with cold water . and they never use soap. When asked how that makes her feel, Resident #31 stated, Like an animal. 2) During an interview on 11/13/23 at 2:22 PM, Resident #43 stated the call light response time is from two to four hours on nights, and on all shifts at least 45 minutes. The resident stated on the 3 PM to 11 PM shift he could hear the staff chatting loudly in the corner, right outside his room, while he was waiting for staff. The resident stated sometimes they just come in and turn off the light, leave, and not come back. Resident #42 stated this was a continued and current concern. An observation outside of the resident's room revealed an alcove with a table and chairs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 2 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0550 Level of Harm - Minimal harm or potential for actual harm Review of the record revealed Resident #43 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, indicating the resident was cognitively intact. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 3 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure of a resident's ability to to use an overhead light for 1 of 1 sampled residents observed (Resident #31). Residents Affected - Few The findings included: Review of the record revealed Resident #31 was admitted to the facility on [DATE] to her current room. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview and observation on 11/14/23 at 10:03 AM, the string that was used to turn the over the bed light on and off by the resident and staff was missing. Resident #31 stated she asked for it to be fixed, and it was supposed to be fixed yesterday. (Photographic Evidence Obtained). When asked if she uses the over the bed light, Resident #31 stated she did and would like it fixed. An additional observation on 11/15/23 at 9:46 AM revealed the pull string was still missing. The missing string was brought to the attention of the Maintenance Director on 11/15/23 in the afternoon, who stated he was unaware of the needed repair. A medication pass observation was made on 11/16/23 at 12:51 PM. The string to the light had been replaced, but remained out of reach for Resident #31, as it had not been connected to the needed extension to reach the resident. The needed extension was wrapped around the resident's mobility rail to her bed, and hanging down toward the floor. Resident #31 further explained the cord was broken by a night nurse when he was a little aggravated and pulled it too hard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 4 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a clean, comfortable, and home like environment for the residents. The findings included: 1). During the Initial Pool process, the following concerns were noted: On 11/13/23 at 9:40 AM, in room [ROOM NUMBER], it was noted that the floor next to Bed A was dirty and the bathroom floor was very dirty and over the toilet chair was rusted. On 11/13/23 at 9:56 AM, in room [ROOM NUMBER], it was noted that the room floors were dirty with food crumbs on the floor. On 11/13/23 at 10:03 AM, in room [ROOM NUMBER], the resident in Bed -A, voiced that his call light has been out for over 2 months, due to an electrical problem, and that the Administrator was in the process of taking care of it. When asked how he has to reach out to the staff when he needs them, Resident #22 stated he has to call front desk during the day and has called the staff on his phone at night. On 11/13/23 at 2:22 PM, in room [ROOM NUMBER], Resident #43 voiced that he and his roommate were unable to watch TV at the same time as the remotes work both televisions. On 11/13/23 at 4:23 PM, in room [ROOM NUMBER], there was an accumulation of dust on the wall mounted air conditioning unit and the unit and the wall to the left of the window was damaged. On 11/14/23 at 10:03 AM, in room [ROOM NUMBER], the laminate on the edge of the over the bed table in of the D-Bed was peeling, exposing the particle board underneath. The string on the overhead light over bed A was broken. Resident #31 stated that the light was supposed to be fixed today (11/14/23). On 11/14/23 at 10:45 AM, in room [ROOM NUMBER], it was noted that the room floors and bathroom floors are dirty. 2). During a tour of the Emerald Unit, on 11/13/23 beginning at 4:06 PM, the following were noted: The covering on the door to the clean linen room was damaged and worn not secured. The wall inside of the room was damaged at the floor and wall juncture. The wall behind the toilet in the restroom behind the nurse's station was damaged. 3). On 11/15/23 at 8:49 AM, Resident #18 was observed on the smoking patio, it was noted that the arms on the resident's wheelchair were damaged to the point that the stuffing underneath the cover was exposed. During an environmental tour, on 11/15/23 10:58 AM, accompanied by the Maintenance Director, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 5 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Maintenance Director acknowledged understanding of the concerns. The Maintenance Director stated that the call light in room [ROOM NUMBER]-A had not been working for at least a month - middle to second week of October, they had to order a part and they have to wait for it to get here. Because it is an older call light system, they had to order the part. They came out yesterday and replaced the part and it worked when he left. My corporate person was here as well, and it went back out again and now it is not re-setting after you press the button to de-activate it. I just got off the phone with PASS (Premium Alarm Service). I started talking to them and within a day or two, they said that the part was on back order. Event ID: Facility ID: 105257 If continuation sheet Page 6 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure 2 of 4 sampled residents were free from abuse and neglect, as evidenced by a resident-to-resident altercation between Resident #87 and #45, resulting in physical harm to Resident #87. The findings included: Review of the policy Abuse, Neglect, Exploitation & Misappropriation revised 11/16/22 documented, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to: hitting, slapping, punching, . Review of the record revealed Resident #87 was initially admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis that included Hemiparesis (one sided weakness). Resident #87 resided on the Emerald Unit. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #87 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS lacked any documented mood or behavior issues. This MDS documented Resident #87 required the extensive assistance from staff for activities of daily living (bed mobility, transferring, walking in the room and corridor, dressing, toilet use, and personal hygiene). Review of a progress note dated 11/12/23 at 1:46 PM indicated on 11/11/23 Resident #87 stated that Resident #45 hit her in her face with her own cane. The progress note further documented Resident #87 stated that because she was yelling for help, Resident #45, who was in the room, yelled at her to shut up and then approached her at which time Resident #87 threw water at Resident #45, who then hit Resident #87 in the face with her cane. This progress note documented a raised area was noted to the lateral aspect of Resident #87's left eye. On 11/13/23 at 9:42 AM, an interview was conducted with Resident #87, in her native language. Resident #87 voiced that the staff do not answer call lights timely, and they can take up to an hour to answer. During the interview, Resident #87 was noted with discoloration and swelling to the left eye, and the eye was teary. When asked what happened to her eye, Resident #87 explained that Resident #45 obtained her reacher and hit her in the face with it. When asked why Resident #45 hit her, the resident explained she was yelling because her stomach was hurting, she had put the call light on for a long time, about 30 minutes, and the staff had not come. Resident #87 stated she yelled for help and they still didn't come. The resident further explained Resident #45 then came in the room, told her to shut up, and began approaching her. Resident #87 stated she was afraid, thought Resident #45 was going to hurt her, therefore she threw water at Resident #45. The resident stated Resident #45 threw water back at her, then obtained the reacher which was located on the bed, and hit her with it in the face. After the interview, Resident #87 needed the call light to ask staff for assistance, but it was noted behind the headboard of the bed, out of the resident's reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 7 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a subsequent observation and interview on 11/16/23 at 11:47 AM, Resident #87 was noted sitting on the edge of the bed, complaining of pain to her left eye which was still noted to be swollen, discolored. and teary. Resident #87 voiced she needed assistance to lie down, and the surveyor asked her to use the call light to ask for staff assistance. Resident #87 stated she couldn't find the call light, and it was again observed on the floor, out of her reach. At 11:47 AM the call light was activated, the call system was heard making the beeping noise, and the light was on in the room and at the entrance door. At 11:56 AM housekeeping staff was observed passing by the room, and did not acknowledged the call light. At 12:00 PM the Maintenance Director was heard talking loudly in the hallway with someone else, and the call light was not acknowledged. At 12:02 PM staff were heard talking in the hallway, and no one answered the call light. At 12:03 PM, 16 minutes after activating the call light, Staff A, the resident's assigned Registered Nurse (RN), answered the call light. Staff A was made aware that Resident #87's call light had been on the floor and out of reach. During an interview on 11/16/23 at 12:06 PM, when asked about the resident-to-resident altercation between Resident #87 and #45, Staff A, RN, stated she did not witness the incident, but was made aware of it by the other direct care nurse on the unit, Staff D, Licensed Practical Nurse (LPN). Staff A explained upon Staff D's return from her break, Staff D, LPN, stated Resident #87 reported to her that Resident #45 hit her in the face. Staff A said she was sitting at the nursing station and would not have heard Resident #87 yelling, because of the distance from Resident #87's room to the nursing station. Staff A voiced she interviewed Resident #87, who explained she was yelling for help, Resident #45 came in the room and yelled at her to shut up, Resident #45 was coming towards Resident #87, hence, Resident #87 threw water at Resident #45 and in return Resident #45 hit Resident #87 in the face. When told Resident #87 had revealed what precipitated the altercation was that no one answered her call light for a long time and she was yelling, Staff A voiced she did not see Resident #87's call light on. During an interview on 11/13/23 at 10:38 AM, Resident #45 stated staff had just moved her to this room (on the [NAME] Unit), a couple of days ago, and she wanted to go back to her room (on the Emerald Unit). When asked why she was moved to the [NAME] Unit, Resident #45 explained a lady was hollering and came at her with a cane. Resident #45 stated she ended up with a mark under her eye, probably from us wrestling with the cane. Resident #45 further explained the staff on the evening and night shifts do not answer call lights. Review of the record revealed Resident #45 was admitted to the facility on [DATE], and readmitted on [DATE] to a room on the Emerald Unit. The record revealed Resident #45 was moved to the [NAME] Unit on 11/11/23. Review of the Quarterly MDS assessment dated [DATE] documented Resident #45 had a BIMS score of 15, indicating she was cognitively intact. A progress note dated 11/11/23 at 7:03 PM by Staff D, LPN documented the LPN entered the room of Resident #87, who was screaming for help. This progress note documented Resident #87 stated Resident #45 attacked her and hit her with the cane. The progress note documented the LPN observed water was on the floor and the two residents were arguing. This note documented Resident #45 was placed on one-to-one supervision and moved to the [NAME] Unit. During an interview on 11/17/23 at 9:48 AM, when asked about the resident-to-resident altercation, Staff D, LPN stated she did not see the incident, but that she was the first staff member to respond. The LPN stated she was returning to the unit from her break and heard Resident #87 crying for help. The LPN stated that Resident #87 said Resident #45 tried to beat me up, but Resident #87 was crying so hard, she could not tell her what happened. The LPN stated she asked the roommate of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 8 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0600 Level of Harm - Minimal harm or potential for actual harm #87, who explained Resident #87 threw water at Resident #45, although Resident #45 denied doing anything. The LPN stated that after Resident #87 calmed down, the resident stated she did throw the water at Resident #45 because Resident #45 was hitting her with the cane. The LPN stated she did see water on the floor. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 9 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to report to the State Survey Agency 2 of 3 allegations of abuse, within two hours. Resident #43 voiced an allegation of abuse by a staff member. Residents #45 and #87 were involved in a resident-to-resident altercation. The findings included: Review of the policy Abuse, Neglect, Exploitation & Misappropriation revised 11/16/22 documented, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to: hitting, slapping, punching, . Mental and Verbal Abuse include, but are not limited to . Threatening residents, depriving a resident of care or withholding a resident from contact with family and friends. Protection: Any suspect, who is an employee or contract service provider, once he/she has been identified, will be suspended pending the investigation. Reporting/Response . report information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . to the Administrator . and to appropriate officials. 1) During an interview on 11/13/23 at 2:22 PM, Resident #43 voiced he had concerns with the timing of his medications, specifically when Staff E, Licensed Practical Nurse (LPN), was his direct care nurse. Resident #43 stated about three weeks ago, Staff E, LPN, brought in his medications, they went back and forth as to the number of medications brought in verses the number of medications that were due at that time. The resident stated, The nurse became threatening, and put his fist in my face. Resident #43 demonstrated with his own fist, in a threatening punching type motion toward his own face. When asked how he felt at that time, Resident #43 stated he was fearful of the nurse. When asked if he felt as if it was abusive, the resident stated he did. When asked if he reported both the medication issue and the threatening manner to anyone, Resident #43 stated he did at the time of the event and again during a recent care plan meeting. Resident #43 stated the LPN had not taken care of him since the event. Review of the requested grievance and allegations of abuse logs provided on 11/14/23, lacked any mention of the alleged threats by Staff E toward Resident #43. A grievance dated 11/07/23 documented only the medication concerns with Staff E. Review of the record revealed Resident #43 was admitted to the facility on [DATE], with numerous hospitalizations and the most recent return on 10/24/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 11/14/23 at 4:03 PM, the Social Services Director (SSD) confirmed they had a recent care plan meeting with Resident #43, and that he voiced concern that Staff E, LPN, was not providing his medications appropriately. When asked if there were any other voiced concerns by Resident #43 related to mistreatment by Staff E, the SSD stated there were not, and further denied knowledge of any allegations of abuse. When told of the threat by Staff E against Resident #43, the SSD stated the resident did not voice that concern, but that would qualify as an allegation of abuse, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 10 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0609 needed to be reported. Level of Harm - Minimal harm or potential for actual harm Review of the Immediate report to the State Agency, for the allegation of abuse by Staff E, LPN, toward Resident #43, documented the SSD became aware of the threatening behavior of Staff E, alleged by the resident, and reported the information to the Nursing Home Administrator (NHA) on 11/14/23 at 3:00 PM. Note the surveyor informed the facility at 4:03 PM. Review of the status log for this report documented the facility submitted the Immediate report to the State Agency on 11/16/23 at 1:59 PM, two days after the facility had been informed of the abuse allegation. Residents Affected - Few During an interview on 11/17/23 at 11:47 AM, when asked when he was to submit to the State Agency an Immediate report for an allegation of abuse, the NHA stated within two hours. When asked why this report of an allegation of abuse from 11/14/23 was not submitted until 11/16/23, the NHA stated, I was a little late and had no reason. 2) Progress notes dated 11/11/23 at 7:03 PM by Staff D, LPN, and on 11/12/23 at 1:46 PM by Staff A, Registered Nurse (RN) both documented an altercation between Residents #45 and #87, resulting in a raised area to the lateral aspect of Resident #87's left eye. Interviews with both Staff A, RN on 11/16/23 at 12:06 PM and with Staff D, LPN, on 11/17/23 at 9:48 AM confirmed the resident-to-resident abuse, and that it had taken place on 11/11/23. On 11/13/23 at 9:42 AM, an interview was conducted with Resident #87, in her native language, in which an altercation between her and Resident #45 was described, resulting in physical abuse. An interview on 11/13/23 at 10:38 AM with Resident #45 also confirmed the altercation between the two residents. Review of the Immediate report for the resident-to-resident abuse documented the event was on 11/11/23 at 3:00 PM. Review of the status log for this report documented the Immediate report was submitted to the State Agency on 11/14/23 at 7:30 PM, three days after the resident-to-resident abuse. During the continued interview on 11/17/23 at 11:47 AM, the NHA agreed the report was submitted late, stating he did not have access with the recent company changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 11 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 observation, interview, record review, and policy review, the facility failed to protect 1 of 4 sampled residents from further abuse, after a voiced allegation by Resident #43, of alleged abuse by Staff E, Licensed Practical Nurse (LPN). The facility also failed to ensure a thorough investigation for 2 of 4 sampled residents involved in a resident-to-resident altercation (Residents #45 and #87). Residents Affected - Few The findings included: Review of the policy Abuse, Neglect, Exploitation & Misappropriation revised 11/16/22 documented, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to: hitting, slapping, punching, . Procedure: . 5. The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. Preliminary Investigation: Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the resident allegation. Investigation: The Abuse coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. Upon completion of the investigation, a detailed report shall be prepared. 1) During an interview on 11/13/23 at 2:22 PM, Resident #43 voiced he had concerns with the timing of his medications, specifically when Staff E, Licensed Practical Nurse (LPN), was his direct care nurse. Resident #43 stated about three weeks ago, Staff E, LPN, brought in his medications, they went back and forth as to the number of medications brought in verses the number of medications that were due at that time. The resident stated, The nurse became threatening, and put his fist in my face. Resident #43 demonstrated with his own fist, in a threatening punching type motion toward his own face. When asked how he felt at that time, Resident #43 stated he was fearful of the nurse. When asked if he felt as if it was abusive, the resident stated he did. When asked if he reported both the medication issue and the threatening manner to anyone, Resident #43 stated he did at the time of the event and again during a recent care plan meeting. Review of the requested grievance and allegations of abuse logs provided on 11/14/23, lacked any mention of the alleged threats by Staff E toward Resident #43. A grievance dated 11/07/23 documented only the medication concerns with Staff E. During an interview on 11/14/23 at 4:03 PM, the Social Services Director (SSD) confirmed they had a recent care plan meeting with Resident #43, and that he voiced concern that Staff E, LPN, was not providing his medications appropriately. When asked if there were any other voiced concerns by Resident #43 related to mistreatment by Staff E, the SSD stated there were not, and further denied knowledge of any allegations of abuse. When told of the threat by Staff E against Resident #43, the SSD stated the resident did not voice that concern, but that would qualify as an allegation of abuse, and needed to be reported. Review of the Immediate report to the State Agency, for the allegation of abuse by Staff E, LPN, toward Resident #43, documented the SSD became aware of the threatening behavior of Staff E, alleged by the resident, and reported the information to the Nursing Home Administrator (NHA) on 11/14/23 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 12 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 3:00 PM. Note the surveyor informed the facility of the allegation at 4:03 PM. Level of Harm - Minimal harm or potential for actual harm Review of requested timecards revealed Staff E, LPN, worked on 11/14/23 from 8:41 AM until 7:38 PM, three and one-half hours after the alleged allegation of abuse. Residents Affected - Few During an interview on 11/17/23 at 11:47 AM, when asked why Staff E, LPN, was not suspended pending investigation, the NHA stated he was not working. When told Staff E, LPN, was on the [NAME] Unit, the same unit where Resident #43 resided, at the time the SSD was made aware of the abuse allegation, and that the LPN continued to work until 7:38 PM as per his timesheet, the NHA had no answer or reason, and agreed the LPN should have been pulled from the shift for the protection of residents. 2) On 11/11/23 at 3:00 PM, there was a resident-to-resident altercation between Residents #45 and #87, resulting in both residents throwing water at each other, and Resident #45 hitting Resident #87 with a reacher (small cane-like device used to pick up items). The facility was asked to locate and provide evidence of their investigation. Review of the investigation for the resident-to-resident abuse revealed only two written statements. The first was from Staff A, Registered Nurse (RN) and direct care nurse for Resident #87, and the second was from the roommate of Resident #87. During an interview on 11/17/23 at 9:48 AM, when asked about the resident-to-resident altercation, Staff D, LPN stated she did not see the incident, but that she was the first staff member to respond. The LPN stated she was returning to the unit from her break and heard Resident #87 crying for help. The LPN stated that Resident #87 said Resident #45 tried to beat me up, but Resident #87 was crying so hard, she could not tell her what happened. The LPN stated she asked the roommate of Resident #87, who explained Resident #87 threw water at Resident #45, although Resident #45 denied doing anything. The LPN stated that after Resident #87 calmed down, the resident stated she did throw the water at Resident #45 because Resident #45 was hitting her with the cane. The LPN stated she did see water on the floor. During an interview on 11/17/23 at 11:28 AM, when asked if the investigation was completed, the Administrator (NHA) stated it was. The NHA also confirmed he was part of the team that completed the investigation for the resident-to-resident abuse. The NHA confirmed both residents were alert and oriented, and when asked if he interviewed them after the event, he stated he interviewed Resident #45, but did not write it down. When asked if he recalled what Resident #45 stated, the NHA explained the resident denied hitting Resident #87. The NHA stated Resident #45 told him she went into the room to visit the roommate, and Resident #87 was making a lot of noise. The NHA explained Resident #45 stated Resident #87 took the cane like she was going to hit her, she grabbed it, and after that she let it go and left the room. When asked about an interview from Resident #87, the NHA stated another staff member interviewed Resident #87, but again did not obtain a written statement. The NHA agreed the investigation also lacked a written statement from Staff D, LPN and direct care nurse for Resident #45, who was also the first staff to respond to the altercation, and lacked any statements from the Certified Nursing Assistants (CNAs) working on the unit. When asked if staffing was reviewed as part of the investigation, the NHA stated their staffing numbers were met. When asked if he determined by his investigation that there was sufficient staff on the unit at the time of the event, the NHA confirmed he had no evidence of that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 13 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete the quarterly Minimum Data Set (MDS) assessment for 2 of 5 sampled residents reviewed for Unnecessary Medications (Resident #83, as it relates to missing diagnosis of Depression; and Resident #71, as it relates to missing diagnosis of Anxiety). The findings included: Resident #83 was admitted to the facility on [DATE] with documented diagnoses which included Huntington's Disease, Acute Follicular Conjunctivitis, Disorders of white blood cells, Adult Failure to Thrive, Muscle Weakness, Unsteadiness on Feet, Dysphasia, Benign Prostatic Hyperplasia, Insomnia, and Anemia. According to Resident #83's MDS Quarterly assessment dated [DATE] (completion date 05/26/23), Resident #83 reported feeling down, depressed and/or hopeless for 2-6 days during the 14 day look-back period. There was no diagnosis of Depression or Anxiety documented, but there were 3 days of antidepressants provided during this time. A Psychiatry Note dated 05/22/23 documented: Chief Complaint: Depression, Anxiety, and Insomnia. History of Present Illness: This is a [age of patient] male patient with a past psychiatric history of Depression, Anxiety and Insomnia. Prior to last visit, patient was at baseline. No sign and symptoms of depression or anxiety reported. He was sleeping and eating well. No medication changes were done. During last visit, patient was suffering from signs and symptoms of depression. He had more restlessness with behavioral agitation. Started Trazodone 25 mg TID (three times daily) for depression/anxiety. Diagnostic Assessment and Plan: Major Depressive disorder, recurrent, mild Generalized anxiety disorder Primary insomnia Plan of Action: Start Med: I decided to start Remeron 7.5 q hs [at bedtime] for depression and appetite Decrease med: I decided to decrease Trazodone 25 mg BID [twice daily] for depression/anxiety. A Consent for the use of Mirtazapine 7.5 mg q hs [at bedtime] was signed by Resident on 06/07/23 for Depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 14 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #83's MDS Quarterly assessment dated [DATE], whose Brief Interview for Mental Status (BIMS) score was documented as being a 9 out of 15 (Moderate Cognitive Impairment), reported feeling down, depressed and/or hopeless for 12-14 days. He was provided 7 days of antidepressant medications, yet there was no diagnosis of Depression or Anxiety noted on this Assessment. A review of the November 2023 electronic Medication Administration Record documented that Resident #83 is currently receiving, and has been receiving since 05/22/23, Mirtazapine 7.5 mg each day at bedtime for the diagnosis of Depression. On 11/17/23 at approximately 1:00 PM, an interview was conducted with the Traveling MDS Coordinator (Licensed Practical Nurse) and Regional MDS Nurse Coordinator (Registered Nurse). Both nurses acknowledged that Resident #83's Depression diagnosis was missed during the Quarterly Assessments for May 2023 and August 2023. An immediate correction was made to Resident #83's assessment by the Regional MDS Nurse Coordinator. 2) Resident #71 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. According to the resident's most recent completed full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #71 had a Brief Interview for Mental Status (BIMS) score of 9, indicating that the resident was moderately cognitively impaired. Resident #71's diagnoses at the time of the assessment included: Anemia, Coronary Artery Disease, Hypertension, Traumatic Brain Injury, Depression, and Schizophrenia. The MDS documented that the resident was taking antianxiety mediations. Record review revealed Resident #71's orders included: -Buspirone HCE Oral Tablet 10 M=G - 10mg by mouth HS (at bedtime) for anxiety - 09/26/23. -Buspirone HCI Oral tablet 15 mg by mouth HS for Anxiety - 09/25/23. A care plan dated 07/11/23, documented The resident uses anti-anxiety medications r/t (related to) anxiety disorder. The goal of the care plan was documented as, The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. with a target date of 02/11/24. Interventions to the care plan included: *Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q shift. * Monitor/document/report PRN any adverse reactions to anti-anxiety therapy. The diagnoses listed on an Admission/readmission Data Collection, date 09/22/23, upon most recent readmission to the hospital did not include a diagnosis of Anxiety. During an interview, on 11/17/23 at 10:32 AM, with Saff C, RN (Registered Nurse), when asked about Resident #71 being seen by psychiatry, Staff C replied, She was here yesterday and saw him. Staff C could was unable to provide documentation and was not aware of any changes to treatment based on evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 15 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy, and staff interview, the Facility failed to complete a Level II PASARR for 1 of 1 sampled resident reviewed with diagnosis of severe mental illness (Resident #77). Residents Affected - Few The findings included: The facility's policy and procedure titled, Preadmission Screening and Resident Review (PASRR), document SS-402, dated 11/08/21, notes: Policy The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ED) residents receive appropriate pre-admission screenings according to Federal/State Guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. Resident #77 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Injury to unspecified Level of Lumbar spinal cord, Schizoaffective Disorder, bipolar type; Anxiety; and Recurrent Major Depressive Disorder. The admission Minimum Data Set (MDS) assessment completed on 07/11/22 documents diagnoses of Depression, Anxiety and Schizophrenia. A Level I PASARR for Resident #77 was completed on 08/19/22, forty-six (46) days after admission. This Level I PASARR documented the following: Section I A: Anxiety Disorder, Depressive Disorder, and Schizoaffective Disorder. Services: Currently receiving services for MI (Mental Illness); Currently receiving services for ID (Intellectual Disability) Finding is based on: Documented History; Behavioral Observations; Individual, Legal Representative or Family Report; and Medications Section II: Other Indications for PASARR Screen Decision-Making: [a yes is check for the following indications]. 1. Resident has an indication that they have or may have had a disorder resulting in functional limitations in major life activities; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 16 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0645 2. Individual typically has or may have had at least one of the following characteristics on a continuing or intermittent basis: Level of Harm - Minimal harm or potential for actual harm A. Interpersonal functioning; Residents Affected - Few B. concentration, persistence and pace; C. Adaption to change. 3. Resident has an indication that he/she has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following: A. Psychiatric treatment more intensive than outpatient care; B. an episode of significant disruption to the normal living situation for which supportive services were required to maintain functioning at home or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials. A Level II PASRR evaluation must be completed prior to admission to a nursing home facility if any box in Section I-A or Section I-B is checked and there is a yes checked in Section II -1, II-2, or II-3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. Section III documents that this resident is not a provisional admission. Section IV documents that this resident may not be admitted to a Nursing Facility. The Level I Form and required documentation is to be used to request a Level II PASARR evaluation because there is a diagnosis or suspicion of Serious Mental Illness. On 11/14/23 at approximately 10:00 AM, the Administrator was asked to provide evidence that a Level II PASARR was completed for Resident #77. As of the time of the survey ended, the Administrator had not provided any evidence to show a Level II PASARR had been completed for Resident #77. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 17 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and revise comprehensive, personalized care plan related to the diagnosis of Depression and use of antidepressant medication therapy for 1 of 5 sampled residents reviewed for Unnecessary Medications (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE] with documented diagnoses which included Huntington's Disease, Acute Follicular Conjunctivitis, Disorders of white blood cells, Adult Failure to Thrive, Muscle Weakness, Unsteadiness on Feet, Dysphasia, Benign Prostatic Hyperplasia, Insomnia, and Anemia. According to Resident #83's MDS Quarterly assessment dated [DATE] (completion date 05/26/23), Resident #83 reported feeling down, depressed and/or hopeless for 2-6 days during the 14 day look-back period. There was no diagnosis of Depression or Anxiety documented, but there were 3 days of antidepressants provided during this time. A Psychiatry Note dated 05/22/23 documents: Chief Complaint: Depression, Anxiety, and Insomnia History of Present Illness: This is a [age of patient] male patient with a past psychiatric history of depression, anxiety and insomnia. Prior to last visit, patient was at baseline. No sign and symptoms of depression or anxiety reported. He was sleeping and eating well. No medication changes were done. During last visit, patient was suffering from signs and symptoms of depression. He had more restlessness with behavioral agitation. Started Trazodone 25 mg TID (three times daily) for depression/anxiety. Diagnostic Assessment and Plan: Major Depressive disorder, recurrent, mild Generalized anxiety disorder Primary insomnia Plan of Action: Start Med: I decided to start Remeron 7.5 q hs [at bedtime] for depression and appetite Decrease med: I decided to decrease Trazodone 25 mg BID [twice daily] for depression/anxiety. A Consent for the use of Mirtazapine 7.5 mg q hs [at bedtime] was signed by Resident on 06/07/23 for Depression. A review of Resident #83's MDS Quarterly assessment dated [DATE], Resident #83, whose Brief (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 18 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview for Mental Status (BIMS) was documented as being a 9 out of 15 (moderate cognitive impairment), reported feeling down, depressed and/or hopeless for 12-14 days. He was provided 7 days of antidepressant medications, yet there was no diagnosis of Depression or Anxiety noted on this Assessment. A review of the November 2023 electronic Medication Administration Record documented that Resident #83 is currently receiving, and has been receiving since 05/22/23, Mirtazapine 7.5 mg each day at bedtime for the diagnosis of Depression. A review of Resident #83's Comprehensive Care Plans completed on 05/18/23 and 08/25/23 had no care plan or interventions related to Resident #83's diagnoses of depression and anxiety per the Psychiatric Evaluation dated 05/22/23 or the use of antidepressant medication to treat the depression/anxiety diagnosis. After concerns regarding Resident #83's Care Plan were made known, a new Care Plan completed on 11/17/23 did have a Focus area added for the use of antidepressant medication related to Depression. Interventions included: Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q [each] shift. Monitor/document/report PRN [as needed] adverse reactions to Antidepressant therapy. On 11/17/23 at approximately 1:00 PM, an interview was conducted with the Traveling MDS Coordinator (Licensed Practical Nurse) and Regional MDS Nurse Coordinator (Registered Nurse). Both nurses acknowledged that Resident #83's Depression diagnosis was missed during the Quarterly Assessments for May 2023 and August 2023. An immediate correction was made to Resident #83's assessment by the Regional MDS Nurse Coordinator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 19 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide enteral feeding as ordered by the physician for 1 of 1 sampled residents reviewed for Tube feeding (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE]. According to a Quarterly Minimum Date Set (MDS) assessment, dated 09/08/23, Resident #58 was not assessed for cognition due to 'the resident is rarely/never understood'. Resident #58's diagnoses at the time of the MDS included: Hyperlipidemia, Alzheimer's disease, Non-Alzheimer's dementia, Malnutrition, Anxiety disorder, Depression, Psychotic disorder, Dysphagia following cerebrovascular disease, Metabolic encephalopathy Syncope and collapse, Disorders of electrolyte and fluid balance, Adut failure to thrive, and Bradycardia. Review of the care plan initiated on 12/13/21 with a revision date of 11/09/23, documented, The resident is at a nutritional risk or potential nutritional risk related to need for enteral nutrition, medical history of Alzheimer's, dementia, Hyperlipidemia, swallowing difficulties/dysphagia, and advanced age. The goal of the care plan was documented as, The resident will maintain adequate nutritional status as evidenced by maintaining weight with 55 of CBW (current body weight), no signs/symptoms of malnutrition, and consuming at least 50% of at least 3 meals through review date with revision date of 11/09/23 and a target date of 02/11/24. Interventions to the care plan included: *The resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after feed - 12/13/21. *Check for tube placement and gastric contents/residual volume per facility protocol and record - 12/13/21. *Monitor/document/report PRN any s/sx (signs/symptoms) of: Aspiration - 12/13/21. *Provide local care to G-tube site as ordered and monito for s/sx of infections - 12/13/21. *RD (Registered Dietitian) to evaluate quarterly and PRN (as needed) - 12/31/21. *The resident is dependent with tube feeding and water flushes. See MD (Medical Doctor) orders for current feeding orders - 12/13/21. *Weight as ordered - 12/13/21. Review of the 'Nutrition Review' dated, 09/08/23, documented, Remains NPO (nothing by mouth) with EN (Enternal Nutrition) via PEG (Percutaneous Endoscopic Gastrostmy) Jevity 1.5 at 60 ml/hr x 20 hrs. Recent d/c (discharged ) from Hospice. Meeting nutritional needs. Skin intact. Flushes 250 ml every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 20 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0693 8 hours. Level of Harm - Minimal harm or potential for actual harm Revie of the physician's orders for Resident #58 included: Nothing by mouth diet, NPO texture - 07/30/23 Residents Affected - Few Jevity 1.5 cal. 60 cc/hr continuous feeding x 20 hours until 1200 ml administered (on at 2 PM and Off at 10 AM) 07/31/23. Further review of Resident #58's electronic health record revealed that the resident has had orders for NPO (nothing by mouth) since 12/10/21. On 11/13/23 at 9:18 AM, Resident #58 was observed in bed with Tube feeding (TF) pump not dispensing supplement to the resident. The date mark on the 1000 ml container of supplement documented initiated at 6AM (not dated) with 900 ml remaining. The display on the pump with a green light signifying that the battery was charging. On 11/13/23 at 3:07 PM, Resident #58 was observed in bed with TF not initiated. Review of the resident's electronic health record showed that there was no documentation to justify not providing the supplement as ordered. On 11/14/23 at 7:47 AM, the resident was observed in bed with TF initiated at 60 ml/hr. The date mark on 1000 ml container documented that it was initiated on 11/14/23 at 6:30 AM. Resident #58 was noted to be laying in a position on her back with HOB not elevated appropriately. On 11/14/23 at 8:18 AM, Staff C, RN (Registered Nurse) confirmed the HOB was not elevated appropriately. During an interview, on 11/16/23 at 11:11 AM, with the Registered Dietitian (RD), the RD confirmed the orders and acknowledged understanding of the concerns. The RD confirmed that the resident would not have received the full benefit of the enteral feeding regiment based on the observations and documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 21 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the medication error rate was 11.11 percent. Three medication errors were identified while observing a total of 27 opportunities, affecting 3 of 8 sampled residents observed during medication administration observations (Residents #65, #31, and #14). Residents Affected - Few The findings included: Review of the policy titled, Oral Administration of Medication revised 08/15/19 documented, Procedure: . Review physician's order. Review the MAR (Medication Administration Record) or eMAR (electronic MAR) should there be any uncertainties verify the MAR or eMAR with the Physician's Order Sheet (POS) and seek clarification as indicated. 1) A medication administration observation for Resident #65 was made on 11/15/23 beginning at 3:42 PM with Staff F, Licensed Practical Nurse (LPN). The LPN pulled two medications, one of which was 100 mg (milligrams) of Caramazepine (Tegretol, a medication to prevent seizures). The LPN popped from the bubble pack (card of pills) one tablet of each medication. The label on the Tegretol documented to administer two tablets in the PM (evening). Staff F, LPN, verified the two medications were all that was due at that time, and verified she had two pills, one of each medication, in the medication cup to administer to Resident #65. Resident #65 took the one Tegretol and the other medication. Staff F, LPN, stated she was done with Resident #65 and continued on to her next resident. Review of the record revealed an order dated 03/20/21 for the nurse to administer Carbamezapine 100 mg in the AM (morning) and two tablets in the PM. Review of the laboratory values for carbamazapine levels documented a low of 2.4 (desired values to prevent seizures of 4.0 - 12.0) on 03/11/23, and a low level of 3.6 on 08/09/23. During an interview on 11/15/23 at 5:07 PM, when asked about the seizure medication for Resident #65 and the number of Tegretol she administered, Staff F verified she gave one tablet. When shown the label for the Tegretol, the nurse read one tablet in the AM and two tablets in the PM. When asked why she did not give two tablets, the LPN stated she thought the resident got two tablets at bedtime, and she was only to give one tablet at that time (evening). When asked to pull the carbamazapine on hand for Resident #65 from the medication cart, the LPN found eight partially used cards that had the potential to hold 30 tablets. There were a total of 209 tablets in the medications cart, some dating back to 12/16/22. A thirty day supply would only be 90 tablets, indicating there was more than a two month supply on hand. (Photographic Evidence Obtained). During a side-by-side review of the record and interview on 11/15/23 at 5:42 PM, the Regional Nurse Consultant confirmed the order was to give one tablet of Tegretol in the morning and two in the evening, and that Staff F, LPN, should have given two tablets during that medication pass observation. During an interview on 11/16/23 at 11:42 AM, the Nurse Practitioner (NP) for Resident #65 confirmed Staff F called her the previous evening, and let her know that she had only provided one tablet of the Tegretol, and that the order was confusing, but she did give a second tablet later that evening. (Note that was after surveyor intervention.) When asked if she was made aware of the amount of pills found in the medication cart, the NP stated she was not. When told there were eight cards with the potential of 30 tablets on each card, the NP agreed the resident may not have been consistently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 22 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few getting her medication as ordered, and that would explain the low Tegretol levels obtained through laboratory draws. The NP confirmed the medication was being provided for Resident #65 for seizures, and not related to a mood disorder, and stated she was grateful the resident did not have a seizure. 2) During the continued medication administration observation on 11/15/23 at 3:49 PM, Staff F, LPN took the blood sugar level for Resident #31. The reading was 176. At 4:10 PM Staff F obtained four pills for Resident #31, and further stated no insulin was needed for Resident #31. Review of the record documented the current sliding scale for the administration of insulin to start at 151 through 200, for the provision of 2 units. During an interview on 11/15/23 at 5:07 PM, Staff F, LPN, was asked to review the sliding scale order for Resident #31. Upon review, the LPN verified she should have given 2 units of insulin and stated the resident used to be on a sliding scale that started at 200. 3) On 11/14/23 at 8:23 AM, an observation of medication administration was conducted with Staff B, a nurse, to Resident #14. Staff B was observed to have administered the following medications to Resident #14, including: 1. Depakote 500 mg 1 tablet by mouth 2. Glipizide 5 mg 1 tablet by mouth. 3. Hydrochlorothiazide 0.5 mg 1 tablet by mouth. 4. Iron 325 mg 1 tablet by mouth 5. Metformin 500 mg 1 tablet by mouth 6. Folic acid 1000 mg mcg 1 tablet po 7. Metoprolol 25 mg 1 tablet by mouth 8. Sertraline 25 mg 1 tablet by mouth 9. Lactulose 30 ml by mouth, before the administration, the nurse confirmed there were 8 pills in the cup and lactulose in another cup. After the administration, at 8:31 AM, the surveyor retuned to the computer system to reconcile the medications with Staff B. During that time it was revealed that Allopurinol 100 mg, 2 tablets were omitted, the surveyor pointed it out to Staff B, in which he acknowledged it and obtained the medication to be administered. He voiced he forgot to withdraw this medication to be administered. Record review revealed Resident #14 was re-admitted to the facility on [DATE] with diagnoses included Diabetes, Aphasia, Depression, Bipolar Disorder, and Heart Failure. On 11/16/23 at 10:13 AM, an interview was conducted with the DON (Director of Nursing) and she was made aware of the medication error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 23 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 - Few 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 observation, interview, and policy review, the facility failed to ensure proper storage of medications in the treatment cart for 1 of 1 sampled resident observed for wound care (Resident #21). This observation was made on the [NAME] Unit were 7 of 22 residents were identified and/or observed to independently ambulate or self-propel throughout the unit, to include sampled Resident #65, #45, #28, #84 and #69. The facility also failed to ensure expired medications were removed from 2 of 6 medication carts (Emerald cart #3 and [NAME] A/front cart). The finding included: Review of the policy Medication Storage (not dated) documented, Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. C. Medications will be stored in an orderly, organized manner in a clean area.F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 1) A wound care observation for Resident #21 was made on 11/16/23 beginning at 8:36 AM. The Wound Care Nurse (WCN) obtained her needed wound care supplies and took them into the residents room. The treatment cart was left at the door of the resident's room, with the drawers facing out into the hallway. The WCN left two large containers of Acetic Acid 0.2%, one of which was opened and belonged to Resident #21, on top of the treatment cart. Six small packets of Triple Antibiotic ointment, along with multiple skin prep pads, were also left on top of the cart (Photographic Evidence Obtained). During the wound care observation, the WCN asked the Assistant Director of Nursing (ADON), who was assisting, to get additional supplies from the cart. The ADON went in and out of the room twice. At 8:59 AM, the roommate of Resident #21 entered the room, walking independently right passed the treatment cart. Upon completion of the wound care on 11/16/23 at 9:17 AM, the treatment cart was noted unlocked. The ADON came out of the resident room and confirmed it was unlocked. The two staff confirmed the other wound care supplies had been left on top of the treatment cart and left unattended. Resident #21 resided on the [NAME] Unit, that occupied 22 residents during the survey, seven of whom were identified and/or observed independently ambulating or propelling throughout the unit. Many of the [NAME] residents had psychological disorders and/or documented behaviors. 2) A medication pass observation for Resident #65 was made on 11/15/23 beginning at 3:42 PM, with Staff F, Licensed Practical Nurse (LPN). A medication error was identified with the medication Carbamazepine (Tegretol), a medication to prevent seizures. When asked to pull the Caramazepine on hand for Resident #65 from the medication cart, the LPN found eight partially used cards that had the potential to hold 30 tablets. There were a total of 209 tablets in the medications cart, some dating back to 12/16/22. A thirty day supply would only be 90 tablets, indicating there was more than a two month supply on hand. (Photographic Evidence Obtained). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 24 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete These medication cards were found by Staff F in multiple locations in the medication cart. Upon further observation, the medication card from 12/16/22 had 18 tablets remaining. These pills had expired as of 07/31/23, three and a half months earlier. Staff F agreed with the observation and stated the expired medication should not be in the medication cart. 3) On 11/14/23 at 11:39 AM medication cart 2 was audited at the Emerald unit with Staff C, a registered nurse, during that time 1 bottle of opened expired aspirin 325 was found in the cart. The Expiration date was 10/2023. Staff C acknowledged the finding. On 11/16/23 at 10:13 AM during an interview process with the DON, she was made aware of the expired medication found in cart 2 of the Emerald Unit. Event ID: Facility ID: 105257 If continuation sheet Page 25 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide food service in a manner consistent with professional standards for food safety. The findings included: A). During the initial kitchen tour, on 11/13/23 at 7:54 AM, accompanied by the Dietary Director, the following were noted: 1. Staff were observed using a damp towel that was kept on the counter of the hot holding unit, to wipe debris from the area. 2. The handle of a spatula that Staff was using to plate the French toast bake was melted and damaged to the point that it was not easily cleanable. 3. There was a leak in the ceiling from the air conditioning unit near the end of the food prep/assembly line/area. The Dietary Director stated that it was from the air conditioning unit and that the facility was waiting for parts to come in to complete the repairs. While the air conditioning unit was not in operation, the facility was using portable air conditioning units. 4. The concentration of quaternary ammonia used for sanitizing food and non-food contact surfaces of equipment was more than 400 Parts per million (PPM). 5. The concentration of quaternary ammonia used for sanitizing food equipment and utensils in the three compartment sink was was more than 400 PPM. The Dietary Director stated that the vendor that the facility used for maintaining the chemicals had been out to the facility recently and reported no concerns to the facility. 6. There was an accumulation of ice on the conduit that covers the electrical lines that power the cooling unit and on the ceiling in the walk in freezer. 7. The interior of a drawer containing scoops was in disrepair in a manner that there was paint peeling from the drawer, creating an uncleanable surface. 8. The shelf under the coffee maker was in disrepair in a manner that there was paint peeling from the shelf, creating an uncleanable surface. 9. There was a scoop in the bulk container of sugar that was noted to have food residue on it. 10. An oven mitt that was in use and kept by the convection oven was noted to be torn and in disrepair. 11. There was an accumulation of food residue on the handles of the doors and the control knobs of the convection oven. At the conclusion of the kitchen tour, the Dietary Director acknowledged understanding of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 26 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0812 concerns. Level of Harm - Minimal harm or potential for actual harm B. On 11/15/23 at 11:18 AM, during the follow up kitchen tour, accompanied by the Dietary Director, the following were noted: Residents Affected - Many 1. The Dietary Director was noted to be wearing a watch on her wrist while handling and plating open foods. 2. Staff were using a scoop with a hole melted into the handle that was uncleanable. At the conclusion of the tour, the Dietary Director acknowledged understanding of the concerns. C. During an observation of lunch being served to the residents in their rooms on the [NAME] unit, on 11/15/23 at 12:15 PM it was noted that the scoop that was being used for ice while providing fluids to the residents had an accumulation of mold on the food contact surface and the non-food contact surfaces of the scoop. The Dietary Director removed the scoop from services upon the finding. D. During an observation of the pantry on the Emerald Unit, on 11/16/23 at 2:45 PM, there was an accumulation of debris and garbage behind the reach in upright refrigerator/freezer and inside of the cabinets under the sink. At the time of the observation, housekeeping staff were asked by the Dietary Director to clean the areas that were noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 27 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the respiratory services contract, the facility failed to maintain accurate and complete records for 3 of 33 sampled residents, related to respiratory services for Resident #1, a fall for Resident #43, and a newly identified skin impairment for Resident #28. The facility also failed to ensure all progress notes completed by the Nurse Practitioner (NP) for the Medical Director were maintained in the medical records. The findings included: 1) Review of the Respiratory Care Services agreement, effective 08/15/23, and signed by both entities, documented, the respiratory services provider was to 1.2 . assist in Facility's evaluation of residents, and to plan and direct care for the Facility's residents in accordance with established plans of treatment and physician's written orders. 2.1 Facility shall (i) have primary responsibility for maintaining all resident records, . 2.2 Facility shall be responsible for obtaining all required written orders for provision of the Respiratory Care Services to eligible residents from their attending physicians in accordance with accepted professional practices. Observations on 11/13/23 at 9:25 AM and on 11/14/23 at 10:30 AM revealed the oxygen administration level for Resident #1 was set at 2.5 liters/minute. During an observation on 11/15/23 at 12:59 PM, respiratory care for Resident #1 was observed, as completed by Staff J, Registered Nurse. Resident #1 had a tracheostomy (artificial opening in the throat for breathing) and oxygen was noted at 2.5 liters/minute via a trach collar (Photographic Evidence Obtained). After the observation, when asked if the facility utilized respiratory services, Staff J, RN, explained a Respiratory Therapist (RT) from an outside company came to the facility weekly and as needed. The RN stated the RT completes the tubing and main tracheostomy outer cannula changes. Review of the record lacked any order for Respiratory Care Services. Further review of the orders documented the current level of oxygen as 4 liters/minute. During an interview on 11/15/23 at 2:38 PM, the [NAME] Unit Manager stated the Respiratory Therapist comes to the facility twice weekly, and they do their charting on paper. Review of the paper chart documented services provided by RT on 08/03/23, 08/12/23, 08/17/23, 08/26/23, undated, 09/07/23, 09/09/23, 09/19/23, 09/21/23, undated, 10/03/23, 10/05/23, 10/16/23, 10/30/23, 11/02/23, and 11/06/23. Each RT note documented Resident #1 was receiving oxygen at 4 liters/minute. During an interview on 11/15/23 at 3:14 PM, the [NAME] Unit Manager agreed the oxygen administration level of 2.5 liters/minute was not as ordered at 4 liters/minute. The Unit Manager agreed with the RT's inaccurate documentation of 4 liters/minute as well. During an interview on 11/16/23 at 10:46 AM, the contracted RT stated he comes to the facility twice weekly for tracheostomy maintenance and staff education. The RT stated he does not write orders, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 28 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0842 Level of Harm - Minimal harm or potential for actual harm but would expect a physician order for RT services, and an order with the current oxygen administration level. When asked about documentation of each visit, the RT stated he documents on paper forms and provides them to the facility. The RT explained his monthly visits to change out the entire tracheostomy set was documented on a flow sheet with all residents listed and provided to the Assistant Director of Nursing (ADON). Residents Affected - Few 2) Review of the record revealed Resident #43 was admitted to the facility on [DATE], and was transferred out to the hospital three times since 08/01/23. A progress note dated 08/02/23 documented Resident #43 complained of right shoulder pain. Review of a transfer evaluation documented the resident was being transferred for complaint of right shoulder pain for past two days, after having had a fall. The record lacked any documentation related to the fall. On 11/17/23 at 12:17 PM the Regional Nurse Consultant agreed with the lack of documentation. 3) An observation on 11/13/23 at 12:36 PM and on 11/14/23 at 10:23 AM revealed the right hand of Resident #38 was wrapped in a gauze dressing. When asked what happened, Resident #28 stated he had a blister that opened on Saturday, and the nurses put a dressing over the open area. Review of the record lacked any documentation of an incident or new skin breakdown on Saturday 11/11/23 or Sunday 11/12/23. The Director of Nursing (DON) was asked to locate and provide any information related to the new open area to the right inner hand of Resident #38. The DON provided her investigation which identified the resident obtained the blister on 11/12/23, as identified by a written statement from Staff F, Licensed Practical Nurse (LPN). The DON agreed the record lacked documentation of the new skin breakdown on 11/12/23, along with a new skin check, physician notification, or order. 4) During an interview on 11/16/23 at 12:35 PM, the Nurse Practitioner (NP) for the facility's Medical Director, was asked about her documentation in the medical records. The NP explained her admission, monthly, and annual notes are documented in the physician's electronic software, and sent to the facility at the end of each month. The NP stated the facility then would upload the note into their electronic medical record. The NP further explained any other supplemental notes are completed on paper an provided to the physician, and not included in the facility's medical record. The NP stated that has been their process since she has been at the facility for about the past year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 29 of 30 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 105257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure collection of urinalysis for 1 of 1 sampled resident, prior to initiation of an antibiotic (Resident #31). Residents Affected - Few The findings included: Review of the policy titled, Antibiotic Stewardship - Orders for Antibiotics revised December 2016 documented, 3. appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). 7. When a culture and sensitivity (C&S) is ordered, it will be completed, and: a. Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. During an interview on 11/13/23 at 9:10 AM, Resident #31 stated she now has a UTI (Urinary Tract Infection). The resident stated they (staff) don't clean her properly, and she was scared she would not get rid of the infection. Resident #31 explained she had an indwelling urinary catheter, and after they took it out she felt burning with urination, and they have since started her on an antibiotic. Review of the record revealed Resident #31 was admitted to the facility on [DATE]. The current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS assessment also documented Resident #31 had an indwelling urinary catheter. An order dated 11/09/23 documented staff were to obtain urine for a urinalysis along with a culture and sensitivity for dysuria (difficulty urinating) to rule out a UTI. An additional order dated 11/09/23 documented to start Macrobid (an antibiotic) every 12 hours for 7 days for UTI. The record lacked any results for the urinalysis. During a side-by-side review of the laboratory services book on 11/15/23 at 2:43 PM, the [NAME] Unit Manager agreed with the lack of a urinalysis for Resident #31. The Unit Manager was asked to locate and provide additional information about the urinalysis for Resident #31. On 11/15/23 at 3:44 PM, the [NAME] Unit Manager explained the nurses were supposed to collect the urine before starting the antibiotic, but since they did not, the Nurse Practitioner (NP) told them to finish the antibiotic, and they would collect a urine sample if the resident was still having symptoms. During an interview on 11/16/23 at 11:45 AM, when asked what happened with the urinalysis for Resident #31, the NP stated the nurses started the antibiotic prior to getting the urinalysis. When asked if that was her intent, the NP explained she specifically told the nurse to get the urine before starting the antibiotic. The NP stated she usually would not order the antibiotic at the same time as the urinalysis, but the resident was uncomfortable, it was a Thursday, and she didn't want the resident to wait over the weekend. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105257 If continuation sheet Page 30 of 30