Inspection·August 18, 2022

F 0583 Level of Harm - Minimal harm or potential for actual harm Review of Resident #7's physician order for the diet, dated 12/16/20, documented, CCD (Carbohydrate Controlled Diet) NAS (no added salt) diet, regular texture, nectar thickened fluids consistency. On 08/17/22 at 9:16 AM, an attempt to interview Resident #7 was made and he did not respond to questions asked. Residents Affected - Few 2. Review of Resident #37's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Aphasia (a disorder that affects how a person communicates), Dysphagia (difficulty swallowing) and Encephalopathy (refers to brain disease, damage or malfunction). The resident's MDS, quarterly assessment 06/22/22, documented a BIMS score of 5 of 15, indicating severe cognitive impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance with his ADLs from the staff. Review of Resident #37's physician order for the diet, dated 08/11/21, documented Regular NAS diet, Dysphagia, advanced texture, Nectar thickened fluids consistency. On 08/17/22 at 9:34 AM, an interview was conducted with Resident#37. The resident was asked if he was on any special diet. and he moved his head from side to side (indicating 'no'). The resident was asked if he was aware that his name and diet were posted by the kitchen door. The resident moved his head from side to side again. The resident was informed that the surveyor was concerned that his personal information was posted in plain view and was asked if he was concerned too. He stated uhm. On 08/17/22 at 9:36 AM, an interview was conducted with Staff I, a Certified Nursing Assistant (CNA), who stated that Resident #37 goes to the dining room on the first floor sometimes. 3. Review of Resident #25 clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Hemiplegia, Malnutrition and Dysphagia. The resident's MDS quarterly assessment, dated 06/08/22, documented a BIMS score of 15 of 15, indicating no cognitive impairment. The assessment documented under Functional Status that the resident needed limited assistance with his ADLs from the staff. Review of Resident #25's physician order for the diet, dated 12/02/21, documented Regular dietDysphagia Puree texture, Nectar thickened fluids consistency. On 08/17/22 at 9:40 AM, observation revealed Resident #25 in the patio area. On 08/17/22 at 10:20 AM, an interview was conducted with the resident. The resident was asked if he was on any special diet and moved his head from side to side (indicating 'no'). The resident was asked if he was aware that this name and diet were posted by the kitchen door and again, he moved his head from side to side. The resident was asked if he was concerned that his diet information was posted in plain view and moved his head from side to side. On 08/17/22 at 9:38 AM, an interview was conducted with the DON and an inquiry made about residents' protected health information being listed in plain public view / area. The DON stated that the residents' information should not be posted in plain public view. The DON was asked if residents's diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 2 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few information was protected health information. The DON stated that residents' diet information was everywhere in PCC (Point Click Care), the facility's electronic medical record. The DON added that she sees the residents' posted diet by the kitchen. The DON stated she did not know the new corporation rules and added that her nursing experience tells her that the diet information should be on the meal ticket. The DON stated the kitchen staff are contracted and they have to coach the kitchen staff to follow the facility's policy. The DON was asked to submit the facility's policy related to protecting residents' health information. On 08/17/22 at 10:10 AM, a joint interview was conducted with the facility's Registered Dietitian (RD) and the Account Kitchen Manager (AKM). The RD and the AKM were asked if the residents' diet was protected health information. The RD stated it is Protected Health Information (PHI). The RD stated that the residents' diet information should not be posted on a public view. The AKM stated the information is on the meal ticket but not posted. A side-by-side review of Residents' #7, #37, and #25 posted diet information next to the kitchen door, was conducted with the RD and the Food Manager, and was noted to be exposed to public view. The RD and the AKM stated that they did not know who posted the residents' PHI on the wall next to the kitchen. The RD and the AKM stated that information should not be there. On 08/17/22 at 10:12 AM, an interview was conducted with the facility's Cook. The [NAME] stated she did not post any residents information on the wall. The residents' posted information was shown to the Cook. The [NAME] stated they are not supposed to do that and was not aware that residents diet information was posted on the wall. On 08/17/22 at 10:18 AM, an interview was conducted with the facility's Administrator who stated that she did not know who posted the resident diet and their name to a public area. The administrator confirmed it is a Privacy (HIPAA) violation. 4. Review of the resident clinical record documented an admission to the facility on [DATE] with diagnoses to include Diabetes Mellitus, Hemiplegia, Morbid (severe) Obesity and Left Eye Blindness. Review of the resident weight report documented a reading of 355.8 lbs. (pounds) on 08/14/22 at 12:54 PM. Review of the facility's census report for 08/15/22 listed Resident #107 in room [room # documented]. On 08/15/22 at 8:16 AM, observation revealed the facility's second floor staff assignment white board that included the staff assignment and a written note that read, CNA: weight [room number documented] 08/14/22 355.8 pounds. On 08/17/22 at 9:38 AM, an interview was conducted with the Director of Nursing (DON) who was apprised of Resident #107's weight reading written on the staff assignment board in plain public view. The DON stated that the resident's health information should not be posted in plain public view. On 08/18/22 at 8:25 AM, an interview was conducted with Staff E, a Licensed Practical Nurse (LPN). Staff E stated she would write on the board if the resident had an appointment. Staff E added that she would write the residents' name on the board and the appointment date and time but did not put anything on board related to residents' weights. Staff E confirmed that Resident #107 was in room [# provided] and was obese. Staff E stated she had seen residents' weights that needed to be done written on the board. Staff E stated that residents' weights are usually done in the day or evening shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 3 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated the CNAs write the residents' name and the weight on the board. Staff E stated that residents' weight should not be written on the board. On 08/18/22 at 10:58 AM, an interview was conducted with Resident #107 and was asked if he was concerned about his weight written on a board that visitors can see. The resident stated he would like that information to be kept private. On 08/18/22 at 3:05 PM, an interview was conducted with Staff F, CNA. Staff F stated that they do get a list of the residents to be weighted. Staff F stated the CNAs will also write the resident's name on the white board when they need to weight them. On 08/18/22 at 3:07 PM, an interview was conducted with Staff G, CNA. An inquiry was made regarding checking the residents' weights. Staff G stated that they do get a list of the residents that need to be weighed. Staff G added that the CNAs will write the residents' name on the white board when they are on weekly weights. On 08/18/22 at 3:10 PM, an interview was conducted with Staff H, CNA. Staff H stated that they do get a list of the residents that need to be weighted. She added that they will write the residents' name on the white board for weight checks. 5. Review of Resident #20's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnosed included Hypertension, dry Eye Syndrome, Epilepsy and Depression. The resident's MDS quarterly assessment, dated 06/01/22, documented a BIMS score of 15 of 15, indicating no cognitive impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance with her ADLs from the staff. Review of Resident #20's staff note, dated 08/17/22, documented resident had dental appointment transportation filed to show up twice .appointment will be rescheduled. Spoke with resident to update her on appointment . On 08/17/22 at 9:04 AM, observation revealed the facility's second floor staff assignment white board with no staff assignment written on it. Further observation revealed a written note that read Appt 08/17/22, [room # documented], (Resident #20's name) at 9 AM. On 08/17/2022 at 9:23 AM, an interview was conducted with Staff J, CNA who stated she was helping out while waiting to take Resident #20 to an appointment. On 08/17/22 at 9:46 AM, observation revealed the facility's second floor staff assignment white board with no staff assignment written. The board revealed a written note that read, Appt 08/17/22, [room # documented], (Resident #20's name) at 9 AM. On 08/17/22 at 9:47 AM, observation revealed the facility's DON by the nurses' station. An interview was conducted with the DON and an inquiry was made regarding Resident #20's and the appointment date, time and the resident's name written on the board. The DON stated that the nurses were supposed to communicate with the CNAs about residents' appointments, but the staff were not supposed to write residents' information on the board. Further observation revealed the DON erasing Resident #20's appointment information written on the white board that was located in plain public view. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 4 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 08/18/22 at 8:25 AM, an interview was conducted with Staff E, a Licensed Practical Nurse LPN). Staff E stated she wrote the resident appointment on the board. Staff E added that she would write the resident's name on the board and the appointment date and time. On 08/18/22 at 12:45 PM, an interview was conducted with Resident #20. The resident stated she went to a dentist appointment on 08/17/22. The resident was asked if she was concerned that her appointment information and her name was written on a board and visible to the public, visitors. The resident stated she did not like that her information was written on a board. Event ID: Facility ID: 105258 If continuation sheet Page 5 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide appropriate assessment and treatment related to mental health concerns; failed to ensure a physician signature on the order for a [NAME] Act; and failed to ensure correct documentation on a [NAME] Act Form for one of one resident, Resident #25. The findings included: Resident #25 was originally admitted to the facility on [DATE]. Resident #25 was sent to the hospital as an involuntary admission to an acute care hospital, as a State [NAME] Act, on 08/08/22. The resident was returned to the facility a few hours later on 08/08/22, as the [NAME] Act had been removed. Resident #25 had a medical history of a stroke, leaving it difficult for him to speak and swallow, muscle weakness, depression and anxiety, seizures, and chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) was completed by the facility on 06/08/22 which showed Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he was cognitively intact. This MDS showed Resident #25's functional status as 'required limited assistance from staff for walking and was independent while using his wheelchair to propel himself around the facility'. This MDS did not identify any previous behavioral issues for Resident #25. During the initial observation of Resident #25 on 08/15/22 at 8:29 AM, it was noted that Resident #25 appeared calm and did not display any overt behavioral issues. The surveyor attempted an interview at this time, but Resident #25's speech was difficult to understand because of his previous stroke. During the initial record review, it was noted that Resident #25 had been [NAME] Acted on 08/08/22 by the facility. The surveyor requested a copy of the [NAME] Act Form and it was provided by the facility. Review of the [NAME] Act Form showed it was not signed by any medical practitioner, and it did not clearly document why Resident #25 was [NAME] Acted. In the section to document Diagnosis of Mental Illness, major depression is the only diagnosis documented. In the comment section for Supporting Evidence, the following is written: [Resident #25] became short tempered because another resident was in his way. [Resident #25] became impatient and began to strike the other resident with unknown object. [Resident #25] has a history of aggression and physical altercations. Closer review of the [NAME] Act Form revealed the professional license number documented at the top of the form was that of a Psychiatric Nurse Practitioner. The surveyor requested the facility's policy regarding [NAME] Acting residents and the Administrator stated there is not a facility policy regarding [NAME] Acts, but that they follow the state regulations. An initial interview was conducted with the facility's Director of Nursing (DON) on 08/18/22 at 12:33 PM. She stated the incident was witnessed by the facility's Administrator and that she was not personally involved in the investigation of the incident. The DON said she was told the residents had been on the smoking patio and were coming back into the facility when the altercation occurred. The DON stated both residents were assessed and had sustained no injuries. When asked if Resident #25 has a history of aggressive behaviors toward others, she stated he is passive aggressive. An interview was conducted with the facility's Social Worker on 08/18/22 at 12:47 PM. She stated she was not involved in this incident and that she did not hear about it until the next day during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 6 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning meeting. When asked if social workers are typically involved in investigating [NAME] Act cases, she stated she did not know. An interview was conducted with the facility's Administrator on 08/18/22 at 1:02 PM. When asked to recount what happened on 08/08/22, she stated the front desk receptionist told her there was a commotion in the dining room. The Administrator said she observed Resident #25 propelling himself backward in his wheelchair toward another resident and that Resident #25 attempted to hit the other with a metal object. When asked if Resident #25 actually hit the other resident with the metal object, she stated he did not. She said Resident #25 was escorted back to his room by a staff member and that a CNA (Certified Nursing Assistant) sat with him because he continued to act in an agitated manner. When asked if Resident #25 showed aggression toward staff members, she said no. When asked by the surveyor what happened next, the Administrator said she was told by the facility's DON to call 911 to [NAME] Act him. She said it took approximately 20 minutes for the police and EMS (Emergency Medical Services) to arrive and that the DON was in the room at the time. When asked by the surveyor if a physician assessed Resident #25 before he was sent to the hospital, she stated she did not know. When asked if the facility's Social Worker was involved in the [NAME] Act process or investigation, she said no, because the DON was spearheading it. When asked by the surveyor who filled out the [NAME] Act Form, she stated a corporate nurse emailed her the form because the social worker was not available at that time and that the DON told her what to document on the form. A secondary interview was conducted with the facility's DON on 08/18/22 at 1:51 PM. She stated she did not help the Administrator fill out the [NAME] Act Form. When asked to clarify who gave her the order to [NAME] Act Resident #25, she said the Psychiatric Nurse Practitioner gave her the telephone order for the [NAME] Act. She then called this Nurse Practitioner while she was in the room with the surveyor on 08/18/22 at 2:03 PM. It was noted at this time by the surveyor that this Psychiatric Nurse Practitioner has the same professional license number that is documented at the top of the [NAME] Act Form. The Nurse Practitioner stated she was called about Resident #25 on 08/09/22, after he had returned from the hospital, and it was at that time she was told by the facility staff that he had been physically aggressive toward another resident and was sent to the hospital as a [NAME] Act. She said she gave the staff member a telephone order for Ativan but that she was not contacted on the day of the incident, and she did not give the order to [NAME] Act Resident #25. When asked if she knew who gave the order for the [NAME] Act, she said she was told that the police gave the order for the [NAME] Act. Review of the physician orders for Resident #25 revealed the order for the [NAME] Act was written on 08/08/22 by the facility's DON under the Primary Care Physician's name. Further review of the physician orders revealed Resident #25 had an order for Psychology / Psychiatry Consult as needed which was written on 02/02/22. Resident #25 also had an order for Escitalopram 10 milligrams daily (a medication used to treat depression). An order was written on 08/09/22 by the facility's DON under the Primary Care Physician's name for Ativan 0.5 milligrams to be used two times daily (a medication used to treat anxiety). Resident #25 had a Care Plan in place regarding his depression. A new care plan was added on 08/08/22 by the Social Worker regarding Resident #25 being physically aggressive toward another resident, but there was no documentation of aggression toward others prior to this date. A Nursing Progress Note was written by the facility's Administrator on 08/08/22 at 2:32 PM which stated the following: Resident was observed being physically aggressive towards others in the dining room. Resident was separated immediately from the rest of the group, placed on 1:1 in his room, until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 7 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0740 law enforcement arrived. Level of Harm - Minimal harm or potential for actual harm A Nursing Progress Note was written by the facility's Director of Nursing (DON) on 08/09/22 at 9:16 AM which stated the following: Resident returned to facility in the evening of 8/8/22 from [an acute care hospital] after being [NAME] Acted for physical aggression toward another resident earlier in the morning in the first floor DR [sic: dining room]. Upon returning resident was very quiet according to report and stayed in his room. Behavior monitoring on going. Residents Affected - Few A Subsequent Psychiatric Note was written by a Nurse Practitioner on 08/09/22 which stated the following: DON called me on 08/08/22 notifying me the resident was [NAME] Act by the police because physical aggression toward another resident. Later on 08/08/22 I was also notified that the resident was discharged and is very anxious and aggressive when he reacts. Recommendation at this time to add antianxiety meds. Add Lorazepam 0.5mg (milligrams) po (by mouth) bid (two times daily). Will continue to monitor. In this note, the Nurse Practitioner documented Resident #25's behavior was cooperative but that he was anxious. This note also stated the resident had no delusions or hallucinations. It is noted by the surveyor that this Psychiatric Nurse Practitioner has the same professional license number that is documented at the top of the [NAME] Act Form that was provided by the facility. This note did not document that this practitioner gave the order to the facility staff to [NAME] Act Resident #25, nor did it document that this practitioner assessed Resident #25 prior to the decision to [NAME] Act Resident #25. A Psychotherapy Note was written by a different Nurse Practitioner on 08/10/22 which stated Resident #25 had anxiety and a recent altercation with another resident but also documented Resident #25 was calm and cooperative. This note stated she worked with Resident #25 on boundary setting and impulse control techniques and that Resident #25 denied any lasting emotional distress related to altercation. An interview was conducted with Resident #25's Primary Care Physician's on 08/18/22 at 1:55 PM. He said he was texted by a staff member during the incident that Resident #25 had hit another resident and the facility wanted to [NAME] Act him and he told the staff, Ok. He admitted he did not assess the resident and that he did not sign the form. He stated he did not think Resident #25 should have been [NAME] Acted as a result of this incident. He said he would not allow this to happen again and that from now on he will assess every resident before giving an order to [NAME] Act. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 8 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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, and record review, the medication error rate was 12 percent (%). Three (3) medication errors were identified while observing a total of (25) opportunities, affecting 2 of 8 residents observed, Residents #54 and #29. Residents Affected - Few The findings included: Review of the facility's policy, titled, General Dose Preparation and Medication Administration with a revision date 01/01/22, documented, in part, .during medication administration .administer medications within the timeframe specified by facility .after medication administration .document necessary medication administration/treatment information . 1. Review of Resident #54's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included Right Femur Fracture, Pleural Effusion, Cholecystitis, Urinary Tract Infection, Gastrointestinal Hemorrhage and Deficiency of other Vitamins. Review of Resident #54's Minimum Data Set (MDS) admission assessment, dated 07/24/22, documented, a Brief Interview of the Mental Status (BIMS) score of 15, indicating the resident has no cognitive impairment. The assessment documented under Functional Status that the resident was totally dependent on staff for her Activities of Daily Living (ADLs) including the administration of the medications. Review of the resident's physician orders, dated 07/18/22, documented, Protonix Tablet Delayed Release 40 milligrams (mg), give 2 tablets by mouth two times a day for GERD,(Gastroesophageal Reflux Disease). Physician order, dated 07/11/22, documented PreserVision AREDS oral tablet (Multiple Vitamins with minerals), give one tablet by mouth one time a day related to Deficiency of other Vitamins. On 08/16/22 at 8:50 AM, a medication administration observation for Resident #54 was performed by Staff B, a Licensed Practical Nurse (LPN). Observation revealed Staff B pulled an over the counter bottle of One Daily multivitamin without minerals, an Iron 325 mg tablet and one Metoprolol 25 mg tablet. During the observation, Staff B stated that the resident was scheduled to have Protonix at this time and added that she did not see Protonix in the medication cart. Staff B added she would have to call the pharmacy for a refill. On 08/16/22 at 1:07 PM, an interview was conducted with Staff B who stated that she requested the Protonix medication for Resident #54 and it had not come yet. Staff B added that the pharmacy told her that it will be in around 1:00 PM, but it never comes on the same day. Staff B was asked if the Director of Nursing (DON) was aware of that and replied that the DON might be aware of that. A side-by-side review of the Resident #54's Multivitamin physician order was conducted with Staff B. Staff B confirmed that the order read PreserVision - multivitamins with minerals. Staff B stated she gave the over the counter multivitamin that they have in stock. A side-by-side review of the One daily multivitamin bottle with no minerals was conducted with Staff B. Staff B was apprised that she did not administer the correct multivitamin. Staff B looked up PreserVision AREDS online and stated, No, we don't have that. Review of Resident #54's clinical record lacked evidence that the physician was notified regarding wrong multivitamin given and the lack of administration of Protonix as ordered on 08/16/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 9 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 On 08/18/22 at 9:53 AM, an interview was conducted with the Director Of Nursing (DON) who was apprised that Resident #54 did not receive Protonix or PreserVision during medication observation on 08/16/22. The DON confirmed the lack of documentation regarding notification to the physician. The DON called the Central Supply Coordinator. During an interview, the Central Supply Coordinator stated that she ordered the equivalent for PreserVision multivitamins. A side-by-side review of the PreserVision substitute (Optimum Vision Support opened on 08/01/22) located in the medication cart was conducted with the Central Supply and Staff C, LPN. The DON stated that she was not aware of Resident #54 not having her medication refilled in a timely manner. The DON stated the nurses are to refill the residents' medications once they see there are 7 days left on the blister package. 2. Review of Resident #29's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included Hemiplegia, Diabetes Mellitus, Overactive Bladder, Urinary Tract Infection and Contractures. Review of Resident #29's MDS quarterly assessment, dated 06/12/22, documented a Brief Interview of the Mental Status (BIMS) score of 9 of 15, indicating that the resident has moderate cognition impairment. The assessment documented under Functional Status that the resident was totally dependent on staff for her ADLs including the administration of the medications. Review of the resident's physician orders, dated 01/25/21, documented Cranberry Tablet 450 mg, give 450 mg by mouth two times a day for Prophylaxis. Physician order, dated 12/09/20, documented Metformin tablet 1000 mg, give 1000 mg by mouth two times a day related to Diabetes Mellitus. Physician order, dated 12/09/20, documented Oxybutynin Chloride tablet 5 mg, give 5 mg by mouth three times a day related for Overactive Bladder. On 08/16/22 at 4:49 PM, an interview was conducted with Staff D, a Registered Nurse (RN) and stated Resident #29 had Metformin to be given at 5:00 PM. Medication administration observation for Resident #29 performed Staff D, RN was conducted. Observation revealed Staff D poured one tablet of Metformin 1,000 mg, and administered the Metformin tablet. Staff D returned to the medication cart and documented the medication administration in the resident's electronic medical record. The observation revealed that Staff D administered one medication and the resident was scheduled to have three medications at 5:00 PM. The resident did not receive the ordered Oxybutnin Chloride medication or the Cranberry supplement. Review of Resident #29's electronic Medication Administration Record (MAR) for August 2022 documented that Staff D, Registered Nurse (RN) administered Metformin tablet 1000 mg, Cranberry Tablet 450 mg and Oxybutynin Chloride tablet 5 mg at 5:00 PM (1700 hours/hrs). On 08/18/22 at 10:24 AM, a side-by-side review of Resident #29's electronic Medication Administration Audit Report for 08/16/22 medication administration was conducted with the DON. The review revealed Staff D documented Resident #29's Oxybutynin 5 mg administration at 9:18 PM (21:18 hrs) and Cranberry 450 mg administration at 9:20 PM (21:20 hrs). The resident's Cranberry tablet and Oxybutynin tablet were scheduled to be given at 5:00 PM. The DON was apprised that Staff D did not administer Resident #29's medication scheduled for 5:00 PM during the 5:00 PM observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 10 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 record review, the facility failed to ensure that residents' medications were properly supervised / stored as evidenced by over the counter medications being left unattended on the resident's bedside table for Resident #22 and #24 and as evidenced by residents' insulin (pens) medications being left on top of the medication cart unattended and unsecured for Resident #106 and #108. The findings included: Review of the facility's policy titled, General Dose Preparation and Medication Administration, with a revision date of 01/01/22, provided by the Director of Nursing, documented .facility staff should not leave medications or chemicals unattended . Review of the facility's policy, titled, Self-Administration of Medications at Bedside, revised on 08/22/17, provided by the administrator, documented .verify physicians order in the resident's chart for self-administration of specific medications under consideration. Complete Self-Administration of Medications Evaluation .complete the Care plan for approved self-administered drugs .The MAR [Medication Administration Record] must identify meds that are self-administered . 1. Review of Resident #22's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Dementia, Syncope and Collapse and Hypertension. Review of Resident #22's Minimum Data Set (MDS) annual assessment, dated 06/01/22, documented a Brief Interview of the Mental Status (BIMS) score of 13 of 15, indicating that the resident has little to no cognition impairment. The assessment documented under Functional Status that the resident needed limited assistance with her Activities of Daily Living (ADLs) from the staff. Further review lacked evidence of the facility's Self-Administration of Medications at Bedside assessment for Resident #22. Review of Resident #22's active care plans lacked evidence of a care plan related to Self-Administration of Medications at Bedside. Review of the resident's physician orders and the Medication Administration Record (MAR) revealed no orders for Centrum-Women Gummies. On 08/15/22 at 8:36 AM, observation revealed Resident #22 in her room, sitting up in the bed. Further observation revealed a bottle of Centrum-Women gummies-multivitamins on top of the resident's night stand and unsecured (Photographic evidence obtained). An interview was conducted with the resident who stated that she takes one of the Centrum Women gummies every day. On 08/15/22 at 9:41 AM, observation revealed Resident #22 walking down the hallway across her room. On 08/16/2022 at 8:37 AM, observation revealed Resident #22 sitting up in her bed listening to music. Further observation revealed the Centrum-Women gummies bottle continued to be on top of her night (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 11 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 stand and unsecured. Level of Harm - Minimal harm or potential for actual harm On 08/17/22 at 12:26 PM, an interview was conducted with Staff B, a Licensed Practical Nurse (LPN), who stated that she did not know that Resident #22 had a bottle of Centrum-Women gummies in her room. Staff B added that she did not know how the resident had the gummies. Staff B was asked if Resident #22 should have the over the counter medication in her room and stated that she thought the resident should not have the vitamins in her room. Residents Affected - Few On 08/17/22 at 12:34 PM, observation revealed Resident #22 continued to have the bottle of CentrumWomen gummies on top of her night stand. On 08/18/22 at 8:05 AM, an interview was conducted with Staff E, LPN, who stated that she did notice that Resident #22 had a bottle of Centrum-Multivitamins on top of her night stand. Staff E added that the family must have brought them in because the resident did not go out of the facility. On 08/18/22 10:24 AM, during an interview, the Director of Nursing (DON) was apprised of Resident #22 having a bottle of Centrum-Women gummies on her night stand. The DON stated that she had removed things from Resident #22's room before. The DON added that the resident has Dementia and can't do self-administration of medications. 2. Review of Resident #24's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included Multiple Sclerosis, Myopia, Diabetes Mellitus, Quadriplegia, Pain, Depression and Vitamin Deficiency. Review of Resident #24's MDS quarterly assessment, dated 06/03/22, documented a Brief Interview of the Mental Status (BIMS) score of 15, indicating that the resident has no cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance with her ADLs from the staff except for eating. Further review lacked evidence of the facility's Self-Administration of Medications at Bedside assessment for Resident #24. Review of Resident #24's active care plans lacked evidence of a care plan related to Self-Administration of Medications at Bedside. Review of Resident #24's physician orders and the MAR for August 2022 lacked evidence of a physician order for Lidocaine Spray to be kept at the residents bedside. On 08/16/22 at 1:23 PM, observation revealed a bottle of Lidocaine spray unsecured on top of Resident #24's table. (Photographic evidence obtained). An interview was conducted with the resident who stated that she uses the Lidocaine spray for pain and added it is the best thing she could have. The resident was asked if the nurses were aware that she was using it and stated that they were aware and told her that if her roommate had not difficulty breathing, she could use it. The resident added her roommate did not have difficulty breathing. On 08/17/22 at 12:26 PM, an interview was conducted with Staff B, a Licensed Practical Nurse (LPN). Staff B stated that Resident #24 had a lot of vitamins before in her room and they were removed. Staff B was asked if Resident #24 was supposed to have over the counter medication (OTC) like the Lidocaine spray at the bedside on the table and stated, I'm not sure. Staff B added that someone like (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 12 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 Resident #24 may have exceptions. Staff B was asked again if the resident is allowed to have over the counter medications (OTC) in her room and stated the residents should not have any OTC in her room. Staff B stated the residents orders gummies and had a lot of stuff in her room. Staff B stated she was not sure what the facility's policy was regarding OTC medications in the residents' room. On 08/18/22 at 8:05 AM, an interview was conducted with Staff E, LPN, who stated that she had not seen a bottle of Lidocaine Spray in Resident #24's room. Staff E added that the resident was aware that she could not have medications in the room and that the facility had taken medications away from her room before. Staff E stated the residents were not supposed to have medications in their room. On 08/18/22 at 10:45 AM, during an interview, the DON was apprised of the findings. The DON confirmed that Resident #24 was not assessed for Self-Administration of Medications at Bedside. 3. Review of Resident #106's clinical record documented an admission on [DATE]. The resident diagnoses included Osteomyelitis of left foot and ankle, Heart Failure, Non Pressure Ulcer of Left Foot, Diabetes Mellitus and Peripheral Vascular Disease. Review of Resident #106's physician orders and the MAR for August 2022 documented Humalog Insulin Pen inject as per sliding scale subcutaneously before meals and a bedtime for Diabetes Mellitus. Review of the resident's MAR for August 2022 documented Humalog Insulin administered by Staff D, RN, on 08/16/22 at 4:00 PM. On 08/16/22 at 4:06 PM, observation revealed Staff D, a Registered Nurse (RN), walking out of Resident #106's room and down the hallway carrying a foam tray that contained a glucose meter and an insulin pen, a prescribed medication. Further observation revealed Staff D placed the foam tray with the pen insulin on top of the medication cart, unsecured and at plain public view. Staff D then walked away from the medication cart, approximately 10 feet, and into a resident's room. Observation revealed Staff D was washing her hands. Further observation revealed a local Hospice Nurse standing at approximately 6 feet away from the medication cart. An interview was conducted with the Hospice staff who stated she was waiting on Staff D. Staff D returned to the medication cart, unlocked the cart and placed the resident's insulin pen insulin in the cart and locked the cart. On 08/16/22 at 4:41 PM, an interview with Staff D, RN, was conducted who stated she did Resident #106's blood glucose test and administered insulin using the insulin pen. An inquiry was made related to Staff D leaving the resident's insulin pen on top of the medication cart unattended. Staff D, replied Did I do that. Staff D was apprised that t surveyor observed her walked away from the medication cart, left the insulin pen, came out of a resident's room, unlocked the medication cart and placed Resident #106's insulin pen inside the medication cart. Staff D stated she was not supposed to leave the insulin pens on top of the medication cart. Staff D stated she should lock them up in the medication cart. Staff D added that she did it because she needed to wash her hands before opening the medication cart. 4. Review of Resident #108's clinical record documented an admission on [DATE]. The resident's diagnoses included Diabetes Mellitus, Parkinson's Disease and Hypertension. Review of Resident #108's physician orders and the MAR for August 2022 documented Insulin Glargine inject 5 units subcutaneously three times a day and Insulin Lispro 5 units subcutaneously three times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 13 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 On 08/16/22 at 4:11 PM, observation of the blood glucose test for Resident #108 performed by Staff D, RN, was conducted. Staff D stated the resident gets two insulin administration scheduled for 5:00 PM. On 08/16/22 at 4:28 PM, observation revealed Staff D gathered the insulin administration supplies and two insulin pens, Lispro insulin pen and Glargine insulin pen. At 4:36 PM, Staff D administered both insulins, placed both pens on the foam tray, removed her gloves, walked out of the resident's room to the medication cart and placed the foam tray with the two insulin pens on top of the medication cart, unsecured. Further observation revealed Staff D, RN walked away from the medication cart, leaving the insulin pens unsecured and unattended on top of the cart, entered a resident room and proceeded to performed handwashing. At 4:41 PM, Staff D returned to the medication cart, unlocked the cart and placed the two insulin pens inside the cart and locked the cart. An interview was conducted with Staff D who stated she was not supposed to leave the insulin pens on top of the medication cart and added she should lock the insulin pens up in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 14 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, policy review and record review, the facility failed to provide physical therapy as ordered by the physicians for 2 of 3 sampled residents (Residents #14 and #36). Residents Affected - Few The findings included: The facility's policy titled Rehab Services Policies and Procedures effective 05/01/02 and revised 11/05/21 reveals Genesis Rehab Services .provide skilled rehabilitation services to patients as ordered by physician or appropriately credentialed/licensed non-physician practitioner (NPP). 1. Resident #14 was admitted to the facility on [DATE] from a long term care facility post spinal fusion. He had additional diagnoses of Dorsalgia, Muscle Weakness, and unsteadiness on feet. His brief interview of mental status (BIMS) was 15, per the Minimum Data Set (MDS) admission assessment with an assessment reference date (ARD) of 05/22/22, which indicated he was cognitively intact. On 05/16/22, the physician wrote an order for physical therapy evaluate and treat. On 08/15/22 at 9:38 AM, Resident #14 was interviewed during the initial pool process. Resident #14 stated that he had an order for physical therapy but he was not receiving physical therapy. The resident was observed in a wheelchair and able to mobilize in the wheelchair. He stated that he could not stand for a long period of time but was able to transfer on his own. An interview was conducted on 08/16/22 at 1:01 PM with the interim physical therapy director who stated that there was no physical therapy screening found for Resident #14 as a result of the physician order of 05/16/22. A Therapy Payer Validation Form, dated 07/28/22, revealed Physical Therapy (PT), Speech Therapy (ST) and Occupational Therapy (OT) were requested by the Physician and resident but no screening was done. The physical therapy interim director stated that the patient had behavior issues and screening was not able to be done but there was no documentation from physical therapy. On 08/17/22 at 9:25 AM, an additional interview was conducted with the physical therapy interim director and Staff A, a physical therapist. They stated that Resident #14 was screened yesterday. Review of the Physical Therapy (PT) evaluation, dated 08/16/22, revealed Patient demonstrates excellent rehab potential. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Muscle Weakness, and cognitive communication deficit. Her BIMS score was 15, per the quarterly MDS with an ARD of 06/22/22. This indicated she was cognitively intact. Record review revealed she had physical therapy from 01/31/21-03/08/21. On 08/16/22 at 9:38 AM, Resident #36 was interviewed during the initial pool process. Resident #36 expressed a desire for physical therapy because she wanted to be able to stand. She stated that she had therapy last year but nothing since then. She felt like she was not making any progress just lying in the bed. A Therapy Payer Validation Form, dated 01/05/22, revealed Physical Therapy and Occupational Therapy were requested by the Physician. In the comments section, it was written private pay no MCR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 15 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [Medicare] part A or B. An interview was conducted with Staff A on 08/16/22 at 1:01 PM, asking if the resident or her brother were asked if they wanted to pay for therapy. Staff A thought someone called her brother but there was no documentation of the facility reaching out to the resident or her brother. Staff A and the interim physical therapy director were asked during that interview about the time frame in completing the screening after they have a physician's order and they said it should be done within 48 hours. On 03/22/22, a therapy screen was done on Resident #36 with a comment written that resident does not require skilled PT/OT/ST services at this time. On 08/16/22, a PT evaluation was conducted on Resident #36. Review of the PT evaluation, dated 08/16/22, revealed Patient demonstrates good rehab potential. Without skilled therapeutic intervention, the patient is at risk for: anxiety, contracture(s), falls, further decline in function, immobility and pressure sores. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 16 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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, interviews and record review, the facility failed to ensure that the residents medications were documented as administered for prescribed medications for 2 of 8 sampled residents, Resident # 24, and Resident #54 during medication administration observation. The findings included: Review of the facility's policy, titled, Physician Orders, revised, on 03/03/21, documented The center will ensure that Physician orders are appropriately and timely documented in the medical record. Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders 1. Review of Resident #54, clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Right Femur Fracture, Pleural Effusion, Cholecystitis, Urinary Tract Infection, Gastrointestinal Hemorrhage and Deficiency of other Vitamins. Review of Resident #54's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident has not cognitive impairment. The assessment documented under Functional Status that the resident was totally dependent on staff for her Activities of Daily Living (ADLs) including the administration of the medications. Review of Resident #54's local hospital discharge medication list, dated 07/18/22, provided by the DON documented .Pantoprazole 40 mg Delayed Release, 2 each, 80 mg, by mouth twice a day . Review of the resident's physician orders, dated 07/19/22, documented, Protonix Tablet Delayed Release 40 milligrams (mg), give 2 tablets by mouth two times a day for GERD (Gastroesophageal reflux Disease). Review of the resident's physicians orders, dated 08/16/22, documented, Protonix Oral tablet Delayed Release 40 mg (Pantoprazole) give 2 tablets by mouth two times a day for GERD was discontinued. Review of Resident #54's Medication Administration Record (MAR) for July 2022 documented, Protonix Oral tablet Delayed Release 40 mg (Pantoprazole) give 2 tablets by mouth two times a day for GERD administered as ordered on 07/19/22. On 08/16/22 at 8:50 AM, medication administration observation for Resident #54 performed by Staff B, a Licensed Practical Nurse (LPN) was conducted. During the observation, Staff B stated the resident was scheduled to have Protonix and that she did not see Protonix in the medication cart. Staff B added that she will have to call the pharmacy. On 08/16/22 at 1:07 PM, an interview was conducted with Staff B, LPN, who stated that she requested the Protonix for Resident #54 and that it had not come. She added that the pharmacy tells her that it will be in around 1:00 PM, but never comes on the same day. Staff B was asked if she informed the Director of Nursing (DON) regarding pharmacy not delivering on the same day and stated that the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 17 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 might be aware of that. Level of Harm - Minimal harm or potential for actual harm On 08/16/22 at 5:00 PM, a side-by-side review of Resident #54's medications supply was conducted with Staff D, a Registered Nurse. Staff D stated they had not received Protonix from the pharmacy at the time for Resident #54. Staff D confirmed the resident was scheduled for Protonix at 5:00 PM. Staff D stated that the pharmacy usually do more than round a day and added that they come at any anytime. Residents Affected - Few Review of Resident #54's MAR for 08/16/22 documented that her scheduled doses of Protonix for 9:00 AM and 5:00 PM were not administered as per physician orders. Review of the resident's eMAR- Medication Administration Note by Staff B, LPN dated 08/16/22 at 8:56 AM documented Medication not available, will call pharmacy to follow up. The resident record lacked evidence of notification / communication with the physician regarding medication not available. Review of the resident's eMAR- Medication Administration Note by Staff D, RN dated 08/16/22 at 5:33 PM documented on order The resident record lacked evidence of notification / communication with the physician regarding medication on order. On 08/17/22 at 2:20 PM, a joint interview was conducted with the facility's Consultant Pharmacist (CP) and the DON. The CP and the DON were apprised that Resident #54 did not receive Protonix as ordered on 08/16/22 9:00 AM dose during medication administration observation performed by Staff B, LPN. The CP was informed that Staff B stated that Protonix was not reordered. The CP and the DON were informed that it was not delivered by 5:00 PM on 08/16/22. The CP stated that the in-house pharmacist informed her that Resident #54's Protonix was on clinical hold meaning that they could not send it because the dose was too high. The DON stated that she was not aware of that. The CP was informed that Staff B did not report that and informed surveyor that she was waiting on the pharmacy. The CP stated that Protonix was ordered on 07/19/22. The CP was apprised that Resident #54's MAR for July 2022 documented that the resident had received the high dose of Protonix since 07/19/22. The CP stated she had not done a pharmacy review for Resident #54 and was not aware of any issues with the resident's Protonix. On 08/17/22 at 3:55 PM, an interview was conducted with Staff C, LPN and stated she administered Resident #54's scheduled 9:00 AM dose of Protonix 2 tablets from the e-kit. The nurse was asked to show the e-kit supply, went to the medication room, turned around, walked to the medication cart and stated she gave the resident the last two pills of Protonix from a bottle the resident brought from the hospital. On 08/18/22 at 9:55 AM, an interview was conducted with Resident #54 and stated that she had not been informed of any medications not been given or not available. On 08/18/22 at 10:24 AM, an interview was conducted with the DON and was apprised of Resident #54 not receiving Protonix on 08/16/22 at 9:00 AM and 5:00 PM. The DON confirmed there was lack of documentation related to notifying the physician regarding the lack of Protonix in the facility for Resident #54. The DON stated that she was not aware of Resident #54 not having her medication refilled in a timely manner. The DON stated the nurses were to refill the residents' medications once they saw there was 7 days left on the blister package. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 18 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 2. Review of Resident #24's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Multiple Sclerosis, Myopia, Diabetes Mellitus, Quadriplegia, Pain, Depression and Vitamin Deficiency. Review of Resident #24's MDS quarterly assessment, dated 06/03/22, documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident has no cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance with her ADLs from the staff except for eating. Review of the physician order documented Lyrica 150 mg every 8 hours. The resident's MAR documented that Lyrica was scheduled for 6:00 AM, 2:00 PM and 10:00 PM every day. Review of Resident #24's June 2022 MAR documented that the resident did not receive Lyrica's dose on 06/07/22 at 2:00 PM; 06/14/22 at 10:00 PM; 06/29/22 at 2:00 PM and 10:00 PM and on 06/30/22 at 2:00 PM and 10:00 PM doses. Review of the resident's (electronic) e-MAR Medication Administration record for 06/07/22 at 2:29 documented spoke to pharmacy tech, told that medication would be coming with their 1:00 PM run. e-MAR Medication Administration record for 06/14/22 at 9:39 documented medication not administered, on order; e-MAR Medication Administration record for 06/29/22 at 1:02 PM documented awaiting medication; and 9:04 PM documented waiting on pharmacy deliver and on 06/30/22 at 1:57 PM and 9:25 PM documented awaiting delivery. Review of Resident #24's June 2022 MAR documented that the resident did not receive Lyrica's dose on 06/07/22 at 2:00 PM; 06/14/22 at 10:00 PM; 06/29/22 at 2:00 P and 10:00 PM and on 06/30/22 at 2:00 PM and 10:00 PM doses. Review of the resident's (electronic) e-MAR Medication Administration record for 06/07/22 at 2:29 [PM] documented spoke to pharmacy tech, told that medication would be coming with their 1:00 PM run. The e-MAR Medication Administration record for 06/14/22 at 9:39 documented medication not administered, on order. The e-MAR Medication Administration record for 06/29/22 at 1:02 PM documented awaiting medication; at 9:04 PM documented waiting on pharmacy delivery and on 06/30/22 at 1:57 PM and 9:25 PM documented awaiting delivery. Further review of the resident's June 2022 MAR documented that the resident did not receive Crestor 5 mg scheduled for 9:00 PM on 06/07/22; 06/08/22; 06/09/22; 06/10/22; 06/11/22 and on 06/15/22. Review of the resident's (electronic) e-MAR for 06/07/22 at 10:08 PM documented awaiting delivery; 06/08/22 at 9:12 PM documented on order ; 06/09/22 at 10:04 PM documented awaiting delivery; 06/10/22 at 9:52 PM documented awaiting delivery; 06/11/22 at 8:34 PM documented awaiting delivery, and on 06/15/22 at 9:47 PM documented waiting on pharmacy delivery. Review of Resident #24's July 2022 MAR documented that the resident did not receive Lyrica's dose on 07/01/22 and 07/02/22 6:00 AM, 2:00 PM and 10:00 PM doses; on 07/03/22 at 6:00 AM and 2:00 PM doses; on 07/09/22 at 10;00 PM and on 07/10/22 6:00 AM, 2:00 PM and 10:00 PM doses. Review of the resident's e-MAR for 07/01/22 at 7:06 AM documented await medication from pharmacy 07/02/22 at 6:37 AM, 1:15 PM and 11:09 PM documented awaiting pharmacy delivery; on 07/03/22 at 5:16 AM and 2:12 PM documented awaiting pharmacy delivery; on 07/09/22 at 10:22 PM and 07/10/22 6:58 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 19 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 documented awaiting pharmacy delivery 07/10/22 at 1:00 PM documented script e-faxed to pharmacy, and on 07/10/22 at 9:01 PM documented waiting for delivery. Further review revealed lack of evidence of communication / notification to the physician related to medications not administered as ordered. Residents Affected - Few Further review revealed that Resident #24 did not receive Bupropion 150 mg scheduled daily at 9:00 AM on 07/01/22 and 07/02/22. Review of the resident's e-MAR for on 07/01/22 at 9:08 AM documented awaiting delivery and 07/02/22 at 8:27 AM documented awaiting pharmacy delivery. Review of Resident #24's August 2022 MAR documented that the resident did not receive Bupropion 150 mg scheduled for 9:00 PM daily on 08/11/22, 08/12/22 and on 08/14/22. Review of the resident's e-MAR for 08/11/22 at 10:55 PM documented await medication from pharmacy; 08/12/22 at 9:31 PM documented waiting on pharmacy delivery, and on 08/14/22 at 9:50 PM documented waiting on pharmacy delivery. On 08/15/22 at 9:55 AM, observation revealed Resident #24 in bed. An interview was conducted with the resident who stated that she had not had her Lyrica and her Wellbutrin as ordered. On 08/16/22 at 1:30 PM, an interview was conducted with Staff B, LPN and was asked if she received Resident #24's Wellbutrin medication from the pharmacy. Staff B stated it must have been delivered sometime last night (08/15/22). On 08/17/22 at 12:53 PM, an interview was conducted with the facility's Consultant Pharmacist (CP) who stated she had not heard any issues related to medications delivery to the facility. The CP added that if any issues, the DON would contact her. The CP stated she would look / review the residents' MAR during a pharmacy review monthly. A side-by-side review of Resident #24's MAR for June, July and August 2022 was conducted with the CP. The CP stated if the medication was missed only one time, it was okay, if more than one or two, the CP stated she would follow up with the DON to see what was going on. The CP stated it was okay for Resident #24 to miss Bupropion, an antidepressant, for a few days. The CP was apprised that Resident #24 had not received doses of Lyrica, Crestor and Bupropion for more than one dose, three doses in one day. The CP was informed that the nurses notes documented waiting on the pharmacy. The CP was asked to research the reasons for the resident missing medications. On 08/18/22 at 10:35 AM, an interview was conducted with the DON. The DON was apprised of Resident #42 medications not been given as ordered multiple times in June, July and August 2022 and no nurses progress notes related to informing the physician. The DON stated she was not aware of the medication not been given. The DON stated that ever since the merge (facility-pharmacy merge) she called the pharmacy, and they gave excuses like waiting on payor source. The DON stated the administrator was aware. On 08/18/22 at 11:15 AM, a joint telephone conference interview was conducted the facility's Consultant Pharmacist (CP) and the DON. The CP stated that Resident #24's Bupropion dose was changed, and it did come in that dose. The in-house pharmacist was calling the nursing staff to call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 20 of 21 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062 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 FORM CMS-2567 (02/99) Previous Versions Obsolete physician to get a dose that could be sent out to the facility. The CP stated that the pharmacy sent a 7-day supply of Lyrica and then wait for a reorder and was not reordered. The CP stated that the pharmacy's corporate policy is if the insurance does not cover, the pharmacy will send a 7-day supply at the time until they get an approval from the facility. The CP stated that Lyrica was never re-order until on 08/17/22. The DON stated that the facility will pay for the 7-day supply and then the facility's Business Office Manager (BOM), is to find out who is the payor source so the residents can get the medications. The DON stated the facility did not have a permanent BOM. The DON added that the facility had a corporate person that was coming once a week. The DON confirmed that the Resident #24 was not getting her medications as ordered. Event ID: Facility ID: 105258 If continuation sheet Page 21 of 21