Health inspection·December 21, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room [ROOM NUMBER]: The room floor tiles were stained, cracked, and areas of small holes, over-bed tables (2 of 2) had areas of peeling paint and rust, bathroom tub exterior in disrepair and could not be used by the residents. First Floor Hallway: Large hole in floor tile, cracked and stained tiles outside of room [ROOM NUMBER] and #120, numerous small holes in tiles, cracked and stained tiles across from nurse's station. Community Shower Room: Entry door would not open properly, and uneven floor tiles at the door entry threshold caused a potential trip hazard. Main Elevator: The elevator's entry floor metal tracks were heavily soiled and noted with large pieces of unknown matter. Exit Door: Wall area surrounding door was noted to be in disrepair with holes and peeling paint. 2) Second Floor: room [ROOM NUMBER]: Resident requesting a room chair and additional room lighting. room [ROOM NUMBER]: Exterior to room dresser was heavily worn and exposed wood areas. And room floor stained black and cracked floor tiles. room [ROOM NUMBER]: Over-bed light (Bed A) was wrapped around the light unit and could not be used by the resident. room [ROOM NUMBER]: Entry door to room could not be opened and was noted to be caught on the room floor. Hallway Handrails: Numerous 4-5-inch areas of peeling paint outside the following rooms: #202, #208, #210, #211, and #212. 3) Laundry Area: Washroom: One of two washing machines was not operational for over 3 months, large areas of peeling paint of room floor, room walls noted to have numerous large holes and areas of peeling paint. Dryer Room: One of two commercial ceiling lights were not working and light fixtures failed to safe guard covers. Following the tour, all of the aforementioned issues were again reviewed and confirmed by the surveyor with the facility's maintenance staff. On 12/20/23 the Administrator acknowledged to the surveyor that he had been informed of all the housekeeping and maintenance issues and had no concerns or questions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 2 of 34 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 12/21/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to initiate a grievance for 1 of 1 sampled resident (Resident #151) who reported the loss of his personal property (cell phone) at the facility. The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses of: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side; Hypertension; Diabetes Mellitus due to underlying condition with other diabetic Kidney complications; Depression unspecified; Anxiety Disorder; Unspecified Psychosis not due to a substance or known physiological condition. Restlessness and Agitation. On 12/18/2023 at approximately 11:33 AM, Resident #151 was observed in bed. During this time, the resident's Power of Attorney (POA) stated, via an identified electronic device, that he had sent a cell phone to Resident #151 in order to facilitate communication with the resident when he is out of his room and around and about the facility. The POA stated, he was told by Resident #151, the phone was missing. The POA said that Resident #151 had not been out of the facility. So, he could not understand why his cell phone was missing. The POA added that he tried calling the office on multiple occasions to get this issue resolved, but no one addressed his concerns. The POA also reported he had been calling for the past weeks, the phone rang a lot and no one answered. At times, they put him on hold and did not come back on the phone. He also said that the electronic communication device he placed in Resident #151's room has been turned off and muted, so he could not speak to his friend. On 12/21/23 at 12:54 PM, the Administrator explained that the electronic video communication device was placed in the Resident's room without their consent or knowledge, which was a violation of the facility's policy. Yet, he still returned it to Resident #15. The Administrator said that he spoke with the Resident regarding the utilization of video equipment, and he also discussed the matter with the Social Worker to ensure that proper actions are taken to remediate the mishap and to also meet the resident's wellbeing and needs. The Administrator said that they will contact the POA to ensure that the policy is followed before allowing the resident to have total liberty to operate the video equipment in the facility. Interview with the Administrator regarding the missing cell phone on 12/21/23 at 1:07 PM, revealed he was still investigating to find out what had happened. He still did not know what had happened to the phone. The Administrator said that he did not file a formal grievance, as of the indicated date and time of this interview but he would inform Social Services. On 12/21/23 at 2:12 PM, a follow-up interview with the Administrator revealed that a grievance was still not initiated to investigate the whereabout of the resident's missing cell phone. The Administrator only acknowledged that he was aware that the phone had been reported missing since 12/18/23. On 12/21/23 at approximately 3:00 PM, the Social Worker reported that she was not aware of the issue. She said that no one had reported to her that the Resident's phone was missing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 3 of 34 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 12/21/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm On 12/21/23 at approximately 5:15 PM, during the exit conference, the Administrator was given the opportunity to present any additional information that the facility might have obtained. It was then that the Corporate Personnel urged the Administrator to submit a copy of the grievance which was initiated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 4 of 34 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 12/21/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 3 of 19 sampled residents (Residents #7, Resident #15 and Resident #45). Residents Affected - Few The findings included: 1. Review of Resident #7's record revealed an admission date of 05/13/13, with the diagnoses of Atherosclerosis, Coronary Heart Disease, Anxiety Disorder and Schizoaffective Disorder. Review of the physician orders documented the following for Resident #7: Seroquel 25 mg at bedtime for Schizophrenia. Seroquel 50 mg at bedtime for Schizophrenia Risperdal 0.25 mg for Schizoaffective Disorders, 1 tab a day; Xanax tablet 2 mg for Anxiety, every 12 hours. Further record review showed that the pre-admission screening and resident review (PASARR) level II was completed on 05/11/21. Review of the quarterly (MDS) assessment section (I) dated 11/9/23 documented Resident # 7 was diagnosed with Anxiety and Schizophrenia which confirmed that the facility was aware of Resident #7's mental status. On 12/21/23 at 9:40 AM, the MDS Coordinator stated that she has been working at the facility for two and half years. The MDS Coordinator said that if the Social Worker told her that the resident had a level II PASARR, she would have documented it in the MDS record. After reviewing that Resident #7 had a PASARR level II since 5/11/2021, the MDS Coordinator said that she will update section A of the MDS. The MDS Coordinator also agreed on 12/21/23 at 10:05 AM that the MDS record was supposed to be updated during the last annual assessment. She said that she would update it immediately. 2. Record review revealed Resident #45 had diagnosis of Schizophrenia and Type 2 Diabetes Mellitus. The Resident's electronic clinical record revealed that a Level I preadmission screening and resident review (PASARR) was completed prior to Resident #45's admission to the facility, at the hospital. The record showed that Resident #45 was receiving psychotherapy once a week. Additional review of the electronic records showed that Resident #45's level II PASARR was completed on 10/11/2023. Review of the Care Plan documented that Resident #45 was taking psychotropic medications on a routine basis. The Level II PASARR documented that no specialized services was deemed necessary given the effectiveness of the current psychotropic management and the resident's mental stability. Review of the minimum data set (MDS) assessment, section A, was not updated to reflect a Level II PASARR for Resident #45 who was diagnosed of qualified psychiatric diseases. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 5 of 34 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 12/21/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm On 12/21/23 at 10:13 AM, the MDS Coordinator, after verifying the record, stated the Level II PASARR was not documented in the annual MDS assessment. The MDS Coordinator said that she would complete an updated assessment to reflect that the Level II PASARR had been completed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 6 of 34 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 12/21/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews, it was determined that the facility failed to have Level II Preadmission Screening and Resident Reviews (PASARR) completed for 2 of 19 sampled residents (Resident #15 & Resident #20). The findings included: Review of the PASARR level I, dated 8/4/2017 and updated on 12/1/2019, documented that Resident #20 was admitted to the facility with a non-provisional PASARR. The level I documented that Resident #20 had diagnoses or suspicion of Significant Mental Illness. Since the resident's admission, no Level II PASARR was completed. Resident #20's relevant diagnoses included: Cognitive communication deficit; Schizophrenia; Legal Blindness; and Convulsions. Review of the Psychiatric evaluation dated 06/15/23 revealed that Resident # 20 exhibited no delusions and no hallucinations. The psychiatric record recommended no changes in Resident #20's medications. The Psychiatrist noted that the benefits outweighed the risks for antipsychotic use. Resident #20 was still taking psychotropic medications. Review of the Physicians' orders for Resident #20 on 12/19/23 revealed the following psychotropic medications were prescribed: Divalproex 250 mg at bedtime, Buspirone 5 mg for Schizophrenia. However, further review of the resident's records revealed that a level II PASARR was not completed. On 12/21/23 at 10:22 AM, an interview conducted with the facility's Social Worker (SW) confirmed that a level II PASARR was required. The SW stated that she failed to submit the resident's records to KEPRO for review. 2) Record review for Resident # 15 revealed the resident was admitted to the facility from an Assisted Living Facility on 04/19/23 with the following diagnoses: Cerebral Infraction, Type 2 Diabetes Mellitus, Hyperlipidemia, Major Depressive Disorder, Hypertension, Schizophrenia, Anemia in Chronic Kidney Disease, GERD (Gastroesophageal Reflux Disease) and Other Schizoaffective Disorders. An initial Level I Pre-admission Screening and Resident Review (PASARR) assessment was conducted on 05/03/23. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident # 15 had a Brief Interview for Mental Status (BIMS) of 14, which indicated that he was cognitively functional. Review of Section A revealed that Resident # 15 did not have a PASARR level II. Review of the Physician's Orders dated 04/20/23 documented Resident #15 had orders for Zyprexa oral tablet 10 mg to give 1 tablet by mouth one time a day related to Schizophrenia; Zoloft Oral tablet 50 mg to give 1 tablet by mouth one time a day for Anti-depressant; Seroquel oral Tablet 200 mg to give 1 tablet by mouth at bedtime for Antipsychotic; and Depakote Oral Tablet Delayed Release 500 mg to give 1 tablet by mouth two times a day for Anticonvulsant. Review of the Care Plan dated 07/27/23 documented that Resident #15 had behaviors of refusing medications with a goal to have fewer episodes of refusing medication. Interventions were to educate the resident on successful coping and interaction strategies, administer medications as ordered; Explain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 7 of 34 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 12/21/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some all procedures to the resident before starting and allow the resident to adjust to changes. In addition, the Care Plan revealed that Resident #15 is on psychotropic medications with a goal to remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, or cognitive/behavioral impairment. Review of the Nurse Progress Notes revealed that Resident #15 refused Depakote 500 mg and Seroquel 200 mg on 09/26/23 and his Physician was notified. Additional Progress Notes, dated 09/04/23, 08/31/23, 08/30/23, 07/25/23, 07/21/23, 07/19/23, 06/06/23, and 05/18/23 revealed that Resident #15 refused medication on these dates. On 12/21/23 at 1:13 PM, an interview was conducted with the Director of Social Services. She stated that a resident eligibility for a Level II Pre-admission Screening and Resident Review (PASARR) assessment would be based on resident's behavior and diagnoses. The Director of Social Services was asked if she had completed a Level II PASARR assessment for Resident #15 due to his diagnosis of Schizophrenia and his recent behavior of refusing his antipsychotic medications. She stated that residents have the right to refuse medications and there have not been any behavioral issues with Resident #15. She stated that she could not find the Level II PASARR in Resident #15's electronic record but will look through the paperwork in her office. On 12/21/23 at 2:25 PM, the surveyor returned to her office, and at this time, the Director of Social Services stated that no Level II PASARR was done for Resident #15. She provided a copy of the fax requesting a Level II PASARR assessment for Resident #15 dated 12/21/23. Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 8 of 34 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 12/21/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services for necessary adaptive eating equipment for 1 of 7 sampled residents reviewed for Nutrition (Resident #28). Residents Affected - Few The findings included: During the observation of the Breakfast meal on 12/19/23 at 8:30 AM, it was noted that the meal tray was served to the room of Resident #28. A review of the tray ticket noted documentation of a Renal Diet with a 1500 ml Fluid Restriction and Weighted Fork. Observation of the meal tray noted only a weighted fork and spoon. Interview with the alert and oriented resident at the time of the observation noted to state that she would like to receive a weighted Knife with all meals and had requested weighted silverware on previous occasions. She further stated that numerous meals she is not receiving weighted silverware and also stated she needs weighted utensils due to poor grasping ability for both hands. During the observation of the Lunch meal on 12/19/23 at 12:30 PM, it was noted on only a weighted fork was included on the meal tray. The tray did not include a regular or weighted spoon and knife. Observation of the tray noted food items that the resident would benefit using a weighted spoon and knife. The resident again stated that she requires a weighted fork, knife, and spoon but does not receive weighted silverware on a daily basis. During an interview conducted with the Food Service Director on 12/20/23 at 10 AM, it was noted that he was not aware and had not been informed that Resident #28 required adaptive weighted fork, knife, and spoon. He further stated and submitted the resident's meal tickets that documented only a weighted Fork to be served with all 3 meals. During an interview conducted with the Director of Skilled Therapy on 12/20/23 at 2 PM, she stated that the resident has never been assessed or screened for the need of adaptive weighted utensils. She further stated that she was not made aware by nursing staff for the need of adaptive weighted utensils and had no idea how the resident's meal tickets documented only a weighted fork with all meals. The Director stated that the resident would be screened for the weighted utensils immediately. Record review of Resident #28 noted the following: * Date of re-admission 8/17/23. * Diagnoses: Chronic Kidney Disease. * Current Physician Orders noted: 4/26/22: Renal Diet 7/25/23: 1500 ml Fluid Restriction = 800 dietary/700 nursing (300/200/100 Further record review revealed no current or previous physician orders for adaptive weighted eating utensils located in the clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 9 of 34 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 12/21/2023 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 0676 Weight History: Level of Harm - Minimal harm or potential for actual harm 11/12/23 = 150 # (pounds) 10/9/23 = 153 # Residents Affected - Few 8/21/23 = 163 # Weight loss of 13 pounds since 8/17/23 re-admission Height = 61 (inches) BMI (Body Mass Index) = 28.4 MDS (Minimum Data Set) Quarterly assessment dated 10/18 /23, noted the following: Section C: BIMS (Brief Interview for Mental Status) score=15 (no cognitive impairment Section G: Eat = Independent Section K: No weight loss Section l: No dental issues Review of current care plans dated 11/12/23 noted no documentation of the requirement of adaptive weighted utensils. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 10 of 34 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 12/21/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a resident receives wound care consistent with professional standards of practice for 1 of 2 sampled residents reviewed for wound care (Resident #200) . Residents Affected - Few The findings included: Review of the facility's policy provided by the facility's Regional Nurse, titled Clinical Guideline Skin and Wound effective 04/01/17 with no revision date documented .on admission/readmission the resident's skin will be evaluated for baseline skin condition and documented in the medical record . Review of Resident #200's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Local Infection of the Skin and Subcutaneous Tissue, Osteomyelitis of Ankle and Foot, Non-Pressure Chronic Ulcer of Foot, Diabetes Mellitus, and Morbid Obesity. Review of Resident #200's Admission/readmission Data Collection (nursing form) and the skilled nurse note dated 12/09/23 lacked written description of Resident#200's foot wound. Review of Resident #200's skilled nurse note dated 12/09/23 documented .resident was discharged from a local hospital . ulcers covered with dry dressing in both feet, no presence of wound vac machine identified . Review of Resident #200's baseline care plan dated 12/10/23 documented that the resident had an ankle, sacral and foot wounds. Review of Resident #200's clinical record and nursing notes from 12/10/23 to 12/21/23 was conducted with the Acting Director of Nursing (A-DON). The review revealed the lack of written documentation regarding the residents' right and left foot wound descriptions and their measurement. The review revealed no evidence of written documentation related to refusal of wound care treatment or contacting the Wound Care Specialist for an evaluation of the resident's wounds. Review of Resident #200's physician order dated 12/11/23 documented wash bilateral heels wounds with normal saline apply wet to dry dressing and cover with dry dressing every other day one time a day every Tuesday, Thursday and Saturday. The wound care was documented as first time administered on 12/12/23 (Tuesday), three days after admission. Resident #200's clinical record lacked written evidence of an evaluation from the facility's contracted wound care specialist. Review of Resident #200's attending physician note dated 12/10/23 documented .under summary of plans: diabetic ulcer, wound vac has not yet arrived, sterile dressing changes while waiting for arrival . Review of Resident #200's paper record contained a copy of the hospital Diagnosis, Assessment and Plan, with a problem list documented as Osteomyelitis of Foot and Pressure Ulcer of Left heel Stage 4 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 11 of 34 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 12/21/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/18/23 at 10:01 AM, an interview was conducted with Resident #200 who stated that he came to the facility from a hospital and was supposed to have a wound vac to his left foot and to continue getting antibiotic as it was at the hospital. The resident added that he was worried because he had a bone infection on his left heel and was supposed to have a wound vac connected to it. The resident stated he was told that the facility did not have anyone that knew how to do the wound vac. Observation revealed Resident #200's left foot wound dressing was dated 12/14/23. The resident stated it was supposed to be changed and it has not been since 12/14/23. The resident stated he had been asking the nurses to change it. On 12/19/23 at 1:09 PM, an interview was conducted with Staff G, Registered Nurse (RN) who stated that Resident #200 was to have a wound vac on admission, and she was told that they were waiting for the wound care doctor to see the resident first. A side-by-side review of the resident's feet dressing was conducted with Staff G. Staff G confirmed that the resident left foot dressing was dated 12/14/23. Staff G stated that Resident #200 had not been seen by a wound care specialist. On 12/19/23 at 3:47 PM, wound care observation for Resident #200 performed by Staff G, RN started. Staff B performed hand hygiene, donned gloves and proceeded to cut up the resident's left foot dry dressing dated 12/14/23. Staff G then removed gloves, performed hand hygiene and cleaned the left foot wound with normal saline solution then applied a dry gauze to the wound and wrapped it with a kling (roll) dry dressing. Observation revealed that Staff G did not apply a wet to dry dressing to the resident's left heel wound as per physician order. On 12/21/23 at 8:17 AM, an interview was conducted with the acting Director of Nursing (DON) who stated that Resident #200 was admitted on [DATE] from a local hospital. The acting DON read Resident #200's attending physician's History and Physical dated 12/10/23 and stated that the physician documented Osteomyelitis of foot and ankle and that the wound vac had not arrived. On 12/21/23 at 9:14 AM, a joint interview was conducted with the Regional Nurse and the acting DON. The Regional Nurse stated that she was involved with Resident #200's wound vac issue. The Regional Nurse stated the resident was supposed to get wet to dry dressing until wound vac was delivered and the nurses were trained. The Regional Nurse stated that the nurses training was previously scheduled for 12/21/23 (12 days later after the resident's admission) and it was canceled. The Regional Nurse was apprised of the lack of nursing written documentation regarding discussion with the attending physician related to the delay of the wound care treatment. The acting DON and the regional nurse were asked the best practice for wet to dry dressing and both stated that wet-dry dressing ideally should be done daily. They both were apprised that Resident #200's wound care to the left heel dressing was not done on 12/16/23 and 12/18/23 as ordered. An inquiry was made regarding Resident #200 wound care consult and the regional nurse stated the facility had a wound care specialist (WCS) came to the facility on [DATE], but she did not know if the resident was seen by the WCS last week. On 12/21/23 at 11:55 AM, during an interview, Staff G, RN was asked how she would do a wound wet to dry dressing and was not able to reply. Staff G was apprised that Resident #200's bilateral heel wound's physician order was wet to dry dressing and that she applied a dry dressing rather than a wet dressing during the wound care observation on 12/19/23. On 12/21/23 at 12:44 PM, an interview was conducted with the Administrator who stated that he did not know if Resident #200 was seen by the WCS on 12/13/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 12 of 34 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 12/21/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/21/23 at 1:09 PM, an interview was conducted with the new contracted wound care specialist from Quality Surgical Management (QSM). The WCS stated that a wet-to dry dressing for Resident #200's left heel wound was not a good idea because it will provide more moisture and the skin around was macerated. On 12/21/23 at 1:52 PM, a telephone interview with Resident #200's Attending Physician (AP) was conducted. The AP stated that he reviewed the resident's hospital record as much as he could. The AP stated he asked some many times and did not realize the resident still did not have the wound consult and added he assumed it was done. The AP stated he was going to have the resident evaluated by an Infectious Disease physician with the understanding that there was a delay treatment. Event ID: Facility ID: 105258 If continuation sheet Page 13 of 34 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 12/21/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to obtain physician orders to provide care to a Central/Midline venous access catheter for 1 of 1 sampled resident reviewed for Catheter Care (Resident #200). Residents Affected - Few The findings included: Review of the facility's policy titled Catheter Insertion and Care- Midline Dressing Changes revised on 01/17/19 documented .change midline catheter dressing .every 5-7 days or if it is wet, dirty, no intact or compromised in any way .the following information should be recorded in the residents' medical record: date and time dressing was changed, condition of sutures, any education given to the resident, resident's statement regarding IV therapy . Review of the facility's policy titled Catheter Insertion and Care-Flushing Central Venous and Midline Catheters revised on 01/17/19 documented .midline and central line access devices will be flushed to maintain patency .flush catheter at regular intervals . the following information should be recorded in the resident'' medical record: date and time the medication was administered, type of solution . Review of Resident #200's Admission/readmission Data Collection (nursing form) dated 12/09/23 documented, .right upper chest vascular access: central line The review revealed lack of written description of Resident #200's central vascular access site. Review of Resident #200's skilled nurse note dated 12/09/23 documented resident was discharged from a local hospital admitted to the facility with history of Diabetes, Hypertension and Chronic Foot Ulcers .vascular access: central line in rights side of chest .treating with vancomycin IV as per nurse report from the hospital. Nursing station of (local hospital name) was contacted by phone regarding the lack of document summary discharge and progress notes regarding medical condition of patient. Director of Nursing and provider notified. Review of Resident #200's December 2023 Treatment Administration Record (TAR) revealed lack of written evidence of the resident's central line care and flushes, as per the facility's policy. On 12/18/23 at 10:01 AM, an interview was conducted with Resident #200 who stated that he came to the facility from a hospital and was supposed to continue getting antibiotics as he was at the hospital. Observation revealed the resident had an intravenous (IV) catheter on his right chest with a dressing dated 12/07/23. The dressing edges were coming apart and blood like material was noted under the dressing. The resident stated the reason the hospital left the IV line in his chest was for him to get IV antibiotic at the facility, which he had not received yet. The resident added that he was worried because he had a bone infection on his left heel. An inquiry was made about his IV line dressing and stated that he had asked twice to have it changed, the latest today around 5:00 AM. The resident added it is supposed to be changed every 7 days, as he was told at the hospital. On 12/19/23 at 9:10 AM, an interview was conducted with Resident #200 who stated the nurse changed his IV line dressing and started the IV antibiotic on 12/18/23. He added he had blood work done this morning and did not get the 6:00 AM IV antibiotic. Consequently, an interview was conducted with Staff G, RN who stated that Resident #200's Vancomycin IV antibiotic was on hold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 14 of 34 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 12/21/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm On 12/19/23 at 1:39 PM, during an interview, Staff G, RN stated that she reviewed Resident #200's hospital discharge orders which were confusing and added that she had to call the hospital on Sunday to be clear with the resident's antibiotic order. Staff G stated that based on the hospital discharge Resident #200 was supposed to have Vancomycin antibiotic until the 01/03/24. Staff G stated that on 12/17/23 she called the resident's attending physician who gave her an order for Vanco (antibiotic)1.5 gram. Residents Affected - Few On 12/19/23 at 1:42 PM, observation of Resident #200's IV Vancomycin administration performed by Staff G, RN started. Staff G retrieved two 10 cc saline syringes, one alcohol pad, IV pump line and a bag labeled Vancomycin 1.5 gram in 300 cubic centimeter (cc) Intravenous at 150 millimeters (ml) over 120 minutes every 8 hours. The bag was dated 12/17/23. At 1:44 PM, Staff G entered the resident's room, placed the supplies on top of the table. Observation revealed two urinals on top of the table next to the IV supplies. Staff G donned gloves connected the IV line to the Vancomycin bag and primed the line. Staff G then wiped the IV port with an alcohol pad and flushed the IV line with 8 cc of saline. Observation revealed the resident's room door was wide open and curtain was pulled open. Staff G was unable to connect the IV line into the IV pump and had to use a dial flow instead of the pump. The infusion was started at 2:38 PM. On 12/19/23 at 5:33 PM, observation revealed Resident #200 Vancomycin IV had approximately 25 cc left in the bag. The infusion was supposed to be done around 4:38 PM (2 hours). On 12/20/23 at 9:24 AM, an interview was conducted with the Consultant Pharmacist (CP) who was apprised regarding Resident #200's IV pump not working and that there was 12 hours between Vancomycin doses rather than 8 hours as ordered. On 12/21/23 at 8:23 AM, an interview was conducted with the A-DON who stated that a central/midline catheter dressing was changed every 7 days or as needed. On 12/21/23 at 8:52 AM, an interview was conducted with Staff H, Licensed Practical Nurse (LPN) who stated that resident's central/midline dressing are to be done every week. Staff H stated she did not change Resident #200's IV line dressing on 12/18/23. On 12/21/23 at 1:14 PM, an interview was conducted with Staff J, Licensed Practical Nurse (LPN) who stated that when she receives a new admission, the first thing she does is to a head to toe assessment of teh resident, including skin check, reviews the hospital packet including the discharge summary and the 3008 (a medical form), and then calls the doctor to review the resident's medications. Staff J stated if the resident had an IV line, she would check for swelling and flush the line to make sure is patent. Staff J stated that if there was not a physician order for the IV line, she would ask the doctor for one. Staff J stated that if a resident comes with a wound dressing she will undress the wound to assess the wound and then obtain doctor's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 15 of 34 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 12/21/2023 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 Based on observation, interview, and record review, it was determined the medication error rate was 12 percent. Three medication errors were identified while observing a total of 25 opportunities, affecting Resident #200, #37 and #12. Residents Affected - Few The findings included: 1) Review of Resident #200's physician order dated 12/17/23 documented Vancomycin Intravenous solution use 1.5 gram intravenously three time a day for Osteomyelitis until 01/03/24, in sodium chloride 0.9%, 500-millimeter (ml) bag, rate: 250 ml/hour every 8 hours. Review of the facility's pharmacy Vancomycin delivery receipt documented that the antibiotic was delivered on 12/18/23 at 1:49 AM. Review of Resident #200's December 2023 Medication Administration Record (MAR) documented Vancomycin Intravenous use 1.5-gram three time a day for Osteomyelitis until 01/03/24, in sodium chloride 0.9%, 500-millimeter (ml) bag, rate: 250 ml/hour every 8 hours. The Vancomycin administration times were scheduled as 9:00 AM, 1:00 PM and 5:00 PM. The review revealed that the Vancomycin antibiotic solution first dose was administered on 12/18/23 at 5:00 PM. The antibiotic doses scheduled for 9:00 AM and 1:00 PM were not administered. Review of Resident #200's e-MAR (nurse note) note dated 12/18/23 9:44 AM documented Vancomycin Intravenous use 1.5 gram intravenously three times a day for Osteomyelitis until 01/03/23 in sodium chloride rate 250 millimeter per hour duration 2 hours every 8 hours. Order clarification. Review of Resident #200's e-MAR note dated 12/18/23 1:45 PM documented Vancomycin Intravenous use 1.5 gram intravenously three times a day for Osteomyelitis until 01/03/23 in sodium chloride rate 250 millimeter per hour duration 2 hours every 8 hours. Order clarification, MD aware. He is coming in today to see the resident. Further review of Resident #200's physician order documented an order date 12/19/23 for Vancomycin Intravenous solution use 1.5 gram intravenously every 8 hours for Osteomyelitis until 12/19/23, in sodium chloride 0.9%, 500-millimeter (ml) bag, rate: 250 ml/hour every 8 hours. Furthermore review, revealed Resident #200's December 2023 Medication Administration Record (MAR) documented Vancomycin Intravenous solution use 1.5 gram intravenously every 8 hours for Osteomyelitis until 12/19/23, in sodium chloride 0.9%, 500-millimeter (ml) bag, rate: 250 ml/hour every 8 hours. The Vancomycin antibiotic schedule times were changed to 6:00 AM, 2:00 PM and 10:00 PM. The review revealed that the resident had a lapse of 12 hours between the Vancomycin antibiotic doses administered. The physician order read to be administered every 8 hours. 2) Review of Resident #37's clinical record revealed a physician order dated 05/12/23 that documented Gabapentin 300 milligrams give 1 capsule by mouth two times a day related to Type 2 Diabetes Mellitus with foot ulcer. Review of Resident #37's December 2023 Medication Administration Record (MAR) documented Gabapentin 300 milligrams (mg) give 1 capsule by mouth two times a day related to Type 2 Diabetes Mellitus with foot ulcer. The medication was scheduled to be administered at 9:00 AM and 5:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 16 of 34 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 12/21/2023 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 Review of Resident #37's nursing progress notes revealed lack of written evidence of notifying the resident's physician related to missing Gabapentin 300 mg on 12/19/23 5:00 PM dose. On 12/19/23 at 4:30 PM, medication administration observation for Resident #37 performed by Staff L, RN started. Observation revealed Staff L poured one tablet of Hydralazine 50 mg and stated that the resident was scheduled for Gabapentin 300 mg but did not have it available in the medication cart. At 4:32 PM, Staff L returned to the medication cart and stated that there was no Gabapentin in the medication room for Resident #37's scheduled dose. Staff L stated that the medication was reordered on 12/18/23. At 4:41 PM, further observation revealed Staff L documented that Gabapentin was on order. During an interview, Staff L was asked what she would do if no scheduled medications were in house and replied, she checks the medication room kit's and will reorder it. Staff L did not mention calling the physician due to missing a scheduled medication. On 12/21/23 at 11:13 AM, an interview was conducted with the Acting Director of Nursing who was apprised of Resident #37's Gabapentin 300 mg not given, not available during medication administration observation on 12/19/23 on the 3-11:00 PM shift. She stated that the facility had an emergency kit (e-kit) and will check if Gabapentin was in the kit. The Acting Director of Nursing stated that the nurse had to notify the physician if a prescribed medication was not given as scheduled. Consequently, a side-by-side review of Resident #37's nursing progress notes was conducted with the Acting Director of Nursing. The review revealed no entry was made related to notifying the physician of missing Gabapentin dose on 12/19/23 5:00 PM dose. A side-by-side review of the facility's e-kit with the Acting Director of Nursing was conducted. The review revealed no Gabapentin was in the e-kit. On 12/21/23 at 12:32 PM, an interview was conducted with Staff G, RN who stated that she was told to reorder the resident's medication refills when there was 6 days left of it. 3) Review of Resident #12's clinical record revealed a physician order dated 09/16/23 that documented Humalog Pen subcutaneous solution Pen Injector (Insulin Lispro). Inject as per sliding scale: .301-350= 9 units .subcutaneously before meals and at bedtime . Review of Resident #12's December 2023's Medication Administration Record (MAR) documented Insulin Lispro, and blood glucose checks scheduled for 6:00 AM, 11:00 AM, 4:00 PM and 9:00 PM. On 12/19/23 at 3:50 PM, observation revealed Resident #12 asking Staff G, RN to do his blood glucose check before his meal. At 5:29 PM, Observation revealed Resident #12 asking Staff M to do his blood glucose check because he did not want to eat cold food. On 12/19/23 at 5:32 PM, medication administration observation for Resident #12 performed by Staff M, RN started. Observation revealed Staff M performing the resident's blood glucose while he was eating. Staff M stated that the resident's blood glucose reading was 208 and that he needed 3 units of insulin coverage. On 12/19/23 at 5:45 PM, observation revealed Staff M drew 3 units of Lispro insulin, entered the resident's room, donned gloves, and administered the insulin while Resident #12 was eating his meal. On 12/19/23 at 5:50 PM, an interview was conducted with Staff M who was apprised that Resident #12 had been asking for his blood glucose check since 3:50 PM and that the insulin coverage was scheduled for 4:00 PM before meals. Staff M replied that Resident #12's blood glucose check was scheduled for 4:00 PM before meal but that she received report from the day shift nurse late. Staff M was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 17 of 34 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 12/21/2023 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 apprised that Resident #12's insulin coverage was not administered timely. Level of Harm - Minimal harm or potential for actual harm On 12/21/23 at 11:45 AM, during an interview, the Acting Director of Nursing was informed of the findings. Residents Affected - Few The Acting Director of Nursing, and the Regional Nurse were asked multiple times to provide a copy of the facility's medication management policy. At the end of the survey the policy was not submitted as requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 18 of 34 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 12/21/2023 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 review of policy and procedure, the facility failed to: 1) ensure that residents medications and biologicals were properly stored as evidenced by medications and biologicals being left on the resident's night stand for 2 of 2 sampled residents (Resident #5 and #12); and 2) to ensure that it secured the Medication cart #1 (second floor unit) and Treatment Cart (second floor unit). The findings included: Review of a document provided by the Acting Director of Nursing titled Medication Storage Information-Best Practice Guidelines undated documented that medication carts and storage rooms must be locked at all times . The document did not address medication at the resident's bedside and did not address treatment carts. The sister facility's Director of Nursing and the Regional Nurse were asked multiple times for the facility policy related to medication Storage and was not provided. 1) Review of Resident #5's clinical record revealed an admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Dementia, Major Depressive Disorder, Diabetes Mellitus Type 2 and Panic Disorders. Review of Resident #5's Minimum Data Set annual assessment dated [DATE] documented the resident's Brief Interview for Mental status score of 0, indicating severe cognitive impairment. Review of Resident #5's physician orders lacked evidence of a written order for self-administration of medications and an order for Pediatric Electrolyte Solution. Review of Resident #5's clinical record lacked evidence of a written care plan related to the resident being able to self-administer medications. On 12/18/23 at 10:23 AM, during the initial tour of Resident #5's room, observation revealed a bottle of Pediatric Electrolyte Solution (an over the counter product used to replace fluids and minerals such as sodium and potassium) unsecured on top of Resident #5's night stand. The Pediatric electrolyte solution bottle was labeled with Resident #5's name and labeled with an open date as of 10/14 (Photographic evidence). The resident was not interviewable. On 12/19/23 at 9:45 AM, observation revealed Resident #5's Pediatric electrolyte solution bottle labeled with Resident #5's name and labeled with an open date as of 10/14 continued to be on top of the resident's night stand and unsecured. On 12/19/23 at 1:09 PM, a side by side review of Resident #5's Pediatric Electrolyte Solution bottle labeled as opened on 10/14 unsecured located in the resident's night stand was conducted with Staff G, Registered Nurse (RN). Staff G confirmed that the bottle was dated 10/14 and added that she did not have a physician order for it. Staff G stated that probably the resident's daughter brought it in. Continued side by side review of the bottle and manufacturers label was conducted with Staff G. The label documented after opening .refrigerate and use in 48 hours . Staff G was apprised that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 19 of 34 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 12/21/2023 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 #5's Pediatric Electrolyte Solution bottle dated 10/14 had been observed in the resident's room since 12/18/23. Staff G did not remove the bottle from the resident's room during the review. On 12/19/23 at 1:20 PM, an interview was conducted with the Acting Director of Nursing who was apprised of Resident #5's over the counter biologicals in the resident's room since initial tour on12/18/23. The Acting Director of Nursing was asked if the over the counter Pediatric Solution was supposed to be in the resident's room unsecured and replied she did not know what the facility did. The Acting Director of Nursing was asked to provide the facility's policy related to medication storage. On 12/21/23 at 11:38 AM, a side by side review of Resident #5's Pediatric Electrolyte Solution bottle dated 10/14 unsecured located in the resident's night stand, was conducted with the Acting Director for Nursing. The solution's instructions were reviewed with the Acting Director for Nursing. Observation revealed the Acting Director for Nursing removed the bottle from the resident's room. 2) Review of Resident #12's clinical record revealed an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Diabetes Mellitus Type 2, Major Depressive Disorder, Schizoaffective Disorder Bipolar Type and Pyogenic Arthritis. Review of Resident #12's Minimum Data Set quarterly assessment dated [DATE] documented the resident's Brief Inteview for Mental Status score of 15, indicating an intact cognition. Review of Resident #12's physician orders lacked evidence of a written order for self-administration of medications and an order for Centrum Vitamin tablet. Review of Resident #12's clinical record lacked evidence of a written care plan related to the resident able to do self-administration of medications. On 12/18/23 at 9:56 AM, during the initial tour of the resident's room, observation revealed a bottle of Centrum Adult 50 tablets, an over the counter vitamin supplement, unsecured on top of Resident # 12's night stand. Consequently, an interview was conducted with the resident who stated that he tries to take one of the Centrum Vitamins daily but he forgets. The resident was asked if the nurse brings him a multivitamin and stated they do not. The resident added that the staff will probably take the Centrum bottle away from him. On 12/19/23 at 9:40 AM, observation revealed a bottle of Centrum Adult 50 tablets, an over the counter vitamin supplement, continued to be on top of Resident # 12's night stand and unsecured. The resident was not in the room. On 12/19/23 at 1:20 PM, an interview was conducted with the Acting Director of Nursing who was apprised of Resident #12's Centrum, vitamin, unsecured on top of the resident's night stand. On 12/19/23 at 5:45 PM, observation revealed a bottle of Centrum Adult 50 tablets, continued to be unsecured on top of Resident # 12's night stand. Consequently, a side by side review of the resident's unsecured bottle of Centrum vitamin was conducted with Staff M, RN. Staff M removed the Centrum bottle from the resident's room and stated the resident was not supposed to have the vitamin bottle in the room. 3) On 12/19/23 at 3:47 PM, wound care observation for Resident #200 performed by Staff G, RN started. The resident had a roommate by the door who was awake and confused. Observation revealed Staff G (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 20 of 34 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 12/21/2023 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 parked the unlocked treatment cart by the resident's door way. At 3:53 PM, Staff G entered the resident's room, went to the bathroom to perform hand hygiene, Staff G left the treatment cart unlocked and unattended. At 4:00 PM, observation revealed Staff G closed the room's door and left the treatment cart by the door unlocked and unattended. At 4:13 PM, observation revealed Staff G, RN walked to the soiled utility room approximately 20 to 30 feet away from the unlocked and unattended treatment cart. At 4:15 PM, Staff G returned to the treatment cart and did not lock the cart. Further observation revealed the Acting Director of Nursing walked by and did not attempt to lock the unattended treatment cart. On 12/19/23 at 4:18 PM, during an interview, Staff G stated that she left the treatment cart unlocked because she did not have a key. 4) On 12/19/23 at 5:03 PM, observation revealed Staff M, RN asked the Staffing Coordinator for a disinfecting wipes container and entered in a resident's room to perform hand washing. The medication cart was parked in the hallway. On 12/19/23 at 5:05 PM, observation revealed the Staffing Coordinator (SC) opening Staff M's, RN medication cart without a key. Consequently, an interview was conducted with the SC. The SC was asked how she was able to open the medication cart and stated that Staff M left it open for her to put a new wipes container. On 12/19/23 at 5:07 PM, during an interview with Staff M, the SC walked by and stated that she brought the wipes container and that she closed the medication cart back up. During the interview, Staff M stated she did not leave the medication cart unlocked. Staff M was apprised that the SC was observed placing the new wipes container in her medication cart. Staff M stated that sometimes the cart can be opened without the key. 5) On 12/19/23 at 5:32 PM, medication administration observation for Resident #12 performed by Staff M, RN started. At 5:46 PM, Staff M left the medication cart unlocked and unattended, walked approximately 15 to 20 feet away and entered Resident #12's room and administered the resident's insulin. At 5:49 PM, Staff M came out of Resident #12's room. Consequently, a joint interview was conducted with Staff M, and two nurse surveyors. Staff M was apprised that she left the medication cart unlocked, unattended and was locked by the Acting Director of Nursing. Staff M stated she locked the cart. Photographic evidence was shown to Staff M. On 12/21/23 at 1:19 PM, an interview was conducted with Staff J, Licensed Practical Nurse (LPN) who stated that medications and treatment carts are to be locked at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 21 of 34 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 12/21/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review it was determined that the facility failed to employ sufficient dietary staff safely and effectively carry out the functions of the food and nutrition service that include; preparation of food to ensure nutritional value, appearance, and palatability, serve meals in a timely manner, ensure sanitation regulations are followed, and ensure physician ordered therapeutic and mechanically altered diets are followed. The findings include: During the initial food service sanitation tour conducted on 12/18/23 at 8:50 AM, it was noted that there were only 2 staff members working in the kitchen preparing and serving the breakfast meal. Further observation noted that the 2 members of staff included a newly hired cook and the Food Service Director (FSD). A review of the posted staffing schedule for 12/18/23 noted that 3 staff members (2 cooks and 2 diet aides) were scheduled. Interview with the FSD at the time of the observation noted that 2 diet aides failed to report to work without notification. Further observation noted that at 10 AM the Contracted Food Service Companies - District Manager reported to the kitchen and was required to be the dishwasher for the breakfast dishes. Interview with the District Manager noted that the FSD is often required to perform the dietary aide function. It was noted that the breakfast meal was served late to the residents after 10 AM. Review of the dinner meal schedule also noted that only 2 facility dietary staff members were scheduled to prepare, serve, and clean resident dishware. A review of the dietary staffing for 12/20/23 noted only 3 members staff were scheduled for the preparation and serving of the lunch meal along with the FSD performing the position as a dietary aide. Observation of the lunch meal in the main kitchen on 12/20/23 at 11:30 noted that the District Manager, a facility Account Manager, and a cook who was scheduled to be off on 12/20/23, were all present to prepare and serve the lunch meal. It was noted that the resident's meal tray assembly line was to begin at 11:30 AM. Further observation noted that the lunch meal service did not begin until 12:20 PM and did not finish until after 1:30 PM. Refer to:

F 804

F 805

F 808

F 812 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 22 of 34 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 12/21/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide 66 of 69 residents with foods that were prepared by methods that conserve nutritive value, flavor, appearance, and is palatable, attractive, and appetizing. Residents Affected - Few The findings included: Review of the facility's Policies & Procedures noted the following: Food Quality and Palatability: Policy Statement (Revised 2/2023): < Food will be prepared by methods that conserve nutritive value, nutritive flavor, and appearance. < Food will be palatable, attractive, and served at a safe and appetizing temperature. < Food and liquids are prepared and served in manner, and texture to meet resident's needs. Procedures Include: < Cooks are responsible for food preparation. Menus are prepared according to the menu, production guidelines, and standardized recipes. < Cooks prepare food in accordance with recipes and use proper cooking techniques to ensure color and flavor retention. 1) During the initial kitchen sanitation tour conducted on 12/18/23 at 8:50 AM, it was noted that there was a kitchen cart located near the walk-in refrigerator that contained numerous pans of prepared left-over foods. Further observation noted that there was a foul (Rotting) smell coming from the foods. The foods located on the cart included: mashed potatoes, rice, cauliflower lima beans, pureed vegetable, pureed meat, ground ham, pureed carrots, and gravy. A temperature test of the foods was taken with the facility's digital food thermometer. The temperatures indicated that the perishable foods had become room temperature (58 F 68 F) from being left out of the walk-refrigerator for an extended period of time and should be discarded. An interview, conducted with the breakfast cook at the time of the observation noted to state he was a new hire and was unaware that the foods should not be utilized for potential food borne illness. It was also revealed during the interview that the food was intended to be pureed for the lunch meal on 12/18/23 and was unaware that the approved menu should be followed for the preparation of fresh pureed foods. 2) During the review of the approved menu for the lunch meal of 12/18/23, the following were noted: < Baked Tilapia Florentine (regular, mechanical soft, carbohydrate controlled, pureed diets) < Tomatoes [NAME] (regular, pureed, mechanical soft, carbohydrate-controlled diets) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 23 of 34 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 12/21/2023 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 0804 < [NAME] Sauce (regular, pureed, mechanical soft diets) Level of Harm - Minimal harm or potential for actual harm < [NAME] Pilaf (regular, pureed, mechanical soft, renal, carbohydrate-controlled diets) < Dinner Roll (regular, pureed, mechanical soft, carbohydrate controlled, renal diets) Residents Affected - Few < Chocolate Cake with Peanut Butter Topping *regular, pureed, mechanical soft, carbohydrate controlled, renal diets) 3) During the observation of the lunch meal in the main kitchen on 12/18/23 at 11 AM, accompanied by the District Food Manager (DFM), the following were noted: (a) Observation of the Tilapia located on the steam table noted that Tilapia Florentine was not prepared properly. A request and review of the standardized recipe and interview with the DFM noted that Tilapia Florentine failed to have all the recipe ingredients that included Spinach), Parmesan Cheese (2/3 cup), and Peppers (3.5 cups). Interview with the lunch cook (Staff D) revealed that the only ingredients added to the fish were garlic, and paprika. (b) Observation of the prepared cooked tomatoes located on the steam table noted that they were not properly prepared. A request and review of the standardized recipe for Tomatoes [NAME] and interview with the DFM noted the following ingredients failed to be included in the preparation; fresh Yellow Onions (2 ounces) , Fresh Peppers (5/8 cup), Margarine (1/4 cup), pepper, and sugar (2 T). Interview with Staff at the time of the observation noted that canned Diced Tomatoes are opened, heated, and served. It was further stated there are no fresh vegetables available. (c) Observation of the [NAME] Sauce located on the steam tables noted that the sauce was not prepared properly. A request and review of the standardized recipe for [NAME] Sauce and interview with the DFM noted the following ingredients failed to be included in the preparation: cooking wine (2 cups), Parmesan Cheese (2/3 cup), Red Peppers 4 cups) , Interview with Staff D at the time of the observation noted that the only ingredients included in the preparation was margarine, flour, and milk. Staff further stated the recipe ingredients were not available. (d) Observation of the [NAME] Pilaf located on the steam table noted that it was not prepared properly. A request and review of the standardized recipe for [NAME] Pilaf and interview with the DFM noted that all ingredients were not included in the preparation that included sauteed onion 7/8 quart, and Chicken soup base 3 5/8 T. Interview with Staff D at the time of the observation noted that the recipe was not reviewed and unutilized. (e) Interview with Staff D, concerning the purred bread noted to state that the ingredients included only pureed bread mix and water. Staff D was unaware that the approved menu documented that the fresh baked dinner rolls were to be utilized for the preparation of the pureed bread. (f) Observation of the Chocolate Cake with Peanut Butter Frosting noted that cake to be torn across the tops and frosting did not appear to be prepared properly. A request and review of the standardized recipe for the preparation of Chocolate Cake with Peanut Butter Frosting and interview with the DFM noted that the following ingredients were not included in the frosting; water (7/8 Qt), Margarine (1-1/4 cups), Creamy Peanut Butter (2-1/2 cups), powdered sugar (4 cup), vanilla extract (1-1/4 T), During the observation of the meal Staff was noted to open a jar of Peanut Butter and spread the thick mixture over the chocolate cake, tearing of the top of the cake. Staff D stated that he was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 24 of 34 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 12/21/2023 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aware that there was a recipe for the frosting but further stated there is insufficient staff and time to prepare the frosting. 4) During the review of the approved menu for 12/20/23, it was noted that the documented entree included Roast Turkey for regular, mechanical altered, and therapeutic diets. During the observation of the lunch meal in the main kitchen on 12/20/23 at 12 PM, it was noted that a whole bone turkey was prepared, and additionally noted that a pressed processed turkey breast was also being utilized. Further observation noted that some of the bone-in turkey was cut away and being served while the processed turkey breast was being cut into large pieces utilizing a French knife and was being served at room temperature with a covering of gravy. Interview with the DFM revealed that the facility does not have a commercial meat slicer and he has been requesting a slicer for months. * A review of the facility's census for 12/20/23 noted that there were 69 residents. Further review noted that there was 1 resident who receives both a gastric tube feeding and a P.O. (by mouth) diet. The facility had 3 residents who receive gastric tube feeding with nothing by mouth (NPO). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 25 of 34 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 12/21/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, The facility failed to ensure pureed foods were prepared in a form to meet the needs of 4 of 4 sampled residents (Resident #6, #16, #20, and #31) with physician ordered pureed diets. The findings include: 1) During the observation of the lunch meal in the main kitchen on 12/18/23 at 11:45 AM, a half pan of Pureed Tilapia was observed and located on the steam table. Further observation of the pureed fish, it was noted to have small pieces of fish within the pureed mixture. At the request of the surveyor, the pureed fish was test tasted by the surveyor and the Contacted District Manager to ensure that the pureed mixture was the correct pureed smooth consistency. The surveyor and District Manager both agreed that the fish was not pureed to the proper smooth consistency and could potentially be an issue for residents with swallowing or Dysphagia issues. The District Manager requested from the cook (Staff C), that the pureed fish not be served until the proper consistency was obtained. A further interview with Staff C, revealed that he was a new hire and had not been properly trained for the preparation of pureed foods. Staff C also stated that he sticks his pinky finger into the pureed mixture to taste for pureed consistency. The surveyor requested that the fish be pureed to the required smooth pureed consistency. 2) During the observation of the breakfast meal in the main kitchen on 12/19/23 at 7:30 AM, it was noted that the Staff C identified a pan of pureed grits that was located on the steam table. Observation revealed the grits to have large particles. The surveyor requested a taste test of the mixture for proper pureed consistency. The taste test conducted by the surveyor and the District Food Director (DFD) concluded that the grits failed to be pureed and was of regular consistency. Interview conducted with Staff C at the time of the observation revealed that he thought that the regular grits consistency met the pureed requirements. The surveyor informed the DFD that the grits needed to be prepared to meet the proper smooth pureed consistency. A review of the facility's Diet Census for 12/19/23 noted that there were currently 4 facility residents with physician ordered Pureed Diets. The four residents included Resident #6, #16, #20, and #31. A review of the clinical records of the four sampled residents noted they all had a current diagnoses of Dysphagia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 26 of 34 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 12/21/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to ensure that physician ordered therapeutic diets (Fluid Restriction) were not followed for 1 of 7 sampled residents reviewed for nutrition (Resident #28). The findings included: During the review of the clinical record of Resident #28, the following were noted: Date Of re-admission: [DATE] Diagnoses: Chronic Kidney Disease of which noted the resident requires Dialysis (3 times per week (Monday/Wednesday/Friday). The resident leaves the facility on these days at 9:30 AM and returns at 4 PM. Review of current physician orders noted: 4/26/22: Renal Diet 7/25/23: 1500 ml Fluid Restriction (800 ml from dietary and 700 ml from nursing) Review of current Quarterly MDS (Minimum Data Set) assessment dated 10/18 /23 noted: Section C: BIMS (Brief Interview for Mental Status score=15 (No Cognitive Impairment) Section G: Eat = Independent Section K: No weight loss Section l: No dental issues During the review of the Breakfast/Lunch/Dinner meal tray ticket, it was noted that the resident was receiving only 560 ml of fluid of the physician ordered 800 ml from dietary (meals) The meal breakdown included the following: * Breakfast: 320 ml fluids (milk=240 ml and apple juice =120 ml) * Lunch: 120 ml of fluids (apple juice) * Dinner: 120 ml of apple juice Review of the December 2023 Medication Administration Record noted, Fluid Restrictions of 700 ml for the 3 nursing shifts, was not being followed. The MAR indicated only a total 600 ml from all 3 shifts (7 AM - 3 PM= 300, 3 PM to 11 PM =200 ml, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 27 of 34 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 12/21/2023 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 0808 and 11 PM to 7 AM = 100 ml). Level of Harm - Minimal harm or potential for actual harm During an interview conducted with alert and oriented Resident #28 on 12/19/23 at 9 AM and 12/20/23 at 8:30 AM, it was noted the resident stated that she is not given a lunch or snack bag to take to the dialysis center and would like to receive one due to being hungry from poor intake of the breakfast meal prior to dialysis. She further stated she is thirsty while at dialysis during the 3 times per week sessions and would like to have fluids sent with her. She further stated that the physician ordered fluid restrictions of 1500 ml per day is not being followed by the facility. Residents Affected - Few During an interview conducted with the Food Service Director and Administrator on 12/20/23 at 9 AM, it was discussed that the physician ordered 1500 ml fluid restriction (800 ml from dietary) per day is not being followed. Specifically, the resident is only receiving 560 ml on meal trays and should be receiving 800 ml as per physician order. It was also discussed that the resident is receiving the allotted 120 ml fluids while at the dialysis center three times per week. It was requested by the surveyor to the Administrator that the resident's fluids for meals and nursing shifts be recalculated to ensure that the physician order is followed, and the resident be reassessed for adaptive eating utensils. On 12/20/23, an interview was conducted with the facility's Consultant Registered Dietitian, which revealed she is very new to the facility and not familiar with Resident #28. The surveyor requested that the resident be reassessed for nutritional status, the physician's order for 1500 ml Fluid Restriction, and the need of adaptive eating equipment (weighted fork) also be re-evaluated. The surveyor requested a copy of the new documentation concerning the resident's nutritional status and fluid restriction. On 12/21/23 at 11 AM the facility's Consultant Registered Dietitian submitted to the surveyor new physician orders and a Nutrition Progress Note that included the following: * Physician Order dated 12/21/23: 1500 ml Fluid Restriction - Dietary - 960 ml (breakfast 240 ml apple juice, (lunch 120 ml apple juice & 240 ml water), and (dinner 120 ml apple juice & 240 ml of water). * Physician Order dated 12/20/23: Nepro (renal liquid supplement) : 240 ml - 7 AM - 3 PM = 120 ml, 3 PM 11 PM = 120 ml, and 11 PM to 7 AM = 60 ml. * Physician Order dated 12/20/223: Nursing 300 ml of water for medication. * Nutrition Progress Notes dated 12/20/23: Fluid Restriction updated to reflect resident's preferences. Resident does not want hot beverages in morning and does not want milk. Resident does not like milk. 1500 ml Fluid Restriction: Dietary = 960 ml (breakfast = 240, lunch = 360 ml. and dinner = 360 ml. Nursing: 300 ml of water for medications Nepro 240 ml (7 AM - 3 PM = 120, 3 PM -11 PM = 120, and 11 PM - 7 AM = 60 ml) The interview with Consultant Registered Dietitian also noted that Resident #28 has not received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 28 of 34 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 12/21/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Nepro for the past few weeks. It was further noted that the resident did not like Vanilla Nepro and had requested Strawberry or Chocolate. The facility has not purchased the resident's request nor was the resident assessed for an alternative renal supplement drink. A follow-up interview conducted with Resident #28 on 12/21/23 at 10 AM, noted that she received a snack for dialysis on 12/20/23, that included apple juice, P & J (peanut butter and jelly) sandwich, and [NAME] Crackers. She stated that she hopes the facility continues the snack bag and drink for dialysis sessions. She further stated she is receiving all weighted utensils (fork, knife, spoon) since the Surveyor investigated her issues. Event ID: Facility ID: 105258 If continuation sheet Page 29 of 34 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 12/21/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that potentially affected 66 of the facility's 69 residents. The findings included: 1) Review of the facility's Dietary Department Policy & Procedures noted the following: 1. Environment (No Implementation Date): * All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Procedures Included: < The Food Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, ceilings, lighting, and ventilation. < The Food Service Director will ensure that all employees are knowledgeable in their proper procedures for cleaning and sanitizing all food service equipment and surfaces. < The Food Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. 2: Food Preparation (Revised 2/2023) < Policy Statement: All foods are prepared in accordance with the FDA Food Code: Procedures Included: < All staff will be responsible for food preparation procedures that avoid contamination. < All utensils, food contact equipment, food contact surfaces will be cleaned and sanitized after each use. < Cooks will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 F or less than 135 F . 3) Labeling and Dating of Foods (no implementation date) Guidelines for Labeling and Dating: < All foods should be dated upon receipt before being stored. < Food labels must include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 30 of 34 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 12/21/2023 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 0812 * The food item name Level of Harm - Minimal harm or potential for actual harm * The date of preparation/removal from freezer. * The use by date (Day 7) Residents Affected - Few 2) During the initial Kitchen/Food Service tour conducted on 12/18/23 at 8:50 AM, the Food Service Director was unable to accompany the surveyor due to lack of dietary staff to produce and serve the breakfast meal. (a) Observation of the entrance door of the walk-in refrigerator noted that the door was in disrepair and the gasket was not appropriately attached. The top of the door was noted to be covered with a black film. (b) The food storage shelves (16) located within the walk-in refrigerator were noted to be heavily soiled and had numerous large areas of dried food matter. (c) Observation of the walk-in refrigerator noted the following issue with left-over foods: < Mixing bowl of tossed salad failed to have a labeled preparation date, use by date and was not covered and open to the air. < Large mixing bowl of [NAME] slaw failed to be labeled with a preparation date and use by date. < A wrapped assortment of luncheon meat (approx. 1 pound) failed to be labeled with a preparation date and use by date. < Third size steam table, a pan noted to be full of sliced ham, failed to be labeled with a preparation date, use by date, and was not covered and open to the air. < Large mixing bowl of Pineapple slices failed to be labeled with a preparation date, use by date, and was not covered and open to the air. < Unknown package of meat and rice failed to be labeled with a preparation date and use by date. < Three-pound container of Ricotta Cheese noted to have a manufacturers expiration date of 10/7/23. (d) The floor of the walk-in refrigerator was noted to be heavily soiled and stained. A large area of unknown liquid substance was observed under the refrigeration unit. (e) The entrance and door of the walk-in freezer was noted to be covered with a thick layer of ice. The door to the unit could not be opened due to the ice-build-up. (f) A food transportation cart was noted to be parked at the rear of the kitchen. Further observation noted that the cart was full of leftover foods. An interview with the cook at the time of the observation revealed that the foods were left over from 12/17/23 and would be reused for pureed diets for the lunch meal of 12/18/23. It was also noted that there was a foul smell of rotting food coming (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 31 of 34 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 12/21/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm from the cart. A temperature test of the foods was conducted by the surveyor utilizing the facility's food thermometer. The temperature test noted that the facility was not holding the foods at the required temperatures of 41 degrees F or below or 135 degrees F or above, as evidence e by the following: < Half pan of Mashed Potatoes = 56 F Residents Affected - Few < Half Pan if cooked [NAME] = 62 F < Half pan of cooked Cauliflower and Lima Beans = 59 F < Half pan of unknown pureed meat = 68 F < Half pan of prepared Gravy = 58 F < Half pan of ground Ham = 68 F < Half pan of pureed Carrots = 68 F * The surveyor informed the [NAME] that the temperatures of the perishable foods were outside the regulatory requirement of storing foods, and requested that the food not be utilized for the residents and to be discarded. (g) The [NAME] was noted to have heavy facial hair and was serving food without a beard protector. The surveyor requested the cook don a beard protector immediately. (h) The commercial bench mounted can opener was noted to be highly soiled with areas of black matter, areas of dried foods, and was rust laden. The surveyor removed the opener from the base to ensure staff would not utilize the unit. (i) Food storage shelving (4) located in the main kitchen were noted to be heavily soiled and had numerous areas of dried food matter. (j) Chemical testing of the 3-compartment sink noted insufficient level of Quaternary chemical present to meet the regulatory requirement. (k) Interior cavity of the commercial microwave was noted to be heavily soiled and had pieces of dried food matter. (l) Observation of the dish machine noted that the covers of the wash and final rinse thermometer covers were covered with a film and could not be read, to ensure that the unit was sanitizing, as per regulatory requirements. (m) The wall vent located in the dish machine area was noted to be covered in a black mold type substance. (n) During the observation of the Reach-in refrigerator #1, the temperature of 8-ounce milk portions were taken, utilizing the facility's food thermometer. The milk was noted not to be held at the regulatory requirement of 41 degrees F or below. The temperature of the milk was recorded at 46 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 32 of 34 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 12/21/2023 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 0812 degrees F. The refrigerator had 14 (fourteen)- 8-ounce containers of milk stored within the unit. Level of Harm - Minimal harm or potential for actual harm Following the initial tour, it was noted that the Food Service District Manager was in the main kitchen on 12/18/23 at 10 AM. The surveyor walked through the kitchen area and pointed out all of the identified sanitation issues from the original tour. Residents Affected - Few Photographic Evidence Obtained for 1 (a) - (n) 3) During a follow-up observation in the main kitchen on 12/18/23 at 11:45 AM, the following were noted: (o) Soiled key chain and keys left on a clean preparation table. (p) Four heavily soiled and stained cleaning cloths were left unattended on the clean preparation surfaces and clean cooking equipment. (q) Observation of lunch cook (Staff C) noted to not have knowledge of calibrating the food thermometer prior to food temperature testing, and sanitizing swabs used by Staff C, to sanitize the thermometer between each food testing, were noted to be dried out, ineffective, and required to be discarded. Photographic Evidence obtained for #3 (o) - (q) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 33 of 34 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 12/21/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents were offered eligible immunizations annually as evidenced by the lack of written consents for declination or acceptance of immunizations for 3 of 5 sampled residents reviewed for immunization review (Resident #5, #21 and #200). Residents Affected - Few The findings included: 1) Review of Resident #5's clinical record revealed an admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Dementia, Major Depressive Disorder, Diabetes Mellitus Type 2 and Panic Disorders. Review of Resident #5's Minimum Data Set annual assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment. On 12/21/23 at 1:38 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated that the admission nurse should be offering the Influenza and Pneumococcal vaccine to the residents on admission. A side by side review of Resident #5's immunization record was conducted with the DON. The review revealed that Resident #5 did not have either a consent or decline for the Influenza and there was no record on file related to Pneumococcal vaccine. 2) Review of Resident #21's clinical record revealed an admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Diabetes Mellitus, Hypertension, and Cerebral Vascular Accident (CVA). Review of Resident #21's Minimum Data Set annual assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment. On 12/21/23 at 1:38 PM, an interview was conducted with the sister's facility Director of Nursing (DON). The DON stated that the admission nurse should be offering the Influenza and Pneumococcal vaccine to the residents on admission. A side by side review of Resident #21's immunization record was conducted with the DON. The review revealed that Resident #21 did not have either a consent or decline for the Influenza for 2023 or Pneumococcal vaccines. 3) Review of Resident #200's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Local Infection of the Skin and Subcutaneous Tissue, Acute Hematogenous Osteomyelitis of Ankle and Foot, Non-Pressure Chronic Ulcer of Foot with unspecified severity, Diabetes Mellitus with Foot Ulcer, Hypertension, and Morbid Obesity. A side by side review of Resident #200's immunization record was conducted with the DON. The review revealed that Resident #200 did not have either a consent or decline for the Influenza vaccine. During the review, the DON stated the vaccine needed to be offered for Resident #200. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105258 If continuation sheet Page 34 of 34