Health inspection·July 27, 2023

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy and procedure review, the facility failed to provide resident refunds and provide a final accounting of resident funds within 30 days of resident death for 14 of 16 accounts reviewed for Residents #1, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #19. Residents Affected - Many Findings include: Review of the facility records documented that Resident #1 was discharged from the facility on [DATE]. Review of account documented that the resident's estate was owed $2776.16, which has not been paid. Review of the facility records documented that Resident #5 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $405.61, which has not been paid. Review of the facility records documented that Resident #7 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $479.71, which has not been paid. Review of the facility records documented that Resident #8 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $1169.89, which has not been paid. Review of the facility records documented that Resident #9 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $44.46, which has not been paid. Review of the facility records documented that Resident #10 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $1179.98, which has not been paid. Review of the facility records documented that Resident #11 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $28.00, which has not been paid. Review of the facility records documented that Resident #12 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $735.55, which has not been paid. Review of the facility records documented that Resident #13 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $828.26, which has not been paid. Review of the facility records documented that Resident #14 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $1071.26, which has not been paid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 2 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 0569 Level of Harm - Minimal harm or potential for actual harm Review of the facility records documented that Resident #15 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $249.70, which has not been paid. Review of the facility records documented that Resident #16 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $492.80, which has not been paid. Residents Affected - Many Review of the facility records documented that Resident #17 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $663.49, which has not been paid. Review of the facility records documented that Resident #19 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $870.00, which has not been paid. During an interview on [DATE] at 11:30 AM, the Business Office Manager (BOM) #1 stated, We did not process these refunds after the residents died. We have six accounts that were not processed refunds. We still have accounts to catch up. I have been aware of this concern for the last two weeks. These 14 accounts should have been paid out to the families. We have not been following policy and procedures for refunds when a resident passes away. During an interview on [DATE] at 11:35 AM, the BOM #2 stated, We have had a lot of turnover and the change of company hands since I started here. There are accounts that have not been paid out and we have been working on them for the last few weeks. I was not aware of this when I came back to this job, but I have been working on them. We have not followed the policies and procedures for refunds. During an interview on [DATE] at 11:55 AM, the Director of Nursing (DON) stated, We were aware that these accounts were not paid out. I don't recall speaking with this family [Resident #1's family], but if I did, I would have told them, I would have the business office contact them. During an interview on [DATE] at 3:15 PM, the Administrator stated, I am aware that there were business office accounts that were not paid. Review of the facility policy and procedure titled Refunds-Accounts Receivables with last revision date of 2/2022, reads, Procedure: After refund balances are verified, the Business Office shall begin the refund workflow process. Private pay: Once a refund has been confirmed with supporting documentation and account notes, a check or electronic retraction will be issued. If a refund check is needed, the Business Office shall submit a request on the A/R Refund Workflow for processing; located on the Company Intranet Portal> My Apps> AR Refund Workflow . Third Party . Upon confirmation of refund process, the Business Office shall document and complete the process accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 3 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on resident record review, interview, and facility policy and procedure review, the facility failed to ensure the resident representative was notified of a significant change in condition of pressure ulcers for 1 of 3 residents reviewed for changes in condition, Resident #4. Findings include: Review of the admission record for Resident #4 documented diagnoses including multiple sclerosis, mild intermittent asthma, heart failure unspecified, unspecified atrial fibrillation, unspecified convulsions, idiopathic normal pressure hydrocephalus, rheumatoid arthritis, age-related osteoporosis, essential primary hypertension, COVID-19, personal history of malignant neoplasm of ovary, hyperlipidemia, primary open angle glaucoma, and acute embolism and thrombosis of deep veins of upper extremity bilateral. Review of the form titled Pressure Ulcer Wound Rounds dated 5/31/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 2 centimeters, Depth: [blank], Stage II . Notes/Recommendations from Doctor: Resident admitted from hospital with wound. Cleansed with NS [Normal Saline] and covered with a silicone bordered dsg [dressing]. Review of the form titled Pressure Ulcer Wound Rounds dated 6/9/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 1 centimeter, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 6/12/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Right buttock, Type: Pressure, Length: 1.5 centimeters, Width: 0.5 centimeters, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 6/14/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 1 centimeter, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 7/12/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3.5 centimeters, Width: 4.5 centimeters, Depth: 0.2 centimeters, Stage III. Review of Resident #4's medical records revealed no skin evaluations or documentation of the wound length, width, or depth from 6/14/2023 until 7/12/2023. Review of the progress notes for Resident #4 revealed no notification of Resident #4's representatives related to the worsening of the pressure wounds. During an interview on 7/27/2023 at 2:25 PM, the Director of Nursing (DON) stated, I don't know why the nurses are not documenting changes in condition with the worsening of the wounds. They have not documented that her family was notified, and they should have. It is our policy to notify families of changes in residents' conditions. We should have followed our policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 4 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 0580 Level of Harm - Minimal harm or potential for actual harm During an interview on 7/27/2023 at 3:18 PM, the Assistant Director of Nursing (ADON) stated, I don't do the daily dressing changes to the wounds. I document wound size and progression weekly. I can't tell you why there is no change of condition notification in her chart. I don't know why her family was not notified about the wounds worsening. We should have notified her family. It is the policy to notify families with any changes in condition. Residents Affected - Few Review of the facility policy and procedures titled Notification of Change in Condition with a revision date of 12/16/2023, and last approval date of 1/2020 reads, Policy: The center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and Resident Representative when there is a(n) . Significant change in the patient/resident's physical, mental, or psychological status. Need to alter treatment significantly . Notify the patient/resident and the resident representative of the change of condition. Document notification in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 5 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 - Actual harm Based on resident record review, interview, and facility policy and procedure review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers, Resident #4. Residents Affected - Few Findings include: Review of the admission record for Resident #4 documented diagnoses including multiple sclerosis, mild intermittent asthma, heart failure unspecified, unspecified atrial fibrillation, unspecified convulsions, idiopathic normal pressure hydrocephalus, rheumatoid arthritis, age-related osteoporosis, essential primary hypertension, COVID-19, personal history of malignant neoplasm of ovary, hyperlipidemia, primary open angle glaucoma, and acute embolism and thrombosis of deep veins of upper extremity bilateral. Review of the form titled Pressure Ulcer Wound Rounds dated 5/31/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 2 centimeters, Depth: [blank], Stage II . Notes/Recommendations from Doctor: Resident admitted from hospital with wound. Cleansed with NS [Normal Saline] and covered with a silicone bordered dsg [dressing]. Review of the form titled Pressure Ulcer Wound Rounds dated 6/9/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 1 centimeter, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 6/12/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Right buttock, Type: Pressure, Length: 1.5 centimeters, Width: 0.5 centimeters, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 6/14/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 1 centimeter, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 7/12/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3.5 centimeters, Width: 4.5 centimeters, Depth: 0.2 centimeters, Stage III. Review of Resident #4's medical records revealed no skin evaluations or documentation of the wound length, width, or depth from 6/14/2023 until 7/12/2023. Review of Resident #4's physician order dated 5/31/2023 reads, Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound. Review of Resident #4's Treatment Administration Record (TAR) for June 2023 revealed no entries documented under Wound Care: Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound for 6/14/2023, 6/18/2023, 6/21/2023, 6/22/2023, 6/27/2023, 6/28/2023, and 6/29/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 6 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 - Actual harm Residents Affected - Few Review of Resident #4's TAR for July 2023 revealed no entries documented under Wound Care: Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound for 7/2/2023, 7/10/2023 and 7/11/2023. Review of Resident #4's physician order dated 7/13/2023 reads, Right upper buttock: Cleanse with NS, alginate and cover with silicone foam dsg daily and as needed every day shift for wound. Review of Resident #4's TAR for July 2023 revealed no entries documented under Right upper buttock: Cleanse with NS, alginate and cover with silicone foam dsg daily and as needed every day shift for wound for 7/13/2023, 7/14/2023, 7/20/2023, and 7/26/2023. During an interview on 7/27/2023 at 2:25 PM, the Director of Nursing (DON) stated, I don't know why the nurses are not documenting wound care. If these have not been documented, it means they are not done. I can't tell you why the resident has not had any wound evaluations or wound measurements or skin assessments between 6/14 and 7/12. The nurses should be doing weekly skin assessments and that would include documenting the wound size and drainage and anything else. [Name of the Wound Care Consultant Company] should have been seeing the wound weekly. I really can't tell you why there are no weekly skin assessments completed. There is no documentation of the wound sizes. The resident was not out of the facility. Her wound did progress from a stage II to a stage III, so I guess that is harmful to the resident. We did not follow our policies and procedures and we should have. We did not follow doctor's orders for wound care when we don't document that the care was done or have wound care evaluate the wounds per the orders, we should be following the orders for care. During an interview on 7/27/2023 at 2:50 PM, Staff A, Licensed Practical Nurse (LPN), stated, I don't know why [Resident #4's name] wasn't seen by [Name of the Wound Care Consultant Company] or the wound nurse did not document her wound sizes. I don't know why the TAR is not documented on. I was taking care of her. Maybe those were the days that the students were here. It is my responsibility to make sure that the wound care treatments are done. If they are not documented, that means they were not done. We should be following doctor's orders for the wound care and to have the wound care team see the residents. During an interview on 7/27/2023 at 3:18 PM, the Assistant Director of Nursing (ADON) stated, I don't do the daily dressing changes to the wounds. I document wound size and progression weekly. I can't say for certainty that the staff were doing the treatments because there is no documentation that they measured the wounds. I did not see the resident because it was not necessary. The nurses were doing the wound care and they should have documented the wound progression. I was told that wound care did not see any pressure wound unless it was a stage III wound. I don't know who told me that. We started seeing her again and the wound was a stage III when we started seeing the wound again. It was worse when we started to see it again. I guess it would be considered harm if it worsened and the wound wasn't measured and not all of the wound care was documented as done. We should have been measuring the wound. We should have had the resident seen by wound care and we should have documented when we did the dressing changes. Review of the facility policy and procedure titled Skin Evaluation with last revision date of 4/1/2017 and an approval date of 1/2023 reads, Policy: A Licensed Nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas, and skin problems. Procedure: 1. A Licensed Nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. 2. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 7 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 - Actual harm evaluating nurse must date and sign each review. 3. If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas complete the Pressure Injury Record. For all other skin conditions, complete the Non-Pressure Skin Condition Record . 5. The Licensed Nurse will document the observations on the skin evaluation form. Residents Affected - Few Review of the facility policy and procedure titled Dressings, Sterile with a revision date of September 2013 reads, Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage. 3. The name and title (or initials) of the individual changing the sterile dressing . 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 8 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on resident record review, interview, and facility policy and procedure review, the facility failed to ensure residents' medical records were accurate and complete for 3 of 3 residents reviewed for pressure ulcers, Residents #2, #3 and #4. Findings include: Review of the admission record for Resident #2 documented diagnoses including cerebral ischemia, rheumatoid arthritis, pressure ulcer of right ankle unstageable, pressure ulcer of left ankle unstageable, cognitive communication deficit, major depressive disorder, unspecified dementia, brief psychotic disorder, hyperlipidemia, essential primary hypertension, and pressure ulcer of left buttock stage 3. Review of the physician order dated 4/5/2023 for Resident #2 reads, Wound Care: Left rear/outer ankle: Cleanse with NS [Normal Saline], apply honey fiber sheet and cover with silicone bordered dsg [dressing] daily every day shift for wound care. Review of Resident #2's Treatment Administration Record (TAR) for April 2023 revealed no entries documented under Wound Care: Left rear/outer ankle: Cleanse with NS [Normal Saline], apply honey fiber sheet and cover with silicone bordered dsg [dressing] daily every day shift for wound care for 4/12/2023, 4/13/2023, 4/14/2023, and 4/15/2023. Review of the physician order dated 4/5/2023 for Resident #2 reads, Wound Care: Rear left thigh: Cleanse with NS, apply honey fiber sheet and cover with silicone bordered dsg daily every day shift for wound. Review of Resident #2's TAR for April 2023 revealed no entries documented under Wound Care: Rear left thigh: Cleanse with NS, apply honey fiber sheet and cover with silicone bordered dsg daily every day shift for wound for 4/12/2023, 4/13/2023, 4/14/2023 and 4/15/2023. Review of the physician order dated 4/5/2023 for Resident #2 reads, Wound Care: Right ankle: Cleanse with NS, apply honey fiber sheet and cover with silicone bordered dsg daily every day shift for wound. Review of Resident #2's TAR for April 2023 revealed no entries documented under Wound Care: Right ankle: Cleanse with NS, apply honey fiber sheet and cover with silicone bordered dsg daily every day shift for wound for 4/12/2023, 4/13/2023 ,4/14/2023, and 4/15/2023. Review of the physician order dated 4/5/2023 for Resident #2 reads, Wound Care: Sacrum: Cleanse with NS, apply Santyl and cover with silicone bordered dsg daily every day shift for wound. Review of Resident #2's TAR for April 2023 revealed no entries documented under Wound Care: Sacrum: Cleanse with NS, apply Santyl and cover with silicone bordered dsg daily every day shift for wound for 4/12/2023, 4/13/2023, 4/14/2023, 4/152023, 4/18/2023, and 4/19/2023. 2. Review of the admission record for Resident #3 documented diagnoses including seizures, acquired absence of right leg above knee, obesity, type 2 diabetes mellitus without complications, metabolic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 9 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some encephalopathy, left knee contracture, sacral region pressure ulcer stage 4, and chronic obstructive pulmonary disease. Review of the physician order dated 2/4/2023 Resident #3 reads, Wound Care: Left Buttock: Cleanse with normal saline or wound cleanser, apply collagen powder, alginate with silver and cover with silicone bordered dressing daily and PRN [as needed], every day shift for left buttock wound. Review of Resident # 3's TAR for May 2023 revealed no entries documented under Wound Care: Left Buttock: Cleanse with normal saline or wound cleanser, apply collagen powder, alginate with silver and cover with silicone bordered dressing daily and PRN, every day shift for left buttock wound for 5/2/2023, 5/8/2023 and 5/11/2023. Review of the physician order dated 5/12/2023 for Resident #3 reads, Wound Care: Left Buttock: Cleanse with normal saline or wound cleanser, apply santyl, alginate and cover with silicone bordered dressing daily and PRN, every day shift for left buttock wound. Review of Resident #3 TAR for May 2023 revealed no entries documented under Wound Care: Left Buttock: Cleanse with normal saline or wound cleanser, apply santyl, alginate and cover with silicone bordered dressing daily and PRN, every day shift for left buttock wound for 5/20/2023 and 5/29/2023. Review of the physician order dated 3/31/2023 for Resident #3 reads, Wound Care: Left lateral foot: Cleanse with NS, apply Santyl, alginate and cover with bordered gauze dressing daily every day shift for wound. Review of Resident #3's TAR for May 2023 revealed no entries documented under Wound Care: Left lateral foot: Cleanse with NS, apply Santyl, alginate and cover with bordered gauze dressing daily every day shift for wound for 5/2/2023, 5/8/2023, 5/20/2023, 5/28/2023 and 5/29/2023. Review of the physician order dated 3/24/2023 for Resident #3 reads, Wound Care: Sacrum: Cleanse with normal saline or wound cleanser, apply collagen powder, alginate with silver and cover with silicone bordered dressing daily and PRN every day shift for sacral wound. Review of Resident #3's TAR for May 2023 revealed no entries documented under Wound Care: Sacrum: Cleanse with normal saline or wound cleanser, apply collagen powder, alginate with silver and cover with silicone bordered dressing daily and PRN every day shift for sacral wound for 5/2/2023, 5/8/2023 and 5/11/2023. Review of the physician order dated 5/12/2023 for Resident #3 reads, Wound Care: Sacrum: Cleanse with normal saline or wound cleanser, apply santyl, alginate and cover with silicone bordered dressing daily and PRN every day shift for sacral wound. Review of Resident #3's TAR for May 2023 revealed no entries documented under Wound Care: Sacrum: Cleanse with normal saline or wound cleanser, apply santyl, alginate and cover with silicone bordered dressing daily and PRN every day shift for sacral wound for 5/20/2023 and 5/29/2023. Review of the physician order dated 6/16/2023 for Resident #3 reads, Wound Care: Left Buttock: Cleanse with normal saline or wound cleanser, apply santyl, alginate and cover with silicone foam bordered dressing daily and PRN every day shift for left buttock wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 10 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #3's TAR for June 2033 revealed no entries documented under Wound Care: Left Buttock: Cleanse with normal saline or wound cleanser, apply santyl, alginate and cover with silicone foam bordered dressing daily and PRN every day shift for left buttock wound for 6/20/2023 and 6/29/2023. Review of the physician order dated 3/31/2023 for Resident #3 reads, Wound Care: Left lateral foot: cleanse with NS, apply santyl, alginate and cover with bordered gauze dressing daily every day shift for wound. Review of Resident #3's TAR for June 2023 revealed no entries documented under Wound Care: Left lateral foot: cleanse with NS, apply santyl, alginate and cover with bordered gauze dressing daily every day shift for wound for 6/20/2023 and 6/29/2023. Review of the physician order dated 6/16/2023 for Resident #3 reads, Wound Care: Left proximal buttock: Cleanse with NS, apply alginate and cover with silicone foam dsg daily and as needed every day shift for sacral wound. Review of Resident #3's TAR for June 2023 revealed no entries documented under Wound Care: Left proximal buttock: Cleanse with NS, apply alginate and cover with silicone foam dsg daily and as needed every day shift for sacral wound for 6/20/2023 and 6/29/2023. Review of the physician order dated 6/16/2023 for Resident #3 reads, Wound Care: Sacrum: Cleanse with dakins, pack with dakins moistened kerlix and cover with silicone foam dsg daily and as needed, every day shift for sacral wound. Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Sacrum: Cleanse with dakins, pack with dakins moistened kerlix and cover with silicone foam dsg daily and as needed, every day shift for sacral wound for 7/4/2023, 7/5/2023, 7/7/2023, 7/8/2023, 7/15/2023, 7/19/2023 ,7/27/2023 and 7/29/2023. Review of the physician order dated 6/30/2023 for Resident #3 reads, Wound Care: Left distal buttock: Cleanse wound with dakins, apply dakins moistened kerlix, cover with silicone foam dsg, every day shift for sacral wound. Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Left distal buttock: Cleanse wound with dakins, apply dakins moistened kerlix, cover with silicone foam dsg, every day shift for sacral wound for 7/4/2023, 7/5/2023, 7/7/2023, 7/8/2023, 7/15/2023, 7/19/2023 and 7/27/2023. Review of the physician order dated 6/30/2023 for Resident #3 reads, Wound Care: Left proximal buttock: Cleanse with NS, apply santyl, alginate and cover with silicone foam dsg every day shift for wound. Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Left proximal buttock: Cleanse with NS, apply santyl, alginate and cover with silicone foam dsg every day shift for wound for 7/4/2023, 7/5/2023, 7/7/2023, 7/8/2023, 7/15/2023, 7/19/2023 and 7/29/2023. Review of the physician order dated 6/30/2023 for Resident #3 reads, Wound Care: Left lateral foot: Cleanse with NS, apply calcium alginate and cover with bordered gauze dsg every day shift for wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 11 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Left lateral foot: Cleanse with NS, apply calcium alginate and cover with bordered gauze dsg every day shift for wound for 7/4/2023, 7/5/2023, 7/7/2023, and 7/8/2023. Review of the physician order dated 7/7/2023 for Resident #3 reads, Wound Care: Left great toe: apply skin prep daily every day shift. Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Left great toe: apply skin prep daily every day shift for 7/7/2023, 7/8/2023, 7/19/2023 and 7/27/2023. Review of the physician order dated 7/7/2023 for Resident #3 reads, Wound Care: Left outer ankle: Cleanse with NS, apply honey ointment, collagen powder and cover with silicone foam dsg daily every day shift for wound. Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Left outer ankle: Cleanse with NS, apply honey ointment, collagen powder and cover with silicone foam dsg daily every day shift for wound for 7/7/2023 and 7/8/2023. Review of the physician order dated 7/13/2023 for Resident #3 reads, Wound Care: Left outer ankle: Cleanse with NS, apply santyl, alginate and cover with silicone foam dsg daily every day shift for wound. Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Left outer ankle: Cleanse with NS, apply santyl, alginate and cover with silicone foam dsg daily every day shift for wound for 7/15/2023, 7/19/2023 and 7/29/2023. Review of the physician order dated 7/13/2023 for Resident #3 reads, Wound Care: Left lateral foot: Cleanse with NS, apply calcium alginate and cover with silicone foam dsg every day shift for wound. Review of Resident #3's TAR for July 2023 revealed no entries documented under Wound Care: Left lateral foot: Cleanse with NS, apply calcium alginate and cover with silicone foam dsg every day shift for wound for 7/15/2023, 7/19/2023 and 7/29/2023. 3. Review of the admission record for Resident #4 documented diagnoses including multiple sclerosis, mild intermittent asthma, heart failure unspecified, unspecified atrial fibrillation, unspecified convulsions, idiopathic normal pressure hydrocephalus, rheumatoid arthritis, age-related osteoporosis, essential primary hypertension, COVID-19, personal history of malignant neoplasm of ovary, hyperlipidemia, primary open angle glaucoma, and acute embolism and thrombosis of deep veins of upper extremity bilateral. Review of Resident #4's physician order dated 5/31/2023 reads, Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound. Review of Resident #4's Treatment Administration Record (TAR) for June 2023 revealed no entries documented under Wound Care: Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound for 6/14/2023, 6/18/2023, 6/21/2023, 6/22/2023, 6/27/2023, 6/28/2023, and 6/29/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 12 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #4's TAR for July 2023 revealed no entries documented under Wound Care: Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound for 7/2/2023, 7/10/2023 and 7/11/2023. Review of Resident #4's physician order dated 7/13/2023 reads, Right upper buttock: Cleanse with NS, alginate and cover with silicone foam dsg daily and as needed every day shift for wound. Review of Resident #4's TAR for July 2023 revealed no entries documented under Right upper buttock: Cleanse with NS, alginate and cover with silicone foam dsg daily and as needed every day shift for wound for 7/13/2023, 7/14/2023, 7/20/2023, and 7/26/2023. During an interview on 7/27/2023 at 2:25 PM, the Director of Nursing (DON) stated, I don't know why the nurses are not documenting wound care. If these have not been documented, it means they are not done. The nurses should be doing weekly skin assessments and that would include documenting the wound size and drainage and anything else. We did not follow doctor's orders for wound care when we don't document that the care was done. During an interview on 7/27/2023 at 2:50 PM, Staff A, Licensed Practical Nurse (LPN), stated, I don't know why the wound nurse did not document her wound sizes. I don't know why the TAR is not documented on. I was taking care of her. Maybe those were the days that the students were here. It is my responsibility to make sure that the wound care treatments are done. If they are not documented that means they were not done. During an interview on 7/27/2023 at 3:18 PM, the Assistant Director of Nursing (ADON) stated, I document wound size and progression weekly. I can't say for certainty that the staff were doing the treatments because there is not documentation that they measured the wounds, not all of the wound care was documented as done. We should have documented when we did the dressing changes. We did not document or follow doctor's orders. Review of the facility policy and procedure titled Dressings, Sterile with a revision date of September 2013 reads, Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage. 3. The name and title (or initials) of the individual changing the sterile dressing . 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 13 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy and procedure review, the facility failed to develop and implement an appropriate plan of action to correct an identified quality deficiencies related to resident refunds and accounting of resident funds. Findings include: 1. Review of the facility records documented that Resident #1 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $2776.16, which has not been paid. Review of the facility records documented that Resident #5 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $405.61, which has not been paid. Review of the facility records documented that Resident #7 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $479.71, which has not been paid. Review of the facility records documented that Resident #8 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $1169.89, which has not been paid. Review of the facility records documented that Resident #9 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $44.46, which has not been paid. Review of the facility records documented that Resident #10 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $1179.98, which has not been paid. Review of the facility records documented that Resident #11 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $28.00, which has not been paid. Review of the facility records documented that Resident #12 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $735.55, which has not been paid. Review of the facility records documented that Resident #13 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $828.26, which has not been paid. Review of the facility records documented that Resident #14 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $1071.26, which has not been paid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 14 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 0867 Level of Harm - Minimal harm or potential for actual harm Review of the facility records documented that Resident #15 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $249.70, which has not been paid. Review of the facility records documented that Resident #16 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $492.80, which has not been paid. Residents Affected - Few Review of the facility records documented that Resident #17 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $663.49, which has not been paid. Review of the facility records documented that Resident #19 was discharged from the facility on [DATE]. Review of the account documented that the resident's estate was owed $870.00, which has not been paid. During an interview on [DATE] at 11:30 AM, the Business Office Manager (BOM) #1 stated, We did not process these refunds after the residents died. We have 6 accounts that were not processed refunds. We still have accounts to catch up. I have been aware of this concern for the last two weeks. These 14 accounts should have been paid out to the families. We have not been following policy and procedures for refunds when a resident passes away. During an interview on [DATE] at 11:35 AM, the BOM #2 stated, We have had a lot of turnover and the change of company hands since I started here. There are accounts that have not been paid out. I was not aware of this when I came back to this job, but I have been working on them. We have not followed the policies and procedures for refunds. During an interview on [DATE] at 11:55 AM, the DON stated, We were aware that these accounts were not paid out. We should have completed a QAPI [Quality Assurance Performance Improvement], conducted an RCA [Root Cause Analysis] and determined if there were any other concerns related to the business office. The administrator was aware of the accounts. During an interview on [DATE] at 3:15 PM, the Administrator stated, I am aware that there were business office accounts that were not paid. Review of the facility policy and procedure titled Refunds-Accounts Receivables with last revision date of 2/2022, reads, Procedure: After refund balances are verified, the Business Office shall begin the refund workflow process. Private pay: Once a refund has been confirmed with supporting documentation and account notes, a check or electronic retraction will be issued. If a refund check is needed, the Business Office shall submit a request on the A/R Refund Workflow for processing; located on the Company Intranet Portal> My Apps> AR Refund Workflow . Third Party . Upon confirmation of refund process, the Business Office shall document and complete the process accordingly. 2. Review of the facility's form titled Trail Balance from [DATE] until [DATE] indicated 50 residents were to receive quarterly account balance statements. On [DATE] at 2:00 PM, upon request for the documentation indicating that the residents received quarterly account balance statements, the facility was unable to provide quarterly statement verification forms. The Business Office Manager (BOM) #1 presented two forms titled Quarterly Statement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 15 of 16 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 105413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601 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 0867 Verification Form both dated [DATE] for the quarter ending on [DATE], and [DATE]. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 2:00 PM, the BOM #1 stated, Quarterly statements for the last two quarters have not been sent to the residents. They should have received these within 30 days of the end of the quarter. I can't tell you why we did not investigate this when we determined that the refunds were not being processed. We should have recognized this. I did inform the administrator about the refunds not being processed; he knew why I was here. Residents Affected - Few Review of the facility policy and procedure titled Resident Trust Fund- RTF Quarterly Statement with last revision date of [DATE] reads, Policy: A quarterly written Resident Trust Fund statement is issued to the resident or to his or her designated representative. Procedure: 1. The quarterly written statement must include the following: a) The balance for the beginning of the period, b) The total deposits and withdrawals, c) The interest earned, d) The balance at the end of the period, e) The identification number and location of the Resident Trust Fund Account . 3. The quarterly written Resident Trust Fund statements are printed and mailed by the Business Office Manager. The date statements were mailed should be documented in the residence file. 4. The Business Office Manager is responsible for ensuring that complete and correct addresses are in the computer system for all residents . 6. A Signed copy of in-house statements should be obtained as acknowledgement from all competent residents and filled with copies of mailed statements. During an interview on [DATE] at 3:15 PM, the Administrator stated, I am aware that there were business office accounts that were not paid, but we are working on this now to get them up to date. I was not aware that the residents were not receiving their quarterly statements until today. We should have determined this when we saw we had a problem within the business office. We should have conducted a QAPI and RCA several weeks ago. We did not evaluate to see the extent of the problems in the business office. Review of the facility policy and procedure titled Quality Assurance Performance Improvement Program (QAPI) with last revision date of [DATE] reads, Policy: The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Procedure: Program Design and Scope: 1. The center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to . k. business office . Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a) Implementation, b) Identify priorities . e) Ensures corrective actions are implemented to address identified problems in systems, f) Evaluates the effectiveness of actions, g) Establishes expectations for safety, quality, rights and choice and respect . Systematic Analysis and Action: The center will ensure systems and actions are in place to improve performance. 11. The center will establish and utilize a systematic approach to identify underlying causes of problems, including but not limited to: a. Root cause analysis, b. Failure Mode Effect Analysis. 12. The center will develop corrective actions based on the information gathered and review effectiveness of actions. 13. The center will review and develop corrective actions on medical Errors and adverse Events . b. Utilize a systemic approach (see below) to identify underlying cause, c. Develop and monitor action plans. Identify Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 14. Center will review department system data. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105413 If continuation sheet Page 16 of 16