Inspection·March 24, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #77 On 03/22/23 at approximately 08:45 AM, an observation of medication administration was completed with Staff Q, Licensed Practical Nurse (LPN) for resident #77. The resident had a physician order dated 3/13/23 to received 4 milligrams (mg) of Dilaudid (used to treat pain) every 12 hours. During the observation a review was conducted of the it the Controlled Medication Utilization Record at the top of the from there was a pharmacy label for Hydromorphone (Dilaudid) 2 mg tablet. The record indicated take 1 tablet (=2mg) by mouth every 8 hours for pain written next to the label in black ink was give two tablets. A review of the Medication Administration Record (MAR) for the Month of March 2023, revealed the resident had been receiving Hydromorphone 2 mg 1 tablet three times a day for pain until 3/13/23 when this ordered was discontinued and a new order was written for Dilaudid 4 mg give 1 tablet every 12 hours for pain. A review of the Controlled Medication Utilization Record for the dates 3/17/23 to 3/22/23 revealed the resident had received only one tablet of hydromorphone 5 times, on 3/17/2023 at 9:00 PM, 3/18/2023 at 9:00 AM, 03/18/2023 at 9:00 PM, 03/19/2023 at 9:00 AM and 3/19/2023 at 9:00 PM. A review of Resident #77 care plan revealed she was at risk for acute or chronic pain related to a surgical incision to her right hip for osteomyelitis and sepsis. Interventions included to administer analgesia per orders. An interview was conducted on 03/24/2023 at approximately 9:50 AM with Staff Q, Licensed Practical Nurse (LPN), who stated, I have noticed that some of the administrations don't show giving the correct dosage. I always look at my MAR) and make sure I am giving the correct doses for all of my residents. An interview was conducted on 03/24/2023 at approximately 1:30 PM, with the Director of Nursing (DON). The DON stated being aware of the discrepancy and the incorrect administration of the Dilaudid. The DON stated, We are in the process of correcting that now. It will be corrected. A review of the Pharmacy policy dated 01/01/2022 revealed facility staff should comply with the facility policy. The policy further states that facility staff should verify the medication name and dose are correct when compared to the medication order on the medication administration record. Resident #518 On 3/22/23 at 8:29 AM, an interviewed was conducted with Resident #518, who was observed grimacing and stated she did not receive the scheduled pain medication and had a 7/10 pain. On 3/22/23 at 12:03 PM, an interview was conducted with Staff E, Licensed Practical Nurse and unit manager. Staff E reviewed resident's MAR and stated the resident should have received her scheduled pain medication at 4:00 AM. Review of the medical record for Resident #518 revealed the resident was admitted on [DATE] with diagnoses of right shoulder osteoarthritis and presence of right artificial shoulder joint. Review of the baseline care plan for Resident #518 dated 3/15/23 revealed a resident goal to maintain comfort (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to highest degree possible and interventions of administering pain medication as ordered and monitor for pain. A review of the Medication Administration Record (MAR) for Resident #518 for March 2023 was conducted, which revealed acetaminophen-codeine #3 oral tablet 300-30 mg 1 tablet by mouth was scheduled for pain every 4 hours related to primary osteoarthritis of right shoulder. Scheduled times were 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Further review of the MAR revealed acetaminophen-codeine #3 oral tablet 300-30 mg was not administered on 3/22/23 at 4 AM. Resident's pain level documentation revealed a pain level of 7 at 6:29 AM. MAR documentation revealed resident received the last dose at midnight and resident had a pain level of 7/10. Resident #28 On 3/20/2023 at approximately 1:54 PM, an interview was conducted with Resident #28. She explained that she did not receive assistance with incontinence care for about 12 hours yesterday. She explained that she had been assisted at midnight and staff did not get around to help her change again until about 12:00 noon today. On 03/22/23 at approximately 4:18 PM, an interview was conducted with Resident #28. She explained that she had not received incontinence care since breakfast that morning. She explained that she felt uncomfortable and asked for help finding someone who could assist with incontinence care. The surveyor went to see what Certified Nursing Assistant (CNA) was assigned to care for Resident #28. Staff Member G, CNA explained that she would gather supplies and assist the resident with incontinence care. A review of Resident #28's care plan dated 1/11/2023 revealed that the resident had bowel incontinence related to self-care deficit, limited mobility and a cognitive deficit. A listed goal was for the resident to remain free from skin breakdown due to incontinence and brief use. Interventions for the care area included the following interventions. Check at least every two hours and as required for incontinence. Change disposable briefs as needed (prn). Wash, rinse, and dry perineum, and change clothing prn after incontinence episodes. The care area that listed interventions relating to Resident#28's potential for skin impairment directed care staff to encourage and assist with turning and repositioning frequently while the resident is in bed. Keep her skin clean and dry. The care plan also listed that Resident #28 had an activities of daily living (ADL) self-care performance deficit and required extra assistance by 1 staff member for toileting. On 3/22/23 at approximately 4:35 PM, Staff Member G, CNA was observed as she provided incontinence care for Resident #28. When the CNA removed the Resident's brief it had a very strong foul odor of urine. The brief was completely saturated with dark yellow urine. The pad under Resident #28 was saturated as well. The surveyor asked Staff Member G, CNA if the resident should have been allowed to sit a wet brief all day. Staff Member G, CNA explained that Staff Member H, CNA had the responsibility to care for Resident #28. Staff Member H, CNA had just left for the day. She also explained that she had just started her shift a few minutes ago. On 3/23/23 at approximately 12:13 PM an interview was conducted with Staff Member H, CNA. She was notified that Resident #28 had complained that she was not assisted with incontinence care from breakfast until 4:30 PM yesterday. Staff member H, CNA said: I went in there to check on her after I got her roommate up after breakfast at 9:30 yesterday. She said not right now. Then she asked for her medication. I went in there before I left at the end of the day and she said no, not now. Those are the two times she was checked yesterday. The surveyor asked Staff Member M, CNA to tell what time she started and ended her shift yesterday. Staff Member M said her shift began at 7:00 AM and ended at 3:00 PM. The surveyor notified Staff Member H CNA that the care plan stated that Resident #28 should be checked at least every two hours and as needed for incontinence. She was asked if should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gone in to check to see if Resident #28 needed incontinence care more often than twice on her shift. She replied: Yes. Based on observations, record reviews, staff interviews, and policy review, the facility failed to implement the care plans for 1 of 3 residents reviewed nutrition (Resident #68), 2 of 3 residents reviewed for pain management (Resident #518 and #77) and for 1 of 1 resident sampled for bowel and bladder (Resident #28). The findings include: Resident #68 Review of resident #68's electronic record revealed a current physician order dated 1/13/23 for the resident to receive a consistent carbohydrate diet with large protein portions for nutrition and low body mass index. The current comprehensive plan of care for nutritional problem with risk for malnutrition and weight loss revealed a current intervention to provide and serve diet as ordered. An observation of resident #68 was conducted during the lunch meal on 3/23/23 at approximately 11:49 AM, in the dining room. The resident was served a plate with 3 golf ball size ravioli with red sauce, mixed vegetables in a bowl, and a roll. An interview was conducted with the employee D (dietary manager) on 3/23/23 at 11:51 AM. Employee D observed resident #68's lunch meal and stated 3 ravioli was not a large protein portion and it should have been a little more. (Photographic evidence obtained.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and policy review the facility failed to provide appropriate treatment to prevent further decrease in range of motion for 1 of 1 residents reviewed for limited range of motion. (Resident #1) The findings include: Observations of resident #1 were conducted on 3/20/23 at 3:59 PM, 3/21/23 at 2:38 PM, and 3/22/23 at 12:14 PM. During the observations the resident was in bed and his right arm was observed to be bent at the elbow and his hand was up near his chin. Review of resident #1's electronic record revealed a quarterly minimum data set with an assessment reference date of 2/14/23 indicating functional limitation in range of motion impairment on both sides of upper and lower extremities. The record revealed no documentation or care plan indicating the resident was receiving services for the limitation in range of motion. An Occupational therapy Discharge summary dated [DATE] indicated the resident had upper extremity contractures and was discharged to the care of the restorative nursing program for a functional maintenance program specifically for right upper extremity elbow and carrot splint in order to prevent decline from current level of skill. An interview was conducted with employee C Personal Care Assistant (PCA) on 3/22/23 at 4:21 PM. Employee C stated the resident was not able to fully extend his right arm, he was not aware of the resident receiving any services to treat this. An interview was conducted with the Director of Nursing (DON) on 3/22/23 4:35 PM. She stated the resident was not receiving services for the contracture. Review of the facility policy for Restorative Nursing Services (RN-100 revised 4/15/22) revealed the center provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition, and goals. Restorative nursing programs are considered for residents who: * Are not a candidate for rehab services * Benefit from restorative along with rehab services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review and review of facility policy, the facility failed to ensure implement interventions to prevent accidents following a resident fall for 1 of 1 resident sampled #565). The findings include: An observation of resident #565 was conducted on 03/21/2023 at approximately 1:20 PM. The resident was sleeping at that time. During observation a hematoma was noted to the left side of her head with a yellowish-green color surrounding the area down to the temple area. A follow-up observation of Resident #565 was conducted on 03/23/2023 at approximately 10:00 AM, which revealed sheep skin type pads to the upper bed rails of her bed. At this time the resident stated, They just came in and put these things on my bed. Can you take them off? I don't know where these came from. An interview was conducted on 03/23/2023 at approximately 8:30 AM, with resident #565. The resident stated she has no pain to her head. She stated she fell out of bed reaching for something on my table. She stated she did hit her head on the floor a couple of weeks ago. She stated a man and a woman placed her back into bed but she does not know who the staff were. A review of Resident #564's medical record revealed Resident #565 was admitted to the facility on [DATE] for care of a wound to the right great trochanter and intravenous antibiotics through a mid-line. Resident #565 was receiving daily wound care that included packing of the hip wound. A review of the Change of Condition form dated 3/05/23 at 6:00 PM and signed by staff member P, a Licensed Practical Nurse (LPN), revealed under Summarize your observations and evaluation: large swelling noted to left side of forehead. Small dark purple area noted to center. Pt (patient) very confused of what happened or when? Pt stated she fell out of bed while trying to reach for something on her bedside table. Not sure of the names of who assisted her back to bed. (only a male and female). There was no other documentation in the patient's record of this event and no update to the care plan until 03/14/2023 when the resident was documented as a risk for behaviors including banging head on the siderail and was at risk for falls and unaware of safety needs. The care plan documented a fall with no injury on 03/15/2023 with interventions to keep bed in low position, bilateral padded bed rails for safety and protection, determine and address causative factors of the fall. An interview was conducted on 03/23/2023 at approximately 9:00 AM with the Director of Nursing (DON). The DON stated, We discuss any falls or incidents in interdisciplinary meetings (IDT) in the mornings. The nurses document and report on any adverse incidents. We discuss to make sure proper interventions are put into place. This resident (#565) was hitting her head on the side of her bedrails. She now has bed pads on the side of her bed. The DON went on to state that the resident did not sustain a fall on 03/05/2023 from what the nurse told me. She went on to report that she had spoken to the nurse who did not report the incident as a fall or that anyone had assisted the resident back to bed. Therefore, she did not conducted an investigation into this event as a fall. An interview was conducted on 03/23/2023 at approximately 2:30 PM with Staff P, LPN, who sated I was working Sunday (3/5/23) day shift. I found the area on her (Resident #565) forehead and wrote up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the report. I am not sure who found her on the floor. Everything happened on the night shift. It was not on my shift. I had worked the day before, so I know it (the swelling to her forehead) wasn't there. I reported it on my shift. I did call the ARNP (Advanced Registered Nurse Practitioner) and reported it to her. She stated to monitor her for any changes. I did neuro checks on her throughout my shift. She did state several times that she had fallen out of the bed trying to get something off of her bedside table. She did state she hit her head. An interview was conducted on 03/23/2023 at approximately 3:40 PM with Staff O, a Patient Care Assistant (PCA). Staff O stated, Yes. This did happen on my shift. I did not see her fall. The nurse told me she was on the floor, and I went in and helped get her up. She was sitting on her butt when I went into the room. She didn't say anything to me about being hurt. I didn't notice any injuries on her. But, the nurse was assessing her after we put her back to bed. A review of the fall policy dated 07/29/2019 revealed that when a resident is found on the floor, a fall is considered to have occurred. The policy revealed post fall strategies to include evaluation and post fall care initiate neurological checks per policy or as directed by physician, notifying the physician and resident representative, reevaluation of the fall risk, updating the care plan and nurse aide [NAME], initiate post fall documentation for 72 hours, IDT review and complete a root cause analysis, update plan of care with new interventions as appropriate, and review the resident weekly for four weeks. A review of the Resident Incident/Accident Reports policy dated 08/24/2017 revealed that incident/accidents are recorded, reviewed, and trended through a Quality Assurance and Performance Improvement process. The procedure of an incident/accident was to be done as stated in the policy to include: any happening not consistent with routine operation or care of a resident warranted a completion of an incident report, physician and representative contacted, incidents to be placed on a 24 hour report, the DON will be reviewed for completion and follow-up, event is to be reviewed by the IDT and executive director, and the Medical Director will review resident incidents/accidents on a quarterly basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on record review, resident interview, staff interview and policy review, the facility failed to provide care and services in accordance with the physician orders for 1 of 1 sampled residents with a urinary catheter (Resident #108) and failed to provide timely incontinent care for 1 of 1 residents sampled for bowel and bladder (Resident #28). The findings include: Resident #108 Review of resident #108's electronic record revealed a current physician order dated 1/12/23 to change the resident's urinary catheter every 2 weeks. Review resident #108's record revealed the catheter had not been changed since 2/11/23 (5 weeks ad 4 days) when he was sent to the hospital after the staff changed the catheter. An interview was conducted with resident #108 on 3/22/23 at 12:15 PM. He stated his catheter had not been changed since he went to the hospital last month. An interview was conducted with employee B, Licensed Practical Nurse Unit Manager, on 3/22/23 at 10:39 AM. Employee B reviewed the record and confirmed a catheter change had not been documented since 2/11/23. Further interview was conducted with employee B on 3/22/23 at 10:56 AM. She stated when she placed the order in the electronic record system she did not click the correct button for it to populate on the treatment record to be completed and recorded. Review of the facility policy for Physician Orders (N-140 Physician Orders revised 3/3/21) revealed the center will ensure that Physician orders are appropriately and timely documented in the medical record. Resident #28 On 3/20/2023 at approximately 1:54 PM, an interview was conducted with Resident #28. She explained that she did not receive assistance with incontinence care for about 12 hours yesterday. She explained that she had been assisted at midnight and staff did not get around to help her change again until about 12:00 noon today. On 03/22/23 at approximately 4:18 PM, an interview was conducted with Resident #28. She explained that she had not received incontinence care since breakfast that morning. She explained that she felt uncomfortable and asked for help finding someone who could assist with incontinence care. The surveyor went to see what Certified Nursing Assistant (CNA) was assigned to care for Resident #28. Staff Member G, CNA explained that she would gather supplies and assist the resident with incontinence care. A review of Resident #28's care plan dated 1/11/2023 revealed that the resident had bowel incontinence related to self-care deficit, limited mobility and a cognitive deficit. A listed goal was for the resident to remain free from skin breakdown due to incontinence and brief use. Interventions for the care area included the following interventions. Check at least every two hours and as required for incontinence. Change disposable briefs as needed (prn). Wash, rinse, and dry perineum, and change clothing prn after incontinence episodes. The care area that listed interventions relating to Resient#28's potential for skin impairment directed care staff to encourage and assist with turning and repositioning frequently while the resident is in bed. Keep her skin clean and dry. The care plan also listed that Resident #28 had an activities of daily living (ADL) self-care performance deficit and required extra assistance by 1 staff member for toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/22/23 at approximately 4:35 PM, Staff Member G, CNA was observed as she provided incontinence care for Resident #28. When the CNA removed the Resident's brief it had a very strong foul odor of urine. The brief was completely saturated with dark yellow urine. The pad under Resident #28 was saturated as well. The surveyor asked Staff Member G, CNA if the resident should have been allowed to sit a wet brief all day. Staff Member G, CNA explained that Staff Member H, CNA had the responsibility to care for Resident #28. Staff Member H, CNA had just left for the day. She also explained that she had just started her shift a few minutes ago. On 3/23/23 at approximately 12:13 PM an interview was conducted with Staff Member H, CNA. She was notified that Resident #28 had complained that she was not assisted with incontinence care from breakfast until 4:30 PM yesterday. Staff member H, CNA said: I went in there to check on her after I got her roommate up after breakfast at 9:30 yesterday. She said not right now. Then she asked for her medication. I went in there before I left at the end of the day and she said no, not now. Those are the two times she was checked yesterday. The surveyor asked Staff Member M, CNA to tell what time she started and ended her shift yesterday. Staff Member M said her shift began at 7:00 AM and ended at 3:00 PM. The surveyor notified Staff Member H C.N.A. that the care plan stated that Resident #28 should be checked at least every two hours and as needed for incontinence. She was asked if should have gone in to check to see if Resident #28 needed incontinence care more often than twice on her shift. She replied: Yes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observations, record review, and interviews, the facility failed to appropriately administer enteral feedings to prevent possible complications for 1 of 1 resident sampled for enteral feeding (Resident #123). Residents Affected - Few The findings include: On 3/21/23 at 5:55 PM, an observation of Resident #123 was conducted while the resident was receiving an enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid) conducted by Staff L, a Licensed Practical Nurse (LPN). During the feeding, Staff L, LPN was observed diluting the 237 ml (milliliters) of 2.0 calories feeding with 200 ml of water. At approximately 75% of the feeding intake, Resident #123 started grimacing and Staff L, LPN concluded the feeding. On 3/22/23 at 8:35 AM, a second enteral feeding observation was conducted with Staff L, LPN. Staff L LPN repeated the previous day's process. Resident #123 received the entire 237 mls of 2.0 calorie feed and the 200 ml of water (a total of 437 mls). Resident #123 waved her hand and had some grimacing during the process. On 3/23/23 at 8:36 AM, an enteral feeding preparation observation was conducted with Staff M, a Registered Nurse (RN). Staff M RN stated Resident #123 was due for both the 237 ml bolus feeding and the 200 ml of water flush. Staff M, RN stated she was not aware she could not give the feeding and the water flushes at the same time. A review of Resident #123's medical record revealed an admission date of 9/7/2022 and diagnoses of aphasia, dysphasia, and gastrostomy. Review of Medication Administration Record (MAR) for March 3/7/23 to present revealed a physician order for enteral feed scheduled 4 times a day for nutrition one can (237 ml) with 60 ml water before and after via a gastrostomy tube (GT), a surgically placed device used to give direct assess to the stomach for nutrition, that were scheduled at 6:00 AM, 12:00 PM, 6:00 PM and 10:00 PM. Further MAR review for March 3/7/23 to present revealed another order for enteral feed 4 times a day for hydration 200 ml water flushes, scheduled 6:00 AM, 9:00 AM, 6:00 PM and 9:00 PM. A review of Staff N, a Registered Dietitian (RD)'s recommendations was conducted. RD wrote recommendations on 3/7/23, that included a discontinuation of current feeds and flushes to be replaced with a feed consisting of 2 cal 237 ml 4 times a day with 60 ml of water before and after, scheduled at 7:30 AM, 11:30 AM, 3:30 PM and 7:30 PM. Recommendation also included 200 ml of water 4 times a day to be scheduled at 6:00 AM, 9:00 AM 6:00 PM and 9:00 PM. On 3/21/23 at 4:02 PM, an interview was conducted with Staff L, LPN revealing resident #123 was receiving 237 ml of feed and 200 ml of water at the same scheduled times. Staff L, LPN stated resident tolerated feeds well. On 3/22/23 at 4:04 PM, an interview was conducted with Staff N, RD. During the interview Staff N stated she sent to facility her recommendations for enteral feedings for Resident #123 on 3/7/23. She further stated the feeds for nutrition and the water for hydration were intended to be given separated, and no more than 300 milliliters at once. Staff N, RD confirmed that facility should correct the scheduled times on the MAR and follow her recommendations to avoid giving the Resident #123 more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 than 300 mls at once. Level of Harm - Minimal harm or potential for actual harm On 3/23/23 at 9:05 AM, an interview was conducted with Staff E, LPN a unit manager. Staff E reviewed Resident #123's MAR and compared with RD's recommendations. She stated nursing have been giving feeds and water flushes at the same time and she understood that was not the RD's recommendations. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Tallahassee 3101 Ginger Dr Tallahassee, FL 32308 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, and review of facility policies, the facility failed to provide appropriate infection control measures during wound care for 1 of 3 residents (resident #77) sampled for pressure ulcers. Residents Affected - Few The findings include: On 3/23/23 at approximately 10:40 AM, an observation was made of Nurse E, a Licensed Practical Nurse (LPN) performing wound care for resident #77 with the assistance of Nurse B, a LPN. Nurse E and B were observed to perform hand hygiene and apply clean gloves, then Nurse E cleansed the wound to resident #77 right foot with gauze and wound cleanser, then place the wound care supplies provided by Nurse B onto the resident's bed side dresser without cleaning the top of the dresser or placing a barrier to the top of the dresser. Nurse E then cleaned the wound to residents right foot again and applied calcium alginate ( a drainage absorbing agent) to the wound bed and covered with dry dressing without changing gloves and performing hand hygiene between cleaning the wound and applying the clean dressing. Nurse E was then observed to remove gloves, perform hand hygiene and apply clean gloves then cleaned resident #77's right hip wound with gauze and wound cleanser, then using a sterile cotton swab packed the wound with iodoform (a iodine infused gauze) strip directly from the bottle, when completing the packing of the wound Nurse B was observed to remove scissors from Nurse E's front scrub top pocket and hand them to Nurse E without cleaning the scissors. Nurse E then cut the packing gauze and applied a clean dressing to the hip wound that was observed to be lying on the bed beside the resident without a barrier. Nurse E did not change gloves and perform hand hygiene in between cleaning the wound and applying the clean dressing. Nurse E was then observed to change gloves and perform hand hygiene. Nurse E then applied clean gloves and cleaned the wound to resident #77 spine and applied clean dressing without performing hand hygiene or changing gloves between cleaning the wound and applying the clean dressing. Nurse E then removed gloves and performed hand hygiene. On 3/23/23 at approximately 10:55 AM, a interview was conducted with Nurse E, who stated that she did not clean the dresser top or apply a barrier prior to placing the wound care supplies on the dresser, Nurse E confirmed that this would be considered a infection control issue. Nurse E stated that she did not perform hand hygiene and change gloves in between cleaning the wounds and applying the clean dressing to the right foot, right hip and spine, Nurse E also confirmed that this would be considered a infection control issue. Nurse E also confirmed that she did not clean the scissors that were removed from her scrub pocket prior to use, which is also a infection control issue. On 3/23/23 at approximately 12:22 PM, a interview was conducted with the Director of Nursing who stated that it was her expectation for the nurse to follow the policy and procedure for wound care for infection control. On 3/23/23 a review was conducted of the facility policy N-1310 for Dressing Change last revised on 12/6/2017 which revealed under Policy: A Clean dressing will be applied by a nurse to a wound as ordered to promote healing. Sterile Dressing will be used only if specifically ordered. Under Procedure: revealed: Identify resident. Explain procedure, provide privacy. Assemble equipment as needed for dressing change. Place supplies on prepped work surface. Perform hand hygiene, apply gloves. Remove and dispose of soiled dressing remove gloves perform hand hygiene apply gloves, evaluate wound for type, color, amount of drainage. Cleanse wound as ordered, dispose of gauze. Remove gloves and perform hand hygiene. Apply treatment as ordered and clean dressing. Discard gloves and perform hand hygiene. Document in medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 12 of 12