Inspection·September 19, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interviews, record review, and policy review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents by not screening 1 of 1 resident sampled for smoking. (Resident #164)On 9/18/25, a chart review was conducted of the electronic medical record (EMR) for Resident #164. No safe smoker screening was documented in the record. On 9/18/25 at approximately 3:25 pm, an interview was conducted with the Director of Nursing (DON). She was asked about the facility process for screening residents for smoking safety. She stated a smoking screen is done on every resident on admission. If the resident smokes, teaching is provided to the resident. The resident is added to the smoking list kept by activities staff. Activities staff are responsible for providing supervision and assistance to residents who smoke. When asked about Resident #164's current smoking status, she stated that the resident does not smoke. If she does want to start smoking, she will then be screened for safe smoking, provided teaching, and set up with Activities staff. On 9/19/25 at approximately 11:02 am, an interview was conducted with Staff K (Activities Assistant), about the residents' current smoking status. She stated that she has observed Resident #164 smoking. When asked how the resident gets cigarettes, she stated that the resident had cigarettes in the lockbox used to store residents smoking supplies. When asked if the resident is on her smoking list, she states that she thinks the resident is on the list. A review of the typed smoking list then provided demonstrates Resident #164's name handwritten on the bottom of the page. The facility's undated policy entitled Smoking/Agreement/Notice of Policy stated: Patients electing to smoke will be provided a safe smoking assessment to determine an evaluate each patient's ability to safely smoke. Event ID: Facility ID: 105433 If continuation sheet Page 2 of 6 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 09/19/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures, the facility failed to provide safe and secure storage of medications for 2 of5 residents observed for medication. (Residents # 24 and 42)The findings include:Resident # 24During an observation on 09/15/2025 at 12:00 PM, Resident # 24 playing had the following medications stored at their bedside table: Medicated body Power, 2 bottles of Isopropyl alcohol 91%, Vitamins A&D Ointment, Hydrocortisone Acetate 1% Cream, Olopatadine Hydrochloride (a medicine for itchy eyes), Ophtalmic solution 0.2%, and Voltaren Arthritis pain Cream. (Photographic evidence obtained). A repeat visit on 9/16/2025 at 1:37 PM, 9/17/2025 at 11:00 AM, and 9/19/2025 at 8:00 AM showed these medications were still in the bedside table. On 09/16/2025, a review of Resident #24's record shows no orders for self-administration of medications.Resident #42On 09/15/2025 at 12:30 PM, 09/16/2025 at 8:15 AM, 9/17/2025 at 11:00 AM, and 9/19/2025 at 8:00 AM, Resident #42 was observed with the following medications at their bedside: Allergy relief nasal spray and fluticasone propionate(glucocorticoid) 50 micrograms per spray (another nasal allergy relief spray).On 09/16/2025, a record review of Resident #42 confirmed they did not have orders for self administration of medications or physician orders for this medication.On 9/18/2025 at 8:45 AM, the Staff Educator was shown the medications in the rooms of Resident #24 and #42. The staff educator stated he would notify the Unit Manager to correct the situation. Event ID: Facility ID: 105433 If continuation sheet Page 3 of 6 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 09/19/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to maintain medical records that were accurate and complete for 1 of 1 resident sampled. (Resident #63)The findings include:On 9/15/2025 at 11:47 AM, an interview was conducted with Resident #63. He stated he had a wound on his back that healed and another one on left arm that had not healed yet. On 9/17/2025 at 11:33 AM, an observation was made of Resident #63 receiving a clean dressing on his left posterior forearm.A review of Resident #63's medical record was conducted. Resident #63 was admitted to the facility on [DATE] with diagnoses including villonodular synovitis pigmented, major depressive disorder, quadriplegia, and morbid obesity. Physician's orders stated, left forearm: cleanse with wound cleanser, apply xeroform then cover with dry dressing every day shift with a start date of 7/15/25. A review of the Treatment Administration Record (TAR) revealed documentation was left blank on 9/3/25, 9/7/25, 9/8/25, 9/11/25 and 9/13/25.On 9/17/2025 at 1:20 PM, an interview was conducted with the Director of Nursing (DON). She reviewed Resident #63's TAR related to left forearm wound care documentation and acknowledged that the TAR was left blank on 9/3/25, 9/7/25, 9/8/25, 9/11/25, and 9/13/25. The DON stated it should have been documented and not left blank.On 9/18/2025 at 11:14 AM, an interview was conducted with Staff C, Registered Dietitian (RD). The RD has worked full time at the facility and had known Resident #63 for over 3 years. She stated Resident #63 had never been diagnosed with morbid obesity. A review of Resident #63's medical record was conducted with the RD including a diagnosis of morbid obesity dated 8/17/23. She then stated the diagnosis was not accurate because Resident #63 had never been obese. Event ID: Facility ID: 105433 If continuation sheet Page 4 of 6 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 09/19/2025 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, record and policy review, and interviews, the facility failed to follow infection control practices for 1 of 1 resident sampled for wound care treatment (Resident #159), 1 of 2 residents sampled for droplet isolation precautions (Resident #34), and 1 of 1 resident sampled for contact isolation precautions. (Resident #107)Resident #107 Residents Affected - Few A chart review conducted on Resident #107 revealed a physician order which stated, Isolation Type – CONTACT-methicillin resistant staphylococcus aureus (MRSA) every shift for monitoring. Observations of the resident’s room door revealed a sign for Enhanced Barrier Precautions (EBP) [a different category of contact precautions] hung on an over-the-door caddy containing Personal Protective Equipment (PPE) supplies such as gown, gloves, and masks. There was no signage for the ordered contact isolation precautions observed posted on the door. On 9/16/2025 at approximately 11:05 AM, an interview was conducted with the resident’s nurse Staff R, a Registered Nurse, about the resident’s current isolation status. He stated the resident is on enhanced barrier precautions. After consulting the resident’s record, he then stated that the resident does have an order for contact isolation precautions due to MRSA. Subsequent observations at 12:40 pm and 2:40 pm showed no change in posted signage. On 9/16/25 at approximately 1:30 pm, an interview was conducted with the Director of Nursing (DON). When asked about her expectations from nursing staff regarding a resident’s isolation status when isolation is ordered by the physician, she stated her expectations would be that the ordered isolation precaution signage would be verified posted on the resident’s door. She stated that the Assistant Director of Nursing (ADON) was responsible for posting isolation precautions when the physician placed an isolation order. On 9/16/25 at approximately 1:45 pm, an interview with the ADON was conducted. She was asked why the ordered contact isolation status was not posted. She stated that, because the resident had been on antibiotics to treat the infection, the risk of transmission is low and he was placed on EBP. The physician was not contacted for clarification on the order. The facility’s policy entitled “Isolation-Categories of Transmission-Based Precautions” last revised 2018 stated: Transmission-Based Precautions are initiated when a resident…has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The policy Interpretation and Implementation stated 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of PPE…a. The signage informs the staff of Centers for Disease Control and Prevention (CDC) precautions, instructions for use of PPE. Resident #34 On 9/15/2025 at 1:44 PM, Resident #34's room was observed with signage stating Droplet Isolation. On 9/16/25, a review of the resident’s medical record was conducted. Resident #34 did receive a positive COVID-19 result on 9/11/25. Physician's orders included Paxlovid (150/100) twice a day for 5 days with a start date of 9/12/25. There were no orders for droplet isolation. On 9/17/2025 at 9:35 AM, an interview was conducted with Staff Q, Licensed Practical Nurse (LPN). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 5 of 6 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 09/19/2025 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 Level of Harm - Minimal harm or potential for actual harm She was asked if the resident was on droplet isolation and she confirmed Resident #34 was on droplet isolation. She was asked if residents that were on droplet isolation would have a physician order for droplet isolation precautions and she stated yes. She then reviewed Resident #34’s medical record and confirmed resident did not have a physician’s order for droplet isolation. Residents Affected - Few Resident #159 On 9/16/25, a review of Resident #159’s physician’s orders was conducted. Orders included the following wound care treatments: Left schium: cleanse with wound cleanser, apply calcium alginate with silver, cover with Abdominal pad. Change daily and as needed. Right ischium: cleanse with wound cleanser, apply calcium Alginate with silver, cover with dry dressing. Change daily and as needed every night shift for wound care. Left upper thigh: cleanse with wound cleanser, apply xeroform, then cover with Abdominal pad daily and as needed every night shift for wound care. On 9/16/2025 at 4:33 PM to 5:57 PM, wound care was observed being performed by Staff D, Licensed Practical Nurse (LPN) and the unit manager, Staff E, Registered Nurse (RN) and Staff F, Certified Nurse Assistant (CNA). Staff D removed heavily soiled dressing. Linens are soiled as well. Staff D, LPN, asked Staff F, CNA, to perform skin care and linen change before continuing with wound care. Staff F, CNA, was observed cleaning Resident #159’s skin at wound site with a rag that had been inserted in soapy water. She was observed introducing the used rag inside the soapy water, squeezing the water out of the rag into the soapy water container and using the rag to clean the posterior thigh around the wound. At this moment, Staff E, RN, told Staff F, CNA, to stop, and educated her “When you use a rag you are supposed to discard it, you don't reuse it again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105433 If continuation sheet Page 6 of 6