Health inspection·August 18, 2022

F 0567 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Resident Trust Fund - Banking Hours revised on 6/8/17 read, All Care Centers will keep banking hours as mandated by law. The procedure list revealed the facility may have an assigned designee, in addition to the Business Office, to assist with resident's request for cash withdrawals after regular banking hours and on the weekends. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 2 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain physician orders upon admission to address wound care for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 68 residents, (#343). Residents Affected - Some Findings: Review of resident #343's medical record revealed she was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease, diabetes, adult failure to thrive, and metabolic encephalopathy. Review of the Nursing admission Assessment form dated 8/10/22 revealed the resident was was alert, her memory was okay, and she was oriented to person, place, and time. The form noted the resident had wounds to left buttock and left heel. Review of the physician progress note dated 8/11/22 at 11:53 AM, showed the resident had sacral and left heel ulcers. A care plan dated 8/10/22 and revised 8/17/22 for risk of skin breakdown, related to decreased mobility included interventions for staff to follow facility protocols and treatment as ordered by the physician and Wound Doctor evaluation and Treatment as ordered/indicated. Review of physician orders, nurses progress notes, Treatment Administration Record (TAR) and Medication Administration Record (MAR) for the month of August 2022 revealed neither treatment orders for wound care nor documentation regarding treatment orders, nor any communication to the physician regarding obtaining orders to address treatment for wounds. On 8/16/22 at 11:25 AM, resident #343 confirmed she had open areas on left buttock and left heal. She stated she was upset that nurses had not done any wound care to the open areas and explained she was diabetic. In an interview and record review on 8/17/22 at 10:42 AM, the Unit Manager (UM) of 300, 400, 500 hallways acknowledged there were no physician orders for wound care to the resident's left heel or left buttocks. She stated the nurse that admitted the resident was responsible to obtain wound care orders. She explained all new admission resident orders were reviewed in the morning clinical meetings but did not explain why wound care orders were not obtained for resident #343. On 8/17/22 at 1:12 PM, the Director of Nursing (DON) stated they ensured all newly admitted resident's charts including physician orders were reviewed in morning meetings. She noted she was unsure what happened with the chart check that morning meeting, after the resident was admitted . She could not explain why the nurse did not notify the physician and obtain orders for resident #343's wounds upon admission. The DON indicated she and the UM were responsible to ensure orders were obtained for new admissions. Review of the facility Policies and Procedures for Physician Orders with an effective date of 11/30/14 and revised date of 3/3/21, The center will ensure that Physician orders are appropriately and timely documented in the medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 3 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0635 Level of Harm - Minimal harm or potential for actual harm Review of the facility Policies and Procedures for Clinical Guideline Skin & Wound with an effective date 4/1/17 revealed To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 4 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess and complete the Minimum Data Set (MDS) assessment Section F-preferences for customary routine and activities for 1 of 4 residents reviewed for activities of a total sample of 68 residents, (#138). Residents Affected - Few Findings: Clinical record review revealed resident #138 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, metabolic encephalopathy, Alzheimer's disease, transient ischemic attack, dementia, and contracture of the right and left hip, and right knee. The resident's significant change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 8/02/22 revealed the resident was rarely/never understood. Assessment for Section F0500 Interview for Activity Preferences indicated it was very important for the resident to have books, newspaper, magazines to read, to do things with groups of people, to do favorite activities, to go outside to get fresh air when the weather is good, to participate in religious services or practices, and it was somewhat important to listen to music, be around animals such as pets, and keep up with the news. Response for F0600 Daily and Activity Preferences Primary Respondent was coded as 1. indicating the primary respondent was the resident. On 8/18/22 at 3:43 PM, the Activity Director stated she completed section F of the resident's significant change MDS. She explained that to complete the assessment, she conducted interviews with the resident/resident representative, and with the assigned Certified Nursing Assistant (CNA). Section F 0500 of the resident's significant change MDS with ARD of 8/02/22 was reviewed with the Activity Director. She acknowledged the findings, and confirmed the she completed the assessment. The Activity Director stated she obtained the responses from observation of the resident. She acknowledged all responses could not be obtained by observations and verified the resident and/or family was not interviewed to complete the assessment. The Activity Director verbalized the resident could not speak, and she had never spoken to the resident. She acknowledged the assessment was incorrect. On 8/18/22 at 4:10 PM, Section F 0500 of the resident's significant change MDS with ARD of 8/02/22 was reviewed with the Director of Nursing (DON). The DON stated resident #138 was rarely understood, and was not capable of answering questions in Section F. The DON stated the expectation was that staff would complete an accurate and truthful assessment. Duties and responsibilities listed on the job description of the Dir. Therapeutic & Recreational Services I &II (Activity Director)' updated 01/2018 included, Conduct and document a thorough assessment of each resident's recreational needs .Complete required documentation in an accurate and timely manner. The Centers for Medicare & Medicaid Services ' Long Term Care Facility Resident Assessment Instrument 3.0 Manual Version 1.17.1 October 2019 Section F read, The intent of items in this section is to obtain information regarding the resident ' s preferences for his or her daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 5 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed for 1 of 3 residents reviewed for PASRR of a total sample of 68 residents, (#36). Residents Affected - Few Findings: Review of resident #36's medical record revealed he was admitted to the facility on [DATE] with diagnoses of schizophrenia, anxiety, depression, and mood disorder. The resident's PASRR form was dated 7/21/20, which reflected a completion date of four months after the resident was admitted to the facility. On 8/18/22 at 11:10 AM, the Social Services Director said, My process is to review the PASRR for completeness and accuracy. I was not here when the resident was admitted and I cannot speak for the previous person. She explained the PASRR form should have been completed prior to resident #36's admission. On 8/18/22 at 11:21 AM, the Corporate Admissions Director stated PASRR forms should be reviewed by facility staff prior to resident's admission. She stated if a resident was admitted with an incomplete PASRR form, usually a nurse or Social Worker would complete the document. The facility's Preadmission Screening and Resident Review (PASRR) Policy and Procedure dated 11/08/21 read, It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 6 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered baseline care plan, that addressed care and services, and failed to provide a summary to the resident and resident representative within 48 hours for 2 of 4 newly admitted residents reviewed for baseline careplans of a total sample of 68 residents, (#108, #343). Findings: 1. Resident #108 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease, hemiplegia and hemiparesis right dominant side, diabetes, and heart failure. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5 out of 15 which indicated the resident's cognition was severely impaired. The assessment noted the resident required extensive assistance from staff with activities of daily living, was occasionally incontinent of bladder and bowel, and was not steady moving from seated to standing position, walking or moving on or off the toilet. Review of the resident's medical record showed a baseline care plan was created on 7/16/22 to address the resident's care needs. The signature on the form from the facility representative was dated 7/28/22 with a handwritten comment, Reviewed with family via phone. The signature and date lines for resident and signature of representative were blank. On 8/17/22 at 2:26 PM, resident #108 stated, no, I didn't sign anything, no one talked to me about a care plan, or things to help me with getting better to go home. On 8/17/22 at 5:03 PM, in a telephone interview with resident #108's wife stated she did not remember discussing the baseline care plan, or services with facility staff by telephone. 2. Resident #343 was admitted to the facility on [DATE], with diagnoses of metabolic encephalopathy, chronic obstructive pulmonary disease, diabetes, adult failure to thrive, hypertension and depressive disorder. Review of the Nursing admission Assessment form dated 8/10/22 at 3:30 PM, revealed resident #343 was alert, and oriented to person, place, and time. Review of the paper medical record revealed a blank baseline care plan with no documentation of concerns, goals, interventions, signatures, or dates. Review of resident #343 electronic medical did not reveal a baseline care plan. There was no baseline care plan developed, implemented or summary provided to the resident, or resident representative. On 8/15/2022 10:45 AM, Resident #343 stated no one spoke to me regarding a baseline care plan, and review of problems, goals was not done. She stated, did not get copy of or sign any care plan form. On 8/17/22 10:39 AM, Unit Manager (UM) 300, 400, 500 hallway explained nurses and the UM do not do anything with the care plans and added they were completed by MDS staff. She stated MDS staff were responsible for baseline care plans, and she was unsure how soon baseline care plan should be completed or when they were discussed with residents or their representative. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 7 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/17/22 at 1:12 PM, the Director of Nursing (DON) stated nurses were responsible for starting the baseline care plan and care needs were discussed in the morning clinical meeting with review of new admissions. She stated MDS staff and nursing staff should review the baseline careplan with resident/representative. She explained the facility practice is the baseline care plans were discussed with resident or representative within 48 hours by the admitting nurse. She further explained the DON and unit managers were responsible to ensure documentation for baseline careplans was completed, it is a collaborative effort. On 8/18/22 at 12:15 PM , the MDS Case Manager stated the team discussed newly admitted residents in morning meetings and base line care plans were started by the admitting nurse. She explained the care plans can be updated as needed. Review of the facility Policies and Procedures for Plans Of Care with an effective date 11/30/14 and a revision date of 9/25/17 revealed under Procedure: Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASRR recommendations, if applicable, and other areas needed to provide effective care of the resident= that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 8 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 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** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for activities for 1 of 4 residents reviewed for activities, (#138), and failed to update a care plan to reflect the residents' preferences and choices for 1 of 4 residents reviewed for choices in a total sample of 68 residents, (#121). Findings: 1. Review of the resident #138's medical record noted she was 64-years-old and admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, Alzheimer's disease, transient ischemic attack, dementia, and contractures of the right and left hips, and right knee. The resident's significant change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/02/22 revealed the resident was rarely/never understood. Assessment for Section F0500 Interview for Activity Preferences indicated it was very important for the resident to have books, newspapers, magazines to read, to do things with groups of people, to do favorite activities, to go outside to get fresh air when the weather is good, to participate in religious services or practices, and it was somewhat important to listen to music, be around animals such as pets, and keep up with the news.' Response for F0600 Daily and Activity Preferences Primary Respondent indicated the primary respondent was the resident. On 8/15/22 at 12:31 PM, 8/16/22 at 9:27 AM, and on 8/17/22 at 10:43 AM, resident #138 was in bed, her eyes were open, but there was no response when spoken to. The resident was not observed in any activities and neither the television nor radio were playing. On 8/16/22 at 4:35 PM, Licensed Practical Nurse (LPN) F stated activities were mainly done during the day shift, but she was unsure of the activities provided for the resident. On 8/17/22 at 5:07 PM, the Activity Director stated resident #138's Certified Nursing Assistant (CNA) offered 1:1 activities for the resident, such as reading, music therapy, and turning on the resident's television to a channel of her choice. She stated Activity staff also provided music and turned on the resident's television. The resident's clinical records were reviewed with the Activity Director and no documentation by activity staff was identified. She stated nothing was charted for the resident today. She could not identify any program of activities for the resident, and said the resident assessment had not yet been completed but was in progress. She explained a care plan for activities would be developed by her based on the resident's assessment, and verbalized she had not initiated/implemented a care plan for activities for the resident. The resident's care plans were reviewed with the Activity Director and no current or past care plan for activities could be identified. 2. Review of the medical record revealed resident #121 was admitted to the facility on [DATE] with diagnoses that included dementia, recurrent depressive disorders, and bipolar disorder. Review of the quarterly MDS assessment with ARD 7/28/22 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated she was moderately cognitively impaired. The assessment showed resident #121 was totally dependent on staff for bed mobility, toileting, and personal hygiene and required extensive assistance with dressing. The assessment revealed transfers occurred only once or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 9 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 twice during the entire 7-day lookback period and noted no rejection of care necessary to obtain goals for her health and well-being. Review of the annual MDS assessment with ARD 10/31/21 revealed it was very important to her to have family involved in the discussions about her care and somewhat important for her to go out and get fresh air when the weather was nice. Review of resident #121's care plan for Activities of Daily Living (ADLs) included a goal for the resident to receive the appropriate staff support with bed mobility, transfers, dressing, toileting, grooming and bathing. Review of the care plan for mood included interventions dated 11/19/20 to provide the resident with a program of activities that was meaningful and of interest and assist the resident or resident representative to identify strengths, positive coping skills and reinforce those. On 8/15/22 at 2:59 PM, resident #121's husband stated he was concerned his wife spent too much time in bed. He said staff were supposed to take her out of bed every Friday so he could take her out to the patio, but this had not been done the two previous Fridays. He mentioned staff were inconsistent when it came to getting his wife ready on Fridays. He indicated he sometimes saw her for weeks at a time in bed, and said, this is her world, and it breaks my heart. He noted she was isolated here because her limited mobility reduced the activities she could participate in. On 8/17/22 at 9:38 AM, resident #121's husband repeated to two Certified Nursing Assistants (CNAs) to get his wife ready by 2:30 PM this coming Friday because it was her birthday and he wanted to take her out. CNA D stated resident #121 looked forward to her husband taking her outside to the patio as he spent a good amount of time with her. On 8/17/22 at 5:39 PM, the 200 Hall Unit Manager (UM) stated she knew resident #121's husband requested his wife to be ready every Friday for him to take her out. She explained he visited every day, but wanted to take her out every Friday. The UM said resident #121's husband called every Friday to remind staff to get his wife out of bed. She indicated she was unsure if this request was included in the resident's care plan and acknowledged it should be. After reviewing the resident's care plan, the UM confirmed the intervention was not included in the care plan. included. On 8/18/22 at 11:38 AM, the MDS Lead explained she made updates to the care plans for each resident based on information she learned during clinical meetings. She said she was not aware resident #121 and her husband had requested to be up and ready every Friday. She reviewed resident #121's care plan and acknowledged the request to be ready each Friday was not included in the care plan. The MDS Lead stated the purpose of the care plan was for everyone to know how to take care of the residents. She indicated if an intervention was something that happened every single Friday, it should have been documented in the care plan so the resident would be ready. Review of the policy titled Plans of Care revised on 9/25/17 read, Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions . The Individualized Person-Centered plan of care may include but is not limited to the following: Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 10 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed, revised, and individualized, for falls for 1 of 4 residents reviewed for falls out of a total sample of 68 residents, (#108). Findings: 1. Resident #108 was admitted to the facility on [DATE] with diagnoses of hemiplegia, hemiparesis, and heart failure. The resident's Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5 out of 15 which indicated the resident's cognition was severely impaired. The assessment identified the resident required extensive assistance of one staff person with activities of daily living, was occasionally incontinent of bladder and bowel, not steady moving from seated to standing position, and walking or moving on or off the toilet. It noted the resident had history of falls since admission, and one fall in the facility with no injury. Review of the medical record showed a care plan initiated 7/18/22 with revision date 7/27/22 that noted risk of falls related to weakness, decreased endurance, recent Coronavirus infection, kidney disease stage 4, cerebrovascular accident with right sided paralysis. The goal was to minimize the risk of falls, and interventions included to anticipate resident's needs, call light in reach, encourage assistance as needed, bed low position, ensure appropriate footwear/nonskid socks when ambulating or mobilizing in wheelchair, and physical therapy to evaluate as ordered or as needed. The medical record revealed resident #108 fell on 7/22/22 at 3:00 PM. A Change in Condition note dated 7/22/22 at 3:55 PM showed resident stated he was walking with walker and fell to the floor. On 8/18/22 at 11:16 AM, the fall incident and record review with Director of Nursing (DON) revealed the resident fell in his room on 7/22/22 at 2:30 PM and he was assessed with no injuries. The DON reviewed the care plan and acknowledged the fall was neither listed on the resident's care plan nor any post fall interventions added. She stated the resident's care plan was not updated, and the expectation was resident care plans to be updated, revised, and individualized. 08/18/22 03:36 PM, the MDS Manager explained the facility always discussed falls in morning clinical meetings with the team and new interventions were included at the time. She stated MDS staff were responsible for updating the care plans and did not know why resident #108's care plan was not done. Review of the facility Policies and Procedures for Plans of Care with an effective date 11/30/14 and a revision date of 9/25/17 under Procedure: showed, Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS Assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented towards attaining or maintaining the highest practicable physical, mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 11 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide oral care for 1 of 4 residents reviewed for Activities of Daily Living (ADL) of a total sample of 68 residents, (#12). Residents Affected - Few Findings: Review of resident #12's medical record noted he was admitted to the facility on [DATE] with diagnoses that included apraxia, schizophrenia, contracture, dementia, and gastrostomy. Review of the physician orders revealed the resident was to have nothing by mouth and had orders for tube feedings, Glucerna 1.5 at 60 milliliters/hour for 22 hours per day. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/25/22 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 3/15. The assessment indicated the resident was totally dependent on staff for bed mobility, dressing, eating, and personal hygiene, and had functional limitation in range of motion on one side of his upper extremity, and on both sides of his lower extremities. On 8/15/22 at 11:27 AM, 8/16/22 at 9:07 AM, and 8/17/22 at 10:47 AM, resident #12 was lying in bed on his back and gave no response when spoken to. The resident's bottom lip was dry, and cracked with plaque/scab noted. On 8/17/22 at 10:51 AM, Licensed Practical Nurse (LPN) I stated resident#12 was on tube feedings. She observed the resident and acknowledged his bottom lip was dry and cracked. On 8/17/22 at 11:00 AM, Certified Nursing Assistant (CNA) G stated she had worked with resident #12 before, and he required total care with all his Activities of Daily Living (ADL) including oral care. She stated the resident was not resistant to care, and was not combative. She explained he received tube feedings, and oral care should be provided every shift but noted she had not provided oral care for the resident. On 8/17/22 at 3:35 PM, the Director of Nursing (DON) stated oral care was to be completed every shift by the CNAs or the nurse and should be documented. A care plan for oral/dental health problems created on 5/30/22 noted intervention to provide mouth care as per ADL personal hygiene. Review of the resident's care plan for ADL self-care performance deficit created 5/30/22 revealed the resident required assistance by 1 staff with personal hygiene and oral care. The facility's policy Oral Hygiene with effective date of 11/30/2014, and revision date of 9/01/2017 listed instructions for mouth care, and directed that staff should repeat procedure as frequently as necessary to keep mouth clean and moist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 12 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure physician's orders were implemented for compression stockings for 1 of 1 resident reviewed for edema, of a total sample of 68 residents, (#114). Residents Affected - Few Findings: Review of resident #114's medical record revealed he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, heart failure, chronic peripheral venous insufficiency, and generalized edema. Review of the the resident's physician orders revealed an order dated 7/14/22 that read, TED hose: Nursing to assist patient with don/doff of TED hose on BLE [bilateral lower extremities], size 2 XL thigh high at all times for edema. 'TED hose are long, tight fitting stockings that place mild static pressure on the legs to prevent blood from clotting. [Retrieved from-health. com 8/26/22] On 8/16/22 at 11:02 AM, resident #114 explained he had edema to his thigh, and approximately three weeks ago, the physician ordered thigh high support stockings for him. He said he had not heard anything about the stockings, and stated he really needed them to help with the edema of his thighs. On 8/17/22 at 4:56 PM, Licensed Practical Nurse (LPN) F reviewed the resident's physician orders, and stated the resident was supposed to have thigh high TED hose on at all times. On 8/17/22 at 5:00 PM, observation of the resident was conducted and LPN F acknowledged the resident did not have TED hose stockings on. On 8/18/22 at 3:11 PM, the resident's physician orders were reviewed with the 100 Hall LPN Unit Manager (UM). She confirmed the resident had an order dated 7/14/22 for thigh hose, and verbalized she was not aware the hose were not available. Clinical record review conducted with the LPN UM revealed no documentation to indicate the physician was made aware the TED hose were not available. On 8/18/22 at 3:20 PM, observation of the resident was conducted with the 100 Hall UM. She confirmed the resident was not wearing thigh high TED hose/stockings but had on knee high tubi-grip. The resident told the 100 Hall UM he was supposed to have thigh high stockings a long time ago and told her that he had never had thigh high stocking. The UM stated the expectation was for nurses to follow through with the physician's orders, and if the treatment was not available, nurses should notify the UM, so the physician could be made aware and new/ additional orders could be obtained. On 8/18/22 at 3:30 PM, LPN I stated resident #114 was included in her assignment, and the resident did not have thigh high hose on, instead he had knee high hose on. LPN I said the expectation was to follow the physician's order, and if the treatment was not available, the physician should be notified. On 8/18/22 at 3:56 PM, the resident's physician's orders were reviewed with the Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 13 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0684 Level of Harm - Minimal harm or potential for actual harm (DON). She confirmed physician's order dated 7/14/22 was for thigh high TED hose. Observations and interview with the resident was shared with the DON. She said the expectation was that nurses would follow the physician's orders, and if order/treatment was not available, the physician should be informed, and encounter documented as communication with the provider. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 14 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 observation, interview, and record review the facility failed to provide bilateral palm guards and left elbow brace per physician orders to prevent further decrease in range of motion (ROM) for 1 of 5 residents reviewed for limited ROM of a total sample of 68 residents, (#139). Findings: Review of resident #139's clinical record noted she was admitted to the facility initially on 7/22/05, with her most recent readmission on [DATE]. Her diagnoses included, injury of head, quadriplegia, spinal stenosis, dementia, and drug induced subacute dyskinesia. Review of the Functional Maintenance Program document with effective date 4/28/22 indicated the resident should have Bilateral Palm guards for 4-6 hours as tolerated. Progress note on 7/22/22 read, Continues on restorative nursing program for activity tolerance, strengthening, splinting .Resident d/c [discharged ] from restorative to have therapy eval.[evaluation] The resident's physician's order dated 5/16/22 read, bilateral upper extremities palmar guard-apply to bilateral hands as needed, left elbow brace-apply daily 3-4 hours. Resident #139's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/04/22 revealed the resident was rarely/never understood. The assessment indicated resident #139 had total dependence of one staff person assistance for bed mobility, dressing, toilet use, and personal hygiene, and had functional limitation in range of motion to both sides of her upper and lower extremities. Observations on 8/15/22 at 12:30 PM, and on 8/16/22 at 9:28 AM, showed resident # 139 lying in bed. Her right and left hands were contracted, and the resident did not have any splint on. On 08/16/22 at 4:35 PM, Licensed Practical Nurse (LPN) F stated resident #139 had contractures and had physician orders for palm guards to both hands, and a brace to her left elbow. On 8/16/22 at 4:46 PM, observation of resident #139 was conducted with LPN F. She confirmed the resident did not have palm guards to her bilateral hands and did not have a brace to her left elbow. She stated Restorative Therapy staff usually placed the palm guards, and they would be removed for activities of daily living (ADL) care. The resident's palm guards were found by LPN F in the resident's chest of drawers, but her splint/brace was not located. On 8/16/22 at 4:58 PM, the 100 Hall LPN Unit Manager (UM) stated resident #139 had contractures of her bilateral hands. The resident's physician orders were reviewed with the UM, she confirmed active orders were in place for palm guards, and left elbow brace, and stated the Director of Nursing (DON) was responsible for the Restorative Nursing Program (RNP). Multiple observations of the resident without palm guards, and her left elbow brace was shared with the UM. On 8/16/22 at 5:29 PM, the Director of Nursing (DON) stated resident #139 was discharged from the RNP on 7/22/22 and was referred to therapy for further evaluation. The DON said she was not sure if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 15 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 therapy was done, or if the resident was currently on therapy caseload. Review of the resident's active physician orders were conducted with the DON. She confirmed the resident had active physician orders for palm guards, and brace to her left elbow. On 8/17/22 at 4:27 PM, the Director of Rehab stated the facility had restorative meetings monthly, and at the meeting on 7/22/22, the DON referred resident #139 back to Therapy and stated the resident's splint and palm guards were missing. The Director of Rehab stated she ordered palm guards, but did not order a splint, and the new palm guards came in on Friday 8/12/22. She stated nursing inputs orders in the electronic medical records, and RNP was discontinued on 7/22/22 for the resident, but orders for palm guards, and left elbow splint were not discontinued. The Director of Rehab stated there was the potential for the resident's contractures to worsen when treatment was not provided as ordered. The resident's care plan for ADL self-care performance deficit related to quadriplegia, impaired ROM to bilateral upper and lower extremities was initiated on 8/16/22. An intervention initiated on 8/16/22 was for bilateral upper extremities palmar guard- apply to bilateral hands as needed, Left elbow brace -apply daily as ordered. A care plan to address the resident's contracture and splinting could not be identified until 8/16/22. The Facility Assessment Tool updated on 5/05/2022 indicated that services and care offered included contracture prevention/care, and management of braces,splints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 16 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure ongoing communication, coordination and collaboration between the nursing home and the dialysis center for 1 of 1 resident reviewed for dialysis of a total sample of 68 residents, (#136). Residents Affected - Few Findings: Resident #136 was admitted to the facility on [DATE], readmitted [DATE] and 8/06/22 with diagnoses including dysphagia, end stage renal disease (ESRD), dependence on renal dialysis, encephalopathy and heart failure. Review of the Minimum Data Set admission assessment with assessment reference date 8/04/22 revealed resident #136 had a Brief Interview for Mental Status score of 4 which indicated he had severe cognitive impairment. He required extensive to total assistance for activities of daily living and did not reject care. Review of resident #136's medical record revealed a physician order dated 8/01/22 for hemodialysis at an outside facility on Mondays, Wednesdays and Fridays at 12:45 PM. Hemodialysis is a procedure where a dialysis machine and special filter are used to remove wastes and fluids from the blood to keep a person healthy when the kidneys no longer function properly (retrieved 8/20/22 from the National Kidney Foundation website at www.kidney.org). A care plan initiated 8/10/22 indicated resident #136 required hemodialysis related to renal failure. Interventions included hemodialysis at an outside center on Mondays, Wednesdays and Fridays at 12:45 PM. The care plan did not include any interventions or approaches for communication, coordination and collaboration between the facility and the dialysis center. A review of resident #136's physical chart revealed the chart did not include any Dialysis Communication forms. A review of the Progress Notes from 8/01/22 through 8/17/22 revealed no documentation the facility communicated with the dialysis center on 8/01/22, 8/03/22, 8/05/22, 8/10/22, 8/12/22 and 8/17/22 following resident #136's return to the facility following dialysis. On 8/17/22 at 2:31 PM, the 400/500 Unit Manager (UM) provided a dialysis binder for resident #136 which contained a blank dialysis information form but did not contain any Dialysis Communication forms. The 400/500 UM verified there were no Dialysis Communication forms in the binder nor in the resident's physical chart. She stated she would check the electronic medical record. On 8/17/22 at 4:00 PM, the 400/500 UM stated she could not locate any Dialysis Communication forms in her office, the paper chart nor the electronic medical record. On 8/17/22 at 4:13 PM, the Medical Records Director stated Dialysis Communication forms were sent with the resident to the dialysis center and were returned with the resident. He explained nursing reviewed the form and provided the form to medical records to be scanned into the electronic medical record. He reviewed the electronic medical record and paper chart and confirmed he had no 'Dialysis Communication forms for resident #136. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 17 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/17/22 at 4:37 PM, Licensed Practical Nurse (LPN) A confirmed that nursing sent Dialysis Communication forms with residents to dialysis. She recalled seeing forms sent from the 100 unit but had not seen forms on the 500 unit. LPN A stated she took vitals and assessed the port site for resident #136 when he returned from dialysis but did not have any communication with dialysis. On 8/17/22 at 4:54 PM, the Director of Nursing stated when a resident went out for dialysis, the nurse assessed the resident before leaving and upon return. She explained there was a communication book with a Dialysis Communication form that went with the resident to the dialysis center. She stated the expectation was for nurses to check the form upon resident's return and to contact the dialysis center if the form was not completed to gather information. She clarified the nurse should document the conversation in the resident's progress notes. The Director of Nursing reviewed resident #136's medical record and verified there were no nursing progress notes regarding communication with the dialysis center. She stated if nurses called and did not document it in the record, the record would be incomplete. The facility's Coordination of Hemodialysis Services policy revised 7/02/19 read, residents requiring an outside ESRD facility will have serviced coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. Procedures included a Dialysis Communication form would be initiated by the facility and reviewed by the ESRD facility. The form would be completed by the ESRD facility and returned with the resident or the ESRD facility would provide treatment information to the facility. Nursing would review the Dialysis Communication form or information sent by the ESRD facility and complete the post dialysis information section on the form and file the completed form in the resident's clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 18 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the accurate dosage of insulin was administered as per physician's orders, and failed to ensure the medication was administered as scheduled to 1 of 7 residents observed for medication administration observation of a total sample of 68 residents, (#9). Residents Affected - Few Findings: Review of resident #9's clinical record showed he was admitted to the facility on [DATE] with diagnoses of diabetes type II with neuropathy, and long-term use of insulin. On 8/16/22 between 10:00 AM-10:05 AM, during medication administration observation with Registered Nurse (RN) H, resident #9's blood glucose was monitored at 360 milligram/deciliter (mg/dL). On 08/16/22 at approximately 10:19 AM, RN H withdrew 15 units of insulin Lispro from a multi-dose vial and administered the insulin in the resident's upper right arm. In an interview conducted with resident #9 immediately after the administration of the insulin, the resident stated he had already eaten breakfast. RN H stated breakfast was served on the unit at 8 AM. RN H reviewed the electronic physician order at the medication cart and verbalized that there was no directive regarding the time of administration. Review of physician's orders for resident #9 revealed he was prescribed Humalog [Lispro] subcutaneously as per sliding scale with meals, instruction was, only give if eating and was scheduled for 8 AM, 11 AM, and 4 PM. The resident was to receive insulin based on his blood glucose results, as follows: if 151-200= 6 units, 201-250=8 units, 251-300=10 units, 301-350=12 units, 351-400=14 units. Additional orders were for Levemir [insulin] 14 units subcutaneously daily. Resident #9's blood glucose was 360 mg/dL indicating the resident should have received 14 units of insulin. RN H administered 15 units of insulin. On 8/16/22 at 2:20 PM, RN H verbalized she administered 15 units of Lispro insulin to resident #9 during medication administration observation. The resident's physician orders were reviewed with the RN. She verbalized that for a blood glucose of 360 mg/dL the resident should have received 14 units of Lispro Insulin. RN H also verbalized the insulin was to be given with meals, at 8 AM, and she was approximately two hours late with administration. On 8/16/22 at 2:28 PM, the resident's physician's orders were reviewed with the 100 Hall Licensed Practical Nurse (LPN) Unit Manager (UM). She confirmed that for a blood glucose level of 360 mg/dL, orders indicated the resident should receive 14 units of Humalog [Lispro] insulin. She verbalized the insulin was to be administered with meals and was scheduled for 8 AM, 11 AM, and 4 PM. The LPN UM stated she would inform the physician of the medication error. On 8/16/22 at 5:40 PM, the Director of Nursing (DON) stated she was aware of the concern and said she spoke with RN H. She said she asked RN H if she had administered 14 units of insulin as she documented on the Medication Administration Record (MAR) and the RN said round about 15 units Review of the resident's MAR for 8/16/22 revealed documentation in the 8 AM box was 14. However, observation during medication administration observation, and interview with RN H, she verbalized and confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 19 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 0760 she administered 15 units of Lispro to the resident. Level of Harm - Minimal harm or potential for actual harm On 8/17/22 at 3:51 PM, the DON verbalized she spoke with RN A again, and the RN said she gave 14 units of Lispro on 8/16/22 at 10:04 AM. She said RN A told hr the resident's blood glucose was checked, and he received his scheduled 11 AM insulin between 12 and 1 PM. Residents Affected - Few The resident's Medication Admin Audit Report for 8/16/22 was reviewed with the DON, and revealed the resident received his scheduled 8 AM insulin at 10:04 AM. Levemir 14 units scheduled for 9 AM, was administered at 10:19 AM, and for Lispro sliding scale scheduled at 11 AM documentation indicated 6 units was administered at 10: 21 AM. The DON stated she was not with the RN when she administered the insulin to the resident, but the administration times documented on the resident's Medication Admin Audit Report did not correspond with the interview she obtained from the RN. The facility's policy Insulin Administration with effective date 11/30/2014 and revision date 11/04/2020 steps in the procedure instructs the staff to obtain physician's order . withdraw the insulin slowly until the correct dose is measured. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 20 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure potentially hazardous foods were at a cold holding temperature of 41 degrees Fahrenheit, or below, to prevent foodborne illness. Residents Affected - Some Findings: Review of the facility lunch menu on 8/17/22, revealed residents had a choice between egg salad sandwich or ham sandwich, creamy dill macaroni salad or potato chips, mandarin oranges, country tomato salad or marinated cucumber and onion salad. On 8/17/22 at 11:35 AM, the lunch tray line was observed and noted one cook, one dietary aide and the Certified Dietary Manager (CDM) in the vicinity of the tray line. [NAME] B checked the temperatures of the cold food items on the holding table with the facility's digital, bayonet style thermometer. She reported the egg salad had a holding temperature of 43.6 degrees Fahrenheit, the macaroni salad had a hold temperature of 43.7 degrees Fahrenheit, the pureed macaroni salad had a holding temperature of 42.3 degrees Fahrenheit, the pureed egg salad had a temperature of 41.6 degrees Fahrenheit and the pureed green bean salad had a holding temperature of 44 degrees Fahrenheit. The items were noted to be in deep pans. The CDM stated the holding temperature was supposed to be 40 degrees Fahrenheit or less for cold items. The CDM instructed the cook and aides to place the items in shallow pans and place them in the freezer. On 8/18/22 at 1:08 PM, the CDM stated upon preparing lunch on 8/17/22, the staff made an error and placed the cold food items in deep pans instead of shallow pans to cool which caused the incorrect holding temperatures. The United States Food and Drug Administration's Food Code 2017, notes in chapter 3 that potentially hazardous foods, need to be at a cold holding temperature of 41 degrees or below. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 21 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document physician's order for thigh high compression hose for 1 of 1 resident reviewed for edema, of a total sample of 68 residents, (#114). Findings: Review of resident #114's clinical record noted he was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, heart failure, chronic peripheral venous insufficiency, and generalized edema. Review of the physician's orders for resident #114 revealed an order dated 7/14/22 read, TED hose: Nursing to assist patient with don/doff of TED hose on BLE [bilateral lower extremities], size 2 XL thigh high at all times for edema. 'TED hose are long, tight fitting stockings that place mild static pressure on the legs to prevent blood from clotting. [Retrieved from-health. com 8/26/22]. On 8/16/22 at 11:02 AM, resident #114 stated he had edema of his thigh, and approximately three weeks ago, the physician ordered thigh high support stockings for him. He said he has not heard anything about the stockings, and stated he really needed the stockings to help with the edema of his thighs. On 8/17/22 at 4:56 PM, Licensed Practical Nurse (LPN) F reviewed the resident's physician's orders, and stated the resident was supposed to have thigh high TED hose on at all times. Review of the resident's Treatment Administrative Record (TAR) for the period 7/14/22 to 8/17/22 revealed nurses signed for the physician order for thigh high TED hose on the day, evening, and night shifts. On 8/18/22 at 3:11 PM, and 3:20 PM, the resident's physician's order and TAR were reviewed with the 100 Hall LPN Unit Manager (UM). She confirmed the resident had orders dated 7/14/22 for thigh high TED hose, and stated the order would populate on the resident's TAR. The UM reviewed the resident's TAR, and verbalized the order was on the TAR, and was signed by nurses as being done. She stated if the resident was not wearing the appropriate size TED hose, signing off on the TAR was not correct. On 8/18/22 at 3:30 PM, LPN I stated resident #114 was included in her assignment. She said the resident did not have thigh high hose on, instead he had knee high hose on. LPN I said the expectation was to follow the physician's order, and if the treatment was not available, the physician should be notified. Review of the resident's TAR for 8/01/22 to 8/18/22 revealed LPN I's signature six times indicating the physician 's orders were followed. LPN I did not explain why she signed for the order when thigh high hose was not available. On 8/18/22 at 3:35 PM, LPN F stated she signed on the resident's TAR for the TED hose which indicated the physician order was followed. LPN F verbalized resident #114 did not have thigh high TED hose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 22 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 in place at the time the TAR was signed. LPN F explained she signed for the order as he the resident had some sort of stocking on even though it was not the correct type. LPN F's signature was on the TAR nine times for the period 8/01/22 to 8/14/22. On 8/18/22 at 3:56 PM the resident's physician's orders were reviewed with the DON who confirmed the order on 7/14/22 was for thigh high TED hose. Observations, and interviews with the resident and staff were discussed with the DON, and the resident's TAR was reviewed. The DON stated the facility did not have a policy regarding documentation, but the expectation was that nurses would follow the physician's orders Event ID: Facility ID: 105440 If continuation sheet Page 23 of 24 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 105440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices to prevent cross contamination during wound care for 1 of 3 residents reviewed for pressure ulcers of a total sample of 68 residents, (#129). Residents Affected - Few Findings: Review of the medical record revealed resident #129 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include vascular dementia, and atrial fibrillation. The physician orders for resident #129 included consult Infectious Disease specialist for left heel wound; obtain an x-ray of the left heel regarding an ulcer related to osteomyelitis or bone infection; and give antibiotics, Augmentin 875-125 milligrams (mg) tablet twice a day and Doxycycline 100 mg twice a day for left heel wound. The physician's wound treatment order directed nurses to apply a non-sting skin protectant and a protective dressing to the left heel daily. On 8/18/22 at 10:15 AM, during resident's wound care observation, Licensed Practical Nurse, (LPN) C washed her hands, put on clean gloves and removed a soiled dressing from the resident's left heel. The dressing had a moderate amount of bloody drainage. LPN C proceeded to clean the wound with normal saline, then applied the skin protectant and covered the area with a border dressing. LPN C did not perform hand hygiene or change her gloves after removing the soiled dressing and before cleaning the wound. LPN C acknowledged she did not wash her hands and don clean gloves after she removed the soiled dressing and cleaned the wound as she only applied a skin protectant film. On 8/18/22 at 4:13 PM, the Director of Nursing (DON) was informed LPN C completed wound care and dressing changes for residents #129 without performing hand hygiene or changing gloves between clean and dirty procedures. The DON said, It is an infection control concern when a nurse does not maintain hand hygiene and change her gloves when performing a dressing change. A Policy and Procedure for Dressing changes, dated 11/30/14 and revised on 12/06/17 provided detailed guidance for nurses regarding wound care. The document read, Perform hand hygiene, apply gloves, remove and dispose of soiled dressing, remove gloves, perform hand hygiene, apply gloves. cleanse wound as ordered, dispose of gauze, remove gloves and perform hand hygiene, apply treatment as ordered and clean dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 24 of 24