Inspection·July 18, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 7/18/24 at 2:10 PM, the Regional nurse confirmed resident #321 did not have a self-administration evaluation assessment completed prior to 7/15/24 for medication self-administration. A review of the facility's policy and procedure for Medication Administration Self-Administration at the Bedside, dated 11/30/2014 and revised 8/22/2017, revealed, Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete Self-administration of Medication Evaluation. Complete the Care Plan for approved self-administered drugs. Event ID: Facility ID: 105440 If continuation sheet Page 2 of 11 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 07/18/2024 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 observation, interview, and record review, the facility failed to review or revise the individualized fall plan of care to include a new intervention after every fall for 1 out of 3 residents reviewed for care plans, from a total sample of 59 residents, (#62). Findings: Review of the medical record revealed resident #62 was admitted to the facility from an acute care hospital on [DATE] and had diagnoses that included history of falls, difficulty walking, paranoid schizophrenia, anxiety disorder, and dementia. The Quarterly Minimum Data Set with Assessment Reference Date 6/29/24 noted the resident scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated she was cognitively impaired. The assessment noted the resident required significant/maximum staff assistance to complete Activities of Daily Living. The comprehensive fall care plan included focus items for an actual fall with a goal that resident #62 would resume usual activities and minimize the risk of further incident through the next review date. The care plan was dated 3/23/23 and revised on 5/01/24. The interventions for the care plan did not include interventions for every fall. On 7/18/24 at 10:32 AM, the Regional Nurse Consultant explained a new intervention relative to the actual fall should be added to the care plan after each fall. She reviewed resident #62's medical record for falls that occurred on 1/08/24 and 1/20/24 and acknowledged there were no new individualized interventions added to the care plan for these and and the other falls identified. She could not explain why new interventions were not included in the fall care plan for all of resident #62's falls. Review of resident #62's medical record revealed she had five falls including the falls on 1/08/24 and 1/20/24 which had no new intervention on the Fall care plan. Review of the Fall Management policy and procedure dated 11/30/14 and revised 7/29/19 included the purpose to identify residents at risk for falls and establish/modify interventions to decrease the risks of future falls and minimize the potential for a resulting injury. Post fall strategies included, Update care plan and Nurse Aide [NAME] with interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 3 of 11 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 07/18/2024 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 0685 Assist a resident in gaining access to vision and hearing 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 a resident had a timely appointment for vision care and services for 1 out of 2 residents reviewed for vision and hearing, of a total sample of 59 residents, (#156). Residents Affected - Few Findings: Resident #156 was admitted to the facility on [DATE] from the hospital with diagnoses including hypoglycemia, adjustment disorder, anxiety disorder, and symbolic dysfunctions. Resident #156's Annual Minimum Data Set (MDS) assessment with a reference date of 3/27/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status exam which indicated he was not cognitively impaired. The MDS assessment indicated resident #156 had adequate vision and did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Resident #156's Order Summary Report showed the resident had an order on 4/19/24 for Optometry/Ophthalmology as needed and an Ophthalmology Appointment order was placed on 7/17/24 for the date of 7/30/24. Review of resident #156's medical record revealed a care plan was initiated on 4/19/24 for impaired visual function related to double vision of the left eye with interventions that included arrange consultation with eye care practitioner as required. The physician's progress noted dated 4/19/24 for resident #156 revealed the chief complaint was a follow up visit for double vision in the left eye. It noted the resident had asked to be seen by an eye doctor and would discuss with facility staff about an eye appointment. The physician' progress note dated 5/09/24 and 5/30/24 for resident #156 noted the chief complaint was a follow up visit for left eye double vision. It also noted social services was to assist with an eye appointment. The physician's progress note dated 7/08/24 for resident #156 revealed the chief complaint again was a follow up visit for double vision. It noted the resident still had double vision which was discussed with social services to set up an eye appointment. On 07/15/24 at 1:27 PM, resident #156 stated he asked to see an eye doctor about a month ago and no appointment had been set up. He acknowledged he had trouble seeing out of both eyes. On 7/18/24 at 2:31 PM, the Social Service Director (SSD) indicated nursing would inform her when the provider requested an eye appointment to be scheduled for a resident. She stated it was her responsibility to schedule eye appointments when ordered. The SSD accessed resident #156's medical record and verified that on 4/19/24, 5/09/24, 5/30/24, and 7/08/24, the provider had requested an eye appointment be scheduled for the resident. She stated she was not informed of the eye appointment request until yesterday, 7/17/24, by the Administrator. The SSD conveyed the resident had not had an eye appointment since being admitted . She acknowledged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 4 of 11 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 07/18/2024 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there should have been an eye appointment scheduled for the resident on 4/19/24 when the provider first requested one. On 7/18/24 at 3:12 PM, the 300/500 Unit Manager (UM) stated he started working at the facility on 5/23/24. He accessed the progress notes for residents #156 and confirmed on 4/19/24, 5/9/24, 5/30/24, and 7/08/24 the provider had requested for the resident to be scheduled an eye appointment. He acknowledged there should have been an eye appointment scheduled for the resident on 4/19/24 when the provider had first requested it. The UM stated he was not informed of the resident needing an eye appointment until yesterday, 7/17/24, when notified by social services. The facility's Medical Consultation policy read, Members of the medical staff will request a medical consultation when appropriate .The member of the medical staff requesting a consultation will order the consultation and a Request for Consultation (Attachment A) will be initiated by nursing to the consulting physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 5 of 11 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 07/18/2024 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 Residents Affected - Many 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 store raw foods (e.g., produce) in a manner to reduce the risk of contamination of ready-to-eat foods and failed to store other food items by sealing, labeling and dating when opened. The facility also failed to ensure dishes and flatware were cleaned and stored under sanitary conditions and equipment was clean and in safe working order. These issues had the potential to negatively affect the health of 154 of the 166 residents in the facility. Findings: On 07/15/24 at 9:55 AM, surveyors entered the kitchen for the initial tour accompanied by the Certified Dietary Manager (CDM). In the walk-in refrigerator, liquid was dripping from the refrigerator condenser onto raw produce including tomatoes, 6 vented plastic containers of strawberries, and other boxes of fresh produce. An approximately 18 inch by 18-inch puddle as well as most of the floor was wet. The CDM stated it was not sanitary to have liquid from a piece of equipment dripping onto food items, but she didn't have anywhere else to put the produce. The surveyors pointed out several other storage area options for the raw, ready-to-eat food items. An open, unsealed box of chocolate chips dated 6/03 were found in the walk-in refrigerator. The exterior of the box had circular spots of discoloration resembling mold on it. The CDM removed this box from the walk-in and stated their policy was to have all food items sealed, dated and discarded after 7 days of opening. The CDM also discarded six undated hardboiled eggs wrapped in plastic wrap. In the walk-in freezer, there were 2 boxes of opened, unsealed and undated hard/frozen food items; one was tilapia fish and the other, burgers. The CDM noted these 2 items were not stored properly and removed them to seal and date them. On a kitchen counter, an opened, unrefrigerated, half-full jar of jelly dated 6/04 was found and the CDM threw it away stating this did not follow their food storage policy. When the CDM ran the dish machine, the wash and rinse temperature dials did not move so their temperatures could not be verified. When she submerged a test strip into the dish machine liquid to measure the concentration of sanitizer, it appeared clear, indicating the amount of sanitizer running in the machine did not register to the minimum 50 points per million. The CDM stated she could not be sure how long the dish machine had been without working temperature dials or sanitizer. Paper products were then used at the next meal until the dish machine could be put into proper working order for cleaning and sanitizing. The nozzles on the juice dispenser were noted to have a dark, slimy film on them. The CDM stated it was obvious cleaning of the juice nozzles had been neglected. She removed both nozzles, with one of the nozzles being very difficult to remove and set them in a pan of hot water. A second visit to kitchen on 7/16/24 revealed the raw produce including the strawberries and tomatoes, were still stored with liquid from the walk-in refrigerator condenser dripping on them. This issue was pointed out as a concern to the facilities Manager-In-Training who verified the findings. The juice dispenser nozzle was found being stored in a large plastic bucket as it continually dripped. The morning cook stated a repair company had been called to fix it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 6 of 11 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 07/18/2024 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 During a 3rd visit to the kitchen on 7/17/24, the District Manager verified the raw produce, including the strawberries and tomatoes, was still stored in the same spot under the condenser now with a sheet pan, approximately 1/2 high, placed on top of it. The shallow sheet pan was catching, and almost filled from, the dripping liquid. The surveyor expressed concern the shallow pan would soon be full and overflow onto the produce again. The District Manager agreed and stated he would take care of it. Residents Affected - Many On the 4th visit to the kitchen on 7/18/24, the pipes from the condenser had been defrosted and were no longer dripping. The produce was still located under the condenser, including one half-full container of strawberries. The District Manager acknowledged concern ov possible contamination of the food items and discarded the remaining strawberries. The food service department Food Storage policy dated 02/23 stated all foods would be appropriately stored in accordance with guidelines of the FDA food code and would be stored wrapped or in covered containers, labeled, and dated and arranged in a manner to prevent cross-contamination. The facility's food service department's equipment policy dated 09/17 indicated all equipment would be kept in proper working order and all food contact equipment would be cleaned and sanitized after every use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 7 of 11 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 07/18/2024 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 Based on observation and interview the facility failed to maintain clean and soiled utility rooms to ensure proper storage of contaminated and clean linens, and failed to maintain adequate handwashing supplies on 2 of 2 units, out of a total of 3 units, to prevent cross contamination, and exposure to blood-borne pathogens and infectious microorganisms according to established guidelines. Residents Affected - Some Findings: The Infection Prevention and Control Program policy revised 10/18 read, An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Coordination and Oversight .The infection prevention and control program is coordinated and overseen by an infection prevention specialist [infection preventionist] .Important facets of infection prevention include .educating staff and ensuring that they adhere to proper techniques and procedures . On 7/16/24 at 10:51 AM, interview and observations were conducted with the Infection Preventionist (IP) Registered Nurse (RN) who said she had been in her current position for only 4 days and had not yet toured the laundry areas or clean and soiled utility rooms in the facility. On the 300/400/500 unit soiled utility room was not organized and the countertops and floors were noticeably dirty. The lid on 1 of 2 soiled laundry bins was open with exposed soiled linens, hand sanitizer on the wall was inaccessible, plastic storage bins used for isolation rooms still needed to be cleaned and sanitized, the handwashing sink drain had a thick layer of black colored film and was plugged with paper/debris which caused the sink to not drain properly. The handwashing sink in the utility room was obstructed by various items on and around the sink which included crutches, lift device battery, open sharps container, 2 flower vases, wheelchair rests, used resident continuous positive airway pressure machine, and other miscellaneous resident equipment items in unlabeled plastic bags. A few minutes later in the clean utility room on the 300/400/500 unit with the IP nurse the handwashing sink was dirty with black residue noted around the sink handle base the soap dispenser was broken and had no soap. The room was not organized and the countertops and floors were noticeably dirty. No garbage can was noted in the room for disposal of soiled paper towels or other trash. On 7/16/24 at 11:36 AM, an interview was conducted with the 300/400/500 Unit Manager (UM) and IP Nurse who validated all the concerns noted in the clean and soiled utility rooms. The UM added that the cleaning and restocking of handwashing supplies should be done by housekeeping staff at least daily for both clean and soiled utility rooms. The UM added the used resident equipment should be labeled once cleaned and put back into circulation by the nursing staff. The IP nurse verbalized the staff should always keep the soiled laundry bins closed to help reduce potential spread of infection from the presence of soiled/wet linens. On 07/16/24 at 11:45 AM, the soiled and clean utility rooms on the 200 unit were observed with the IP Nurse. The soiled utility room had 1 of 2 large bins overflowed with soiled/wet laundry which billowed over the top so the lid would not close. The sink on the right of the room had no hand sanitizer for hand hygiene and the hand sanitizer dispenser outside the soiled room was empty as well. The mini fridge in the right corner of the room was dirty and had brownish, sticky residue/streaks outside the door. In the small, clean utility room, 2 large carts were noted with clean linens. The floor was visibly soiled with brown dust and numerous insects lying dead on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 8 of 11 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 07/18/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/16/24 at 11:50 PM, the IP nurse validated the condition of the soiled/clean rooms on 2 of 2 units (300/400/500 and 200) were not maintained in clean or sanitary condition, nor were the clean/soiled linens stored properly to prevent cross contamination and exposure to blood-borne pathogens and infectious microorganisms according to established guidelines. On 7/17/24 at 3:44 PM, the Housekeeping and Laundry Supervisor was informed of the concerns noted on 300/400/500 and 200 units soiled and clean utility rooms. He said the housekeeping staff were supposed to clean the countertops, sinks, exterior refrigerator surface, sweep and mop floors, refill hand soap at least daily. He said all staff should make sure the soiled laundry was covered to prevent potential spread of infections as well. The Environmental Services Account Managers and Laundry Employees policy revised 10/23 read, Handling, Transport and Storage of Laundry .Regardless of the location where laundry is processed, facility staff is required to handle, store, process and transport all linens and laundry in line with accepted national standards .prevent the spread of infection to the extent possible all use laundry as potentially contaminated FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 9 of 11 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 07/18/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide proof of consent, refusal, or medical contraindication for Pneumococcal vaccine for 2 of 5 residents reviewed for immunizations, (#5, and #129). Residents Affected - Few Findings: 1. Resident #105, a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition, dysphagia, malignant neoplasm of prostate, anemia and chronic obstructive pulmonary disease. Review of resident #105's medical record on 7/17/24 revealed no documentation of consents, refusal, or medical contraindication for the Pneumococcal vaccine. 2. Resident #129, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of muscle weakness, type 2 diabetes, dysphagia, hypertension, cerebrovascular disease, syncope and collapse. Review of resident #129's medical record on 7/17/24 revealed no documentation of consent, refusal, or medical contraindication for the Pneumococcal vaccine. On 7/17/24 at 4:42 PM, the Regional Registered Nurse (RN) verified the prior Infection Preventionist Nurse was no longer working in that role and the new one started within the last week. The Regional RN explained residents #105 and #129 should have been offered the Pneumococcal vaccine and given education upon admission to the facility. Review of the facility's Policy and Procedure for Pneumococcal Vaccine revised October 2019 read, All resident will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, resident will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty [30] days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 10 of 11 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 07/18/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain the walk-in refrigerator in safe operating condition for all mechanical and electrical equipment. This issue had the potential to negatively affect the health of 154 of the 166 residents in the facility who received food and nutrition by mouth. Residents Affected - Many Findings: On 07/15/24 at 9:55 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), it was noted the walk-in refrigerator's condenser was leaking liquid onto food products including raw produce. Most of the floor was wet along with a puddle measured approximately 18 inches by 18 inches. The CDM stated they dry mopped the walk-in floor regularly to remove liquid from it. She stated the condenser had been dripping liquid for more than 6 months. The CDM demonstrated the floor underneath the condenser was soft and boggy from the moisture when it dipped down as she jumped on it. She stated she had informed the Maintenance Department and Administration about the leak. The facility's food service equipment policy with revision date of September 2017 stated all food service equipment would be clean, sanitary, and in proper working order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105440 If continuation sheet Page 11 of 11