Inspection·December 2, 2021

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 record review and staff interview, the facility failed to develop and implement an individualized, person-centered care plan for 1 (#24) of 4 residents reviewed for care planning. Failure to develop and implement a comprehensive care plan can lead to the resident's medical, physical, mental, and psychosocial needs not being met. The findings included: Review of Resident #24's clinical record revealed the resident was admitted to the facility on [DATE]. An admission comprehensive Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/20/21 was completed and transmitted. Based on the assessment, care plan decisions were completed on 9/24/21 to proceed to care plan for areas of communication, risk for pressure ulcers, behaviors and psychotropic (drugs that affect a person's mental state) medication. The Registered Nurse (RN) MDS Coordinator certified and signed the care plans for Resident #24 were completed but the facility failed to develop a comprehensive and individualized care plan for Resident #24. Review of the MDS assessment dated [DATE] showed Resident #24 was coded for the following: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others); behaviors put the resident at significant risk for physical illness or injury and Significantly interfere with the resident's care and interfere with the resident's participation in activities or social interactions; rejection of care. Those behaviors listed above were noted daily during the look back period, but a behavior care plan was not in place with interventions for staff to use when the resident exhibited these behaviors. Resident #24 was prescribed an antidepressant daily for a diagnosis of depression. A Psychotropic medication care plan was not completed. Resident #24 had expressive and receptive communication impairment. The MDS noted Resident #24 was rarely or never understood for ability to express ideas and wants, considering both verbal and non-verbal expression. The MDS documented Resident #24 rarely or never understood verbal content, however able (with hearing aid or device if used). A Comprehensive care plan to ensure the resident's communication needs were met was not completed. On 12/2/21 at 9:45 a.m., in an interview with the Regional MDS Coordinator and the facility MDS Coordinator, the facility MDS Coordinator acknowledged the facility failed to develop a comprehensive care plan for Resident #24 as required by regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 2 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review, policy review, and staff interview, the facility failed to provide pharmacy services to ensure 3 (Resident #52, #24, and #37) of 7 residents medication administration records reviewed received medication in accordance with physician orders. The findings included: The facility's policy 7.0 Medication Shortages/Unavailable Medications with a revision date of 1/1/13 read, .Upon discovery that Facility has an inadequate supply of a medication to administer to a Resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy . If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery . Action may include . Use of an emergency (back-up) Third Party Pharmacy. If emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions . 1. Record review revealed Resident #52 had a physician's order, dated 11/17/21, for the antibiotic medication Cefazolin 1 gram to be given IV (intravenously) every morning for 10 days to treat an upper respiratory infection. The medication was scheduled to start on 11/18/21. Resident #52's Medication Administration Record (MAR) for November 2021 was reviewed and showed the antibiotic was not started until 11/19 noting the delivery was pending from the pharmacy. The stop date for the antibiotic was changed to 11/29/21. On 11/27/21 and 11/28/21 the nurse entered 9 (other/see nurse notes) on the MAR. The nurse documented in a medication administration note for 11/27/21 and 11/28/21, Awaiting pharmacy. No more in fridge. The clinical record documentation showed the IV antibiotic was only administered for eight days and not for 10 days as ordered. On 12/1/21 at 12:39 p.m., in an interview the facility's Pharmacy Consultant said the pharmacy log indicated the medication was sent on 11/17 probably later in the day. More doses were sent on 11/22. She said she was still checking to see if the medication actually arrived at the facility on 11/17 but confirmed the resident did not receive the full 10 doses as ordered. 2. Record review revealed Resident #24 had a physician's order for Omeprazole one tablet daily for Gastroesophageal reflux disease, and Gabapentin 100 milligrams three times a day for nerve pain. Resident #24's MAR for September, October and November 2021 were reviewed. The Omeprazole was not documented as given on 9/28, 10/1, 10/2, 10/4, 10/8, 11/12, 11/16, 11/17, and 11/24. The Gabapentin was not documented as given for one dose on 11/6, and two doses on 11/7. Each time the nurse entered 9 (Other/See Nurse notes) on the MAR and documented n/a on the nurses note indicating the medication was not available. 3. Record review revealed Resident #37 had a physician's order for Rivastigmine patch for treatment of Dementia daily and Ropinirole one daily for tremors. Resident #37's MARs for September, October and November 2021 were reviewed. The Rivastigmine patch was not documented as given on 9/6. The nurse documented the medication was not available. The Ropinirole was not given on 10/10. The nurse documented awaiting pharmacy delivery. On 12/1/21 at 12:34 p.m., reviewed the concern of medications not being available from the pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 3 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 0755 Level of Harm - Minimal harm or potential for actual harm with the Director of Nursing. She said she was not aware of issues of medications not being available. She said she gets reports of medications not given but it would not notify her if there was a nursing note with a reason. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 4 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview the facility failed to ensure proper storage of medications in 1 (Nurses station #2) of 2 medication storage rooms. This has the potential for expired medications to be administered to residents. The findings included: On 11/30/21 at 11:30 a.m., observation of Medication room at Nurses station #2 with Licensed Practical Nurse (LPN) Staff M revealed: Three bottles of Pro Stat expired 9/3/2021. Photographic evidence obtained Four bottles of Magnesium Chloride best by 8/21. Photographic evidence obtained One bottle of Calcium + D3 expired 8/21. At the time of the observation, LPN Staff M confirmed the medications were expired. On 11/30/21 at approximately 11:40 a.m., in an interview, the Regional Director of Nursing confirmed the medications were expired and removed them from the medication room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 5 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 staff interview, the facility failed to maintain the kitchen in a clean and sanitary manner and in good repair by having openings into the ceiling with potential contamination of the food areas; uncleanable surfaces in food storage and preparation areas, and outdated food items. The findings included: 1. On 11/29/21 at 9:28 a.m., during the initial tour of the kitchen, the following was observed: The ceiling upon entry to the kitchen had a partially detached broken rusted vent with a three-inch-by-three-inch hole. Photographic evidence obtained The ceiling tiles in the main kitchen were stained with a brown substance in front of the stove and food prep areas. Photographic evidence obtained Several of the ceiling vents and support frames were heavily soiled with a black bio-growth. Photographic evidence obtained The pipe next to the plate warmer and steam table had a one-inch opening into the ceiling around the pipe. The plastic coating was peeling on the surface of a utility cart holding beverages. Photographic evidence obtained The inside frame of the reach-in freezer was stained/soiled with a brown substance. Several of the utility and storage carts had rusted/corroded wheels creating an uncleanable surface. Photographic evidence obtained The door frame of the walk-in refrigerator was heavily soiled/stained and in disrepair. Photographic evidence obtained The floor was in disrepair with large sections of loose concrete across entrance to the freezer area. Photographic evidence obtained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 6 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 The inside of freezer floor was heavily soiled with spillage and debris. Level of Harm - Minimal harm or potential for actual harm Photographic evidence obtained Two egg salad sandwiches dated 11/24 being were stored in the reach-in refrigerator for potential use. Residents Affected - Many Photographic evidence obtained On 11/29/21 at 10:04 a.m., in an interview [NAME] Staff G said the storage of leftover food was for three days and confirmed the egg salad sandwiches should have been disposed of on 11/27. [NAME] Staff G removed the sandwiches. 2. On 11/29/21 at 11:25 a.m., observation revealed [NAME] Staff G taking the temperature of the uncovered food on the steam table. There were two uncovered bins of rolls next to the food. Maintenance Staff F was observed on a step ladder in front of the steam table with a spray bottle cleaning the biogrowth off the ceiling vents. [NAME] Staff G said maintenance was usually not in the kitchen when food was present on the steam table. On 11/29/21 at approximately 11:30 a.m., in an interview, the Registered Dietitian (RD) came into the kitchen and said she was aware of Maintenance Staff F being in the kitchen but did not realize uncovered food was on the steam table. The RD confirmed the potential contamination of the food on the steam table and instructed Maintenance Staff F stop cleaning the vents. On 11/29/21 at 1:30 p.m., in an interview, Maintenance Staff D said normally he does not do any maintenance work when food is being prepared or served and waits until after hours. He said he had no record of being told to clean the vents and relied on the kitchen staff to tell him. He said this morning around 10:30 a.m., Food Services Supervisor Staff H notified him to clean the vents as quickly as possible. He said Maintenance Staff F was using a bleach mixture to get rid of the biogrowth on the vents. 3. On 11/29/21 at 1:45 p.m., biogrowth on the wall in the storage area was observed along with the RD who said she was unaware of this. She acknowledged the floor of the food storage area was soiled and rust was present on the food storage racks. On 12/2/21 at 11:51 a.m., in a follow up tour with the RD the broken grate was still present in the ceiling in front of the entry door of the kitchen. The inside of the reach in freezer was soiled and stained. The denuded cart was still in use, holding drinks. a dead insect was observed on the floor under the rack. The RD acknowledged the rusted wheels were uncleanable and needed to be replaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 7 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and staff interview, the facility failed to ensure medical records contained accurately documented information for the administration of medications for 6 (24, #37, #52, #48, #53, #86) of 7 residents medication administration records reviewed. The findings included: The facility's Policy N-853 Medication-Oral Administration Of (revised 9/22/17) indicated to, . Chart on Medication Administration Record (MAR) according immediately following when medication is given and before proceeding to the next resident . The facility's policy 7.0 Medication Shortages/Unavailable Medications with a revision date of 1/1/13 read, .Upon discovery that Facility has an inadequate supply of a medication to administer to a Resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy . If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery . Action may include . Use of an emergency (back-up) Third Party Pharmacy. If emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions . 1. Review of Resident #37's clinical record revealed the physician's orders included to administer Trileptal twice a day for seizures. On 11/30/21 Resident #37's MARs for September, October, and November 2021 were reviewed. There was no documentation the Trileptal was administered on 11/10 and 11/19 and 11/30. On 12/1/21 at 10:26 a.m., Licensed Practical Nurse Staff B reviewed the MARs for Resident #37 and confirmed if there was no check mark in the box and a code number was entered in the MAR, it meant the medication was not given and the reason should be documented in the nurses' notes. Staff B confirmed there was no documentation as to why the medication was not given in the nursing notes. 2. Resident #52's clinical record revealed the physician's orders included Diltiazem daily for rapid heart rate; Colace twice a day for constipation; Eliquis twice a day for heart disease/blood thinner; Levetiracetam three times a day for seizures; and Azithromycin daily for 5 days treatment for Upper Respiratory infection. On 11/30/21 Resident #52's MARs for September, October and November 2021 were reviewed. There was no documentation the morning dose of Diltiazem, docusate sodium and Eliquis were administered on 9/1/21. The clinical record lacked documentation the 1:00 p.m. dose of Levetiracetam was administered on 9/1 and 10/17. The Azithromycin 500 was not documented as administered on 11/20/21. 3. Review of Resident #24's clinical record revealed the physician's orders included Gabapentin three times a day for nerve pain and Eliquis daily for heart disease/blood thinner. On 11/30/21 Resident #24's MARs for October, and September 2021 were reviewed. There was no documentation of the Gabapentin being given on 10/17, or the Eliquis being given on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 8 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 9/16 and 9/17. Level of Harm - Minimal harm or potential for actual harm On 12/1/21 at 12:34 a.m., during an interview with the Director of Nursing (DON), reviewed the concern with medications not being documented as given or if not given, the reason noted in the medical record. The DON said she was not aware of any issues with medications not being given. She said she gets a report if there are omissions (left blank) with the medications but had not identified any concerns. Residents Affected - Some 4. On 12/2/21 clinical record reviewed for Resident #86 including Medication Administration Records (MAR) for October 2021 and November 2021. The MARs lacked documentation Cyanocobalamin 1000 micrograms intramuscular was administered as ordered on 10/28/21, 11/18/21 and 11/25/21. There was no documentation the Senna tablet 8.6 micrograms (mg) was administered as ordered for constipation on 10/28, 11/14, 11/23, 11/25 and 11/27/21. 5. On 12/2/21 clinical record reviewed for Resident #48 including MARs. The MARs lacked documentation risperidone tablet 2 milligrams (mg) was administered at bedtime as ordered for schizophrenia on 10/28/21, 11/14/21, 11/23/21 and 11/27/21. 6. On 12/2/21 clinical record reviewed for Resident #53 including MARs. The MARs lacked documentation of administration of atorvastatin calcium tablet 40 mg at bedtime for cholesterol, trazodone HCL tablet 50 mg at bedtime, levetiracetam solution 7.5 milliliters for seizures on 10/28/21, 11/14/21, 11/23/21, and 11/27/21. There was no documentation the blood glucose was monitored, and Regular insulin administered based on the blood glucose result as ordered at 6:00 a.m., on 10/14/21 and 9:00 p.m., on 10/28/21, 11/14/21, 11/23/21 and 11/27/21. On 12/02/21 at 11:25 a.m., in an interview with the Director of Nursing (DON) about documentation of medication administration expectation, the DON said, Staff are expected to administer medications as ordered and to document when they administer them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 9 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 Based on record review, review of the facility's policy and procedure, staff and resident interview, the facility failed to administer the influenza vaccine as requested to 1 (Resident #56) of 6 sampled residents reviewed for immunization. Residents Affected - Few The findings included: Review of facility policy titled Influenza Vaccine - Resident with a revision date of 8/17/2020 stated, Residents will be offered the influenza vaccine annually (between October 1st and March 31 st unless otherwise directed by the CDC) to encourage and promote the benefits associated with vaccinations against influenza, in accordance with the local health department and Centers for Disease Control Guidelines . Have the resident / resident representative sign the informed consent, indicating acceptance or declination. Obtain a physician's order. Administer the vaccine, and document on the Medication Administration Record (MAR) . On 11/29/21 at 11:18 a.m., in an interview Resident #56 said she has been asking for an influenza vaccine since her admission to the facility on 9/29/21. The resident said she's asked multiple nurses over the past several weeks since October, but they just keep brushing her concerns to the side and not telling her why she cannot have the flu vaccine. On 12/1/21 review of the clinical record revealed on 10/26/21 Resident #56 signed an informed consent for the influenza vaccine. The options I accept and give the facility permission to administer the influenza vaccine and I was offered the influenza vaccine but have already received the vaccine during the current season outside of the facility were checked off. The nurse wrote N/A (not applicable) followed by her initials next to the option indicating the resident already received the vaccine during the current season. Review of Resident #56's immunization record in Florida Shots (centralized online immunization information system) showed Resident #56 had not received the influenza immunization for the 2021/2022 flu season. Review of Resident #56 electronic clinical record showed an update immunization entry for the influenza, seasonal, injectable noting a Consent confirmed date of 11/5/2021. The note indicated Resident #56 refused the vaccine. The reason refused was, Resident refused. On 12/1/21 at 11:45 a.m., in an interview Licensed Practical Nurse (LPN) Staff B said she was not sure why the consent to give and the refusal were both checked off on Resident #56's informed consent for the influenza vaccine. LPN Staff B pointed to the 11/5/2021 entry and said, Here it says that she refused the vaccine. LPN Staff B said she would speak with Resident #56 regarding the influenza vaccine. On 12/1/21 at 12:10 p.m., in an interview LPN Staff B said she spoke with Resident #56 and verified the resident wanted the influenza vaccine. She said she did not know how the decline got placed in the electronic clinical record. On 12/1/2021 at 1:20 p.m., LPN Staff B wrote in a progress note, Miscommunication about flu and pneumonia vaccine consent. Upon further research and discussion with resident she states that she does want both vaccines . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 10 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 Level of Harm - Minimal harm or potential for actual harm On 12/2/21 at 11:25 a.m., in an interview the Director of Nursing (DON) confirmed Resident #56 requested the influenza vaccine several times but did not receive it. The DON confirmed this was a breakdown in the immunization process. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 11 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 7. On 11/30/21 at 10:31 a.m., the shared bathroom for Resident #37 and Resident #52 was observed to have unmarked, unidentified personal care items being stored in an unsanitary manner. A resident's wash basin was being stored on the floor next to the toilet, a tube of skin protectant, bottle of periwash, and bottle of mouth rinse were on the sink. On 12/1/21 at 4:19 p.m., the unlabeled personal care items were observed being stored on top of the paper towel dispenser. 8. On 11/30/21 at 10:31 a.m., Resident #24's shared bathroom was observed to have unmarked unidentified personal care items being stored in an unsanitary manner. A toothbrush was lying on the top of the toilet tank with the bristles up against the wall along with a tube of toothpaste; an unmarked denture cup was on the sink; a bottle of periwash, mouthwash, skin protectant, were present and a can of hairspray was on the towel bar. On 12/1/21 at 4:19 p.m., the unidentified personal care items were still present including a comb being stored on the toilet tank along with the toothbrush. 9. On 11/29/21 during a tour of the facility, three of the side chairs in the living room of the Memory Care unit were observed to be in disrepair with the protective surface rubbed off creating uncleanable surfaces. The chairs were observed to be low to the ground with high arms, light weight, and easily moved. On 11/30/21 at 3:00 p.m., an incontinent pad was noted on one of the chairs. Certified Nursing Assistant (CNA) Staff A was present during the observation and said because the chairs are so worn, if a resident is incontinent, urine will soak down into the cushion of the chair due to no barrier. The CNA said the chairs are difficult for residents to get up out of and easily move creating a fall hazard. On 12/2/21 at 5:15 p.m., the facility's Administrator acknowledged the concern with the chairs being in disrepair. Photographic evidence obtained Based on observations and staff interviews the facility failed to maintain/store resident personal care items in a sanitary manner to prevent potential cross contamination for 9 (Residents #11, #39, #48, #77, #86, #91, #24, #37, and #52) of 20 sampled residents. In addition, the resident chairs in the Memory care unit were in disrepair. The findings included: 1. On 11/29/21 at 9:45 a.m., the shared bathroom of Resident #77 and #86 was observed to have unmarked, unidentified personal care items being stored in an unsanitary manner. An opened bottle of total bath wash and a bottle of mouthwash were stored on the sink. A tube of toothpaste and a toothbrush with the bristles facing down and against the wall were stored on the soap dish. Photographic evidence obtained The same observation was made on 11/30/21 at 10:10 a.m., and 12/1/21 at 9:51 a.m. The unmarked, unlabeled personal care items remained stored on the sink and the soap dish. On 12/01/21 at 10:15 a.m., Certified Nursing Assistant (CNA) Staff K verified the personal care items in the shared bathroom of Residents #77 and #86 were not labeled and stored in a sanitary manner. CNA Staff K said he did not know which items belonged to which resident and said, I don't know. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 12 of 13 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 105443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few use the items for both residents if needed. They are low on supplies here. I have been to other places where they have the items bagged with the resident's name on the bag but not here. This is how I have seen it in every room here. I haven't seen any of the rooms with the items separated here. 2. On 11/29/21 at 11:15 a.m., the shared bathroom of Resident #48 and #39 was observed to have unlabeled, unidentified personal care hygiene items stored in an unsanitary manner. An opened bottle of total bath wash, a bottle of shaving cream, and two toothbrushes with the bristles against the sink were stored on the bathroom sink. Photographic evidence obtained The same observation was made on 11/30/21 at 10:07 a.m. On 12/01/21 at 9:40 a.m., the bottle of total bath wash, a bottle of shaving cream, and two toothbrushes remained stored on the sink. An unlabeled bottle of mouthwash was stored on the toilet tank. On 12/1/21 at 145 p.m., in an interview CNA, Staff L, caring for Residents #48 and #39 confirmed the residents' personal items were unlabeled and stored on the sink and on the toilet tank in the shared bathroom. When asked how she knew who the items belonged to, she said, I think they are [Resident #48's]. [Resident #39] keeps most of his stuff in his drawer. CNA, Staff L said, We don't have space to keep them separate in the bathroom. 3. On 12/1/21 at 12:05 p.m., observed Registered Nurse (RN) Staff N washing her hands in the sink of the shared bathroom of Resident #11 and #91. A partially filled bottle of total bath was observed stored on the sink. In an interview at the time of the observation RN Staff N said she did not know who the bottle of total wash belonged to. She said, I think they use it for both of them. They are both bed baths since they do not go to the showers. On 12/02/21 at 8:45 a.m., in an interview regarding policy for storage of residents' personal hygiene items Regional Registered Nurse (RN) said, We do not have a specific policy. It is expected that they maintain their hygiene items separately to maintain cleanliness. On 12/02/21 at 11:15 a.m., in an interview about storage of residents' personal hygiene items, Licensed Practical Nurse (LPN) unit manager Staff B said, They should be separate and bagged or in a bin labeled. After looking at the photographic evidence obtained from the shared bathrooms of residents #39, #48, #77, and #86, LPN Unit Manager Staff B said, We have been using a lot of agency staff, but they should know better. I am going to go room by room and throw away all of the items now and educate the staff. On 12/2/21 at 11:25 a.m., in an interview the Director of Nursing (DON) said Residents' personal care items should be labeled and stored separately. After looking at the photographic evidence obtained from the shared bathroom of residents #39, #48, #77, and #86 the DON verified the personal care items were not stored in a sanitary manner and could be an infection control issue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105443 If continuation sheet Page 13 of 13