Inspection·January 6, 2023

F 0677 The MDS noted Resident #7's cognitive skills for daily decision making were moderately impaired. Level of Harm - Minimal harm or potential for actual harm The care plan initiated on 12/1/21 noted staff were to provide a full bed bath when a shower could not be tolerated and to check nail length, trim and clean nails on bath days and as necessary. Residents Affected - Some Review of the Certified Nursing Assistant (CNA) shower schedule showed Resident #7 was scheduled for showers on the evening shift on Tuesdays, Thursdays, and Saturdays. On 1/3/23 at 1:54 p.m., Resident #7 was observed in his wheelchair in the day room. The resident's fingernails were long, extending 1/2 inch from the base, with a brown substance under the nail beds. The resident said he did not like to have his nails long. Resident #7 looked disheveled with a beard growth of approximately three days. On 1/4/23 at 8:50 a.m., Resident #7 was observed in bed wearing the same clothing as 1/3/23. There were pieces of food on the right side of his shirt from the morning meal. On 1/5/23 at 9:05 a.m., Resident #7 was observed in bed wearing the same clothing from 1/3/23 and 1/4/23. Review of the CNA documentation for November 2022 documented Resident #7 received a bed bath on 11/19/22 and 11/24/22, refused bathing on 11/22/22 and received a partial bed bath on 11/26/22. The CNA documentation showed no additional documentation Resident #7 received his scheduled showers or bed baths. Review of the CNA documentation for December 2022 documented resident #7 received a bed bath on 12/1/22. The CNA documentation showed no additional documentation Resident #7 received scheduled showers or bed baths for December 2022. On 1/4/23 at 9:16 a.m., CNA Staff B, said the CNA documentation since September 2022 was completed by hand on paper and was located in a white binder at the nurse's station. The CNA said they were charting on the computer now. A review of the CNA Binder showed one CNA ADL Tracking Form for Resident #7 without a date to indicate the month or the year the form was completed. On 1/4/23 at 9:28 a.m., Unit Manager Licensed Practical Nurse (LPN) Staff A said the CNAs were documenting ADLs in the CNA books on paper. LPN Staff A verified there was no date, including the month and year on the CNA forms. LPN Staff A said the sheets in the book were for December 2022 and said she would take the book and date the forms. On 1/4/23 at 9:42 a.m., the Director of Nursing (DON) said the CNA forms in the CNA binder were for the month of December 2022. The DON confirmed there was no date on any of the forms in the binder and without a date there was no way to verify when the forms were completed. On 1/5/23 at 10:31 a.m., the DON confirmed Resident #7's fingernails extended approximately 1/2 inch with an accumulation of brown substance underneath. 2. Review of the clinical record revealed Resident #24 had a readmission date of 11/16/22 with diagnoses including dementia, anxiety, and muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 2 of 8 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The admission MDS with an assessment reference date of 11/28/22 documented Resident #24 required extensive assistance for personal hygiene and bathing. The MDS noted Resident #24 had no impairment in cognitive skills for daily decision making. The care plan initiated on 2/27/19 noted Resident #24 preferred bed baths three times a week and as necessary. On 1/3/23 at 11:00 a.m., Resident #24 was observed in her room in bed. The resident's fingernails were approximately 1/2 inch in length and there was brown substance under nail beds. Resident # 24 said a girl here was supposed to cut them every week but sometimes she does not get them done. She said she receives bed baths but not as often as she would like. Resident #24 said sometimes, I don't get my scheduled bed baths. On 1/4/23 at 12:58 p.m., Resident #24 said was observed in bed dressed in the same clothing as the previous day (1/3/23). The resident said, I don't always get my bed baths. Resident #24 said the CNA said maybe if she had time this afternoon, she would give her a bath. Resident #24 fingernails were long with brown substance under the nails. She said, they will be cut today, I hope. Review of the CNA shower schedule showed Resident #24 was scheduled for bed baths on the day shift on Mondays, Wednesdays, and Fridays. Review of the CNA documentation showed no documentation Resident #24 received the scheduled bed baths for November and December 2022. On 1/5/23 at 9:55 a.m., the DON said the expectation for CNA's was to follow the shower schedule and document the care provided. The DON said, if a resident declined care, then the nurse was to document it in a progress note. 3. Review of the Policies and Procedures for Bathing/Showering (N1130) revised 9/1/17 revealed assistance with showering and bathing will be provided at least twice a week and as needed to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. On 1/3/23 at 11:06 a.m., Resident #60 said she is supposed to get a shower twice a week but the last time she had a shower was on 12/26/22 when she had loose stools. She said she was not permitted to shower without staff because she could slip and fall. She said she recently refused showers at 7:00 a.m., and 11:00 p.m., because it was too early and too late. She said she wanted to have a shower twice a week like she is supposed to. Review of the South Station Shower List revealed Resident #60 was scheduled to receive showers on Fridays 7-3 shift and Tuesdays 3-11 shift. Review of the Skin Observation sheets for Resident #60 revealed on 12/3/22 Resident #60 refused a shower and requested to be showered in the morning. Resident #60 also refused a shower on 12/17/22 and received a shower on 1/5/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 3 of 8 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 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 No other skin observation was noted in the binder for Resident #60. Level of Harm - Minimal harm or potential for actual harm On 1/5/23 at 10:07 a.m., the Director of Nursing said the certified nursing assistants (CNAs) should be documenting personal hygiene care on individual Skin Observation sheets. Residents Affected - Some On 1/5/23 at 3:34 p.m., Resident #60 said when she was admitted to the facility four months ago, showers were not mentioned. She said she assumed she would get a shower once a week, but her showers are not even that often. On 1/6/23 at 9:30 a.m., Certified Nursing Assistant Staff I said residents are supposed to get showers twice a week or whenever they want one. She said Resident #60 required assistance with showers. On 1/6/23 at 9:48 a.m., Licensed Practical Nurse Staff A said the CNAs did not tell her Resident #60 refused showers. She would write a progress note about the refusal so the interdisciplinary team was aware of the refusal via the 24 hour report. On 1/6/23 at 10:10 a.m., the Director of Nursing (DON) acknowledged the lack of showers for Resident #60. She said the CNAs are to shower according to the Shower List and document findings on the Skin Observation sheets contained in the binder at the nurse's station. On 1/6/23 at 2:00 p.m., the DON said she reviewed Resident #60's progress notes and there was nothing about Resident #60 refusing showers. 4. Clinical record review for Resident #55 revealed a date of admission of 11/17/22. The admission MDS dated [DATE] noted the resident's cognition was intact. The MDS noted it was very important for the resident to choose what clothes to wear, and choose between a shower, tub bath, bed bath or sponge bath. Resident #55 was dependent on staff for bathing. Resident #55 Care plan, revised on 9/24/22, stated the resident has an ADL self-care performance deficit related to diagnosis of low back pain, Muscular Dystrophy, Hiatal Hernia, Impaired balance, and limited mobility. The goal was to improve the current level of function in ADL tasks. The interventions included checking nail length, trimming and cleaning on bath day, and, as necessary, providing a sponge bath with a full bath or shower cannot be tolerated; the resident requires total assistance from one-two staff with bathing. The South station shower schedule noted Resident #55's showers were scheduled on Tuesdays, Thursdays and Saturdays during the day shift. The ADL tracking sheet revealed Resident #55 received three partial baths and no showers for December 2022. On 01/3/23 at 10:22 a.m., Resident # 55 stated, today is the 11th day without a shower. I asked for a shower today, and they said they don't have any soap. On 01/4/23 at 9:15 a.m., resident #55 stated, I did not shower yesterday or today, now 12 days. He said he asked the Certified Nursing Assistant who said once the state leaves, they will be able to shower him because they will have more time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 4 of 8 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/5/23 at 9:39 a.m., CNA Staff D said she has been working in the facility through an agency on and off for five years. She confirmed there was a shower book at the nursing station to check daily for scheduled showers. She said she did not recall resident #55 ever refusing care. On 1/5/23 at 10:31 a.m., the Director of Nursing (DON) said she expected showers to be done according to schedule. She said she would speak to the staff right away about Resident #55's showers. On 1/5/23 at 3:01 p.m., the DON reviewed shower logs showing resident #55 had not been showered in 12 days. The DON confirmed showers were a problem and would work on it. On 1/6/23 at 2:31 p.m., Resident #55 stated, I felt like hell when I didn't get showered. It made me feel like I didn't want to be around anyone because I stunk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 5 of 8 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 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** 2. Review of the medical record for Resident #67 indicated an initial admission date of 8/3/19. Residents Affected - Few Review of the of the Weekly Skin Integrity assessment dated [DATE] revealed documentaion of a bilateral lower extremity rash identified by Licensed Practical Nurse Staff J. On 1/3/23 at 3:05 p.m., observed bilateral lower legs of Resident #67. They were swollen and red with areas of dried blood. Resident #67 said the lower legs itch and burn so bad, he scratches them until they bleed. He said the nurse is aware of it, but he has not seen a doctor and the facility is not treating it. (See photographic evidence) On 1/5/23 at 10:27 a.m., Resident #67 said he still had the rash. He lowered his socks to reveal both lower legs swollen with redness and scratches with dried blood. On 1/6/23 at 9:37 a.m., CNA Staff I said she was aware of the condition of Resident #67's lower legs, she did not report it to the nurse as she assumed it was being taken care of. On 1/6/23 at 9:42 a.m., LPN Staff A said she was not aware of Resident #67's lower leg redness and scratching. She said any time a change in skin condition is identified, a progress note is written, and the doctor notified. On 1/6/23 at 10:03 a.m., the Director of Nursing (DON) said she was not aware of Resident #67's bilateral lower leg swelling, redness and scratches. She acknowledged the Weekly Skin Assessment on 1/2/23 identifying a new rash of the lower legs. The DON said the nurse should have also written a progress note and it would have been discussed in the 24-hour report with call to the doctor for direction. The DON said there was no skin treatment for the lower leg condition and this change in condition was overlooked. On 1/6/23 at 12:10 p.m., during a telephone interview LPN Staff J said she identified Resident #67's lower leg swelling, redness and scratching when she worked the night shift on 1/2/23. She said she forgot to write a progress note or contact the physician. She said she has not been back to work at the facility since 1/2/23. Based on observation, record review, resident and staff interviews, the facility failed to ensure 2 (Resident #61 and #67) of 5 sampled residents for change in condition received appropriate care in accordance with professional standards of practice. The findings included: Facility policy and procedures (N-140) revised 3/3/2021 regarding physician orders stated, the center will ensure that physician orders are appropriately and timely documented in the medical report. The Clinical Nurse 1 job description duty and responsibilities listed conduct a thorough evaluation of each residents' medical status upon admission and throughout the resident's course of treatment and assist in the implementation of an individualized treatment plan for each resident assigned. 1. Clinical record review revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included Heart Failure, and renal insufficiency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 6 of 8 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 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 Residents Affected - Few The physician order dated 11/17/2022 specified to apply knee-hi TED hose (compression stockings) to patients' legs bilaterally before patient gets out of bed every morning and remove bilateral knee high ted hose before bed every day. The care plan revised on 12/13/22 noted the resident had edema (swelling) to the legs, shortness of breath upon exertion. Resident #61 was not able to lay flat. The interventions included to apply TED hose as ordered for the edema to the legs. On 1/3/23 at 1:23 p.m., 1/4/23 at 9:03 a.m., and 12:19 p.m., and 1/5/23 at 11:05 a.m., Resident #61 was observed with bilateral lower extremity edema and resident #61 was not wearing compression stockings or TED hose. The skin around her ankles and lower legs was tight and shiny. On 1/4/23 at 9:03 a.m., Resident #61 said she would wear the compression stockings but has not had them since her admission to the facility. On 1/5/23 at 11:14 a.m., Certified Nursing Assistant (CNA) Staff C said she did not recall ever seeing resident #61 with TED hose and did not recall ever seeing TED hose in her room. She said she has never applied TED hose to the resident's legs. On 1/5/23 at 11:30 a.m., Agency Licensed Practical Nurse (LPN) E, confirmed the order for ted hose for Resident #61. She verified the resident was not wearing the ted hose as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 7 of 8 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide necessary services to prevent a decline in range of motion for 1 (Resident #41) of 2 sampled residents with limited range of motion. On 1/4/23 at 9:40 a.m., Resident #41 was observed in his room sitting in his wheelchair. His right wrist/hand was contracted. The resident was not wearing any positioning device or splinting to the area. Resident #41 said he had a right splint for the contracture, but it was misplaced during the evacuation after Hurricane [NAME] and needs to be remade. He said when he had his splint he wore it daily. Review of the clinical record for Resident #41 revealed the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41's cognition was intact. Resident #41 had a diagnosis of Cerebral Palsy. Review of the physician's orders revealed an active order for a right hand splint to be worn daily for 6 hours as tolerated, restorative was to apply/remove every day shift starting 9/11/20. Review of the Interdisciplinary Therapy Screen dated 12/15/22 revealed documentation, As per chart review and discussion with nursing staff, patient with significant increase in muscle tone resulting in increased tightness in right hand and wrist. Splint that was previously used for contracture prevention has been displaced since evacuation for Hurricane [NAME]. On 1/5/23 at 9:22 a.m., Resident #41 was observed in his wheelchair in the hall. He was not wearing a splint on his right hand/wrist. His wrist was bent forming a right angle between his palm and his inner forearm. On 1/5/23 at 4:22 p.m., Restorative CNA Staff F said Resident #41's right wrist splint was misplaced during the evacuation following Hurricane [NAME]. She said Resident #41 was good about wearing the splint and did not refuse to wear it. She said she thought the Rehabilitation Director was ordering another one. She said Resident #41 was not on schedule to receive Restorative Therapy while the splint was being manufactured and had not been on the restorative therapy schedule in a long time. On 1/6/23 at 9:05 a.m., the Rehabilitation Director confirmed Resident #41's splint had been misplaced, and was not sure how long the splint had been missing. The Therapy Director continued, Resident #41's tone has increased, and everything is tighter, indicating he has declined. She said Resident #41 was discharged from Occupational Therapy on 7/8/22. She said the splinting of the right hand/wrist continued but Restorative Therapy was not ordered for Resident #41. On 1/6/23 at 10:26 a.m., the Restorative CNA said the residents evacuated before hurricane [NAME]. She said she has not worked with Resident #41 for range of motion exercises since he was re-admitted . The Therapy Department did not refer him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 8 of 8