Inspection·June 26, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treated/followed by wound care; 6/15/25 left lower leg venous ulcer being treated followed by wound care/treatment in place; There was no weekly skin integrity completed for 6/22/25.On 6/24/25 at 04:02 p.m., Registered Nurse (RN) Staff B said she heard about Resident #892 spilling his coffee on his leg. Staff B stated, It looks like a burn. She said she did not place a bandage over it and she did not document on it. Staff B checked the resident's orders and said there was no order to place a bandage on the right thigh or any treatment order for the burn. Staff B said with an injury like a burn you need to call the doctor, document a change in condition assessment, notify the next of kin, and write an order for any treatment. On 6/24/25 at 4:15 p.m., in an interview with the Assistant Director of Nursing (ADON) RN, she said she did not know about the burn the resident got at the facility. On 6/24/25 at 4:21 p.m., in an interview with Staff E, RN, Unit Manager (UM) said she did not know about the burn to Resident # 892's right inner thigh. She said she did not know who placed the bandage on the burn. She said someone should have notified the physician, obtained an order, completed a change in condition, and initiated an incident report. Staff E, RN UM said there should always be a treatment order to apply a bandage.On 6/24/25 at 5:07 p.m., the Director of Nursing (DON) said it was very concerning there was no order, no treatment, and it was not reported. She stated, No nothing. She said the burn should have been reported. She stated, You can tell it's a burn, it's a good size.On 6/25/25 at 12:12 p.m., observed a wound to Resident #892's right inner/upper thigh. The wound was approximately 2.5 inches in length by 2 inches in width. The top layer of skin had peeled away revealing bright pink flesh. (photographic evidence obtained). On 6/25/25 at 3:22 p.m., in an interview with the DON and the Regional Nurse they said there was no investigation for the burn because it was not reported by the nurse(s). They said they just began an investigation. They said they started education on change in condition, initiating an incident report in risk management, notifying the physician and emergency contact. They said they completed a full house skin sweep and are collecting staff statements as part of the investigation. On 6/26/2025 at 2:45 p.m., in an interview with Staff B RN, she said she was the nurse for Resident #892 on 6/20/2025, 6/21/2025, and 6/22/25. She said she didn't complete a Weekly Skin Assessment because she was too busy that Sunday and didn't get around to it. 2. Review of medical record revealed Resident # 66 was admitted to the facility on [DATE] with diagnosis including but not limited to Acute embolism (an obstruction of a blood vessel by a floating clot) and thrombosis (when a clot forms inside a blood vessel) of left tibial vein (deep vein in your lower leg), congestive heart failure (heart doesn't pump blood as well as it should), generalized anxiety disorder, muscle weakness, and difficulty walking.The admission Minimum Data Set (MDS) Assessment with a target date of 5/12/25 revealed a Brief Interview for Mental Status (BIMS) Resident #66 scored a 15 indicating intact cognition.Review of care plan dated 5/23/25 reveals Resident #66 has an alteration in usual functional performance in mobility/transfer status related to congestive heart failure, anxiety, depression, weakness, and impaired mobility. Interventions include chair to bed, bed to chair transfer Resident #66 is dependent with staff assist.The admission Minimum Data Set Assessment with a target date of 5/12/25 noted the resident was dependent on staff for chair to bed transfer (Helper does all of the effort. Resident does none of the effort to complete the activity). Review of CNA Kardex indicated Resident #66 is dependent with staff assist for transferring.Review of the facility list of residents who require a mechanical lift with assist of 2 staff to transfer from chair to bed, bed to chair include resident #66. On 6/23/25 at 2:13 p.m., Certified Nursing Assistant (CNA) Staff C, was observed in the room with Resident #66 and the Hoyer Lift. (A Hoyer Lift is a type of mechanical lift whereby 2 staff are recommended while using in healthcare facilities.) Resident #66 was sitting in a wheelchair. Staff C said he operated the Hoyer Lift alone while (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 2 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he transferred Resident #66 about 6 feet from the bed to the wheelchair. He said he knew he was supposed to have another staff with him, but he could not find anyone, so he transferred the resident with the Hoyer Lift alone. On 6/23/25 at 2:20 p.m., the DON asked Staff C if he transferred Resident #66 with the Hoyer Lift by himself. Staff C confirmed he used the Hoyer Lift without another staff. The DON said Staff C had just completed the Skills training including Hoyer Lifts and should have known better. The DON said the staff are trained to use 2 for the Hoyer Lifts. The CNA did not follow the training. Review of Mechanical Lift Skills Competency Assessment bullet #2 states 2 staff members are used during transfer. Review of Mechanical Lift Skill Competency Assessment for Staff C, CNA 3/12/25 reveals Staff C is competent to perform a mechanical life transfer independently and without supervision. The Competency Assessment was evaluated and signed for by the DON on 3/12/25.On 6/23/25 at 2:30 p.m., the DON started education on safe use of the full body mechanical lift using two staff members. Review of the facility's Fall Management policy and procedure, dated 11/30/2014, with a revision date of 7/29/2019, stated in the overview: A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as the result of an overwhelming external force . Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .Post Fall Strategies: 1. Resident will be evaluated and post fall care provided. 2. Initiate neurological checks as per policy or directed by physician order. 3. Notify the physician and resident representative. 4. Re-evaluate fall risk utilizing the Post Fall Evaluation. 5. Update Care plan and Nurse Aide Kardex with intervention(s). 6. Initiate post fall documentation every shift for 72 hours. Review of the facility's incident log revealed on 6/9/25 the facility conducted a fall investigation for Resident #442. Review of the facility's investigation related to Resident #442's fall revealed on 6/7/25 around 3:00 a.m., Resident #442's roommate was awakened by Resident #442 falling out of his bed and hitting the floor. Resident #442's roommate called for help, and a female Certified Nursing Assistant (CNA) came to the room, saw Resident #442 on the floor and went to get Resident #442's nurse, Licensed Practical Nurse (LPN) Staff A. The investigation noted: LPN Staff A came to the room a couple of minutes later with a male CNA. LPN Staff A asked Resident #442 several questions and put Resident #442 back into his bed. Staff A did not document in Resident #442's medical record that he was found on the floor on 6/7/25 around 3:00 a.m. LPN Staff A did not assess Resident #442 prior to placing the resident back in bed, did not initiate neurological checks as per facility policy, did not complete a Post Fall Evaluation form, and did not notify Resident #442's primary care physician (PCP) and resident representative. LPN Staff A LPN did not inform Registered Nurse (RN) Staff B that Resident #442 was found on the floor around 3:00 a.m. that morning as required during the morning shift change report. RN Staff B entered Resident #442's room around 12:30 p.m. The resident stated that he was nauseous and had a headache. Resident #442's roommate informed RN Staff B that Resident #442's headache could be related to the fall he had that morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 3 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 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 0689 Resident #442 verified he sustained a fall that morning. Level of Harm - Minimal harm or potential for actual harm RN Staff B notified the Advanced Practice Registered Nurse of Resident #442's fall and complaint of nausea and headache. The APRN Said she was not notified of the fall and would be at the facility within 45 minutes to assess the resident. He issued an order for Zofran to control Resident #442's nausea and vomiting. Residents Affected - Some The APRN arrived at the facility, assessed Resident #442 and issued an order to transfer Resident #442 to an acute care hospital for further evaluation. The APRN documented the hospital admitted Resident #442 with a diagnosis of head injury/concussion. On 6/25/2025 at 11:30 a.m., in an interview RN Staff B said on 6/7/25 LPN did not inform her Resident #442 had fallen that morning. RN Staff B stated she was not aware of the resident's fall until 12:30 p.m. when he complained of nausea and reported the fall to her. She assessed Resident #442 and notified The APRN of the resident's fall and complaint of nausea and headache. She said when a resident falls, they are required to conduct a fall evaluation at that time and provide post-fall care. RN Staff B said that the nurse should notify the physician, the resident's family, the Unit Manager, the DON and/or the Assistant Director of Nursing as soon as possible. The nurse should also initiate neurological checks if they think the resident hit their head during the fall. On 6/25/25 at 12:00 p.m., in an interview the APRN said on 6/7/25 RN Staff B notified him via text of Resident #442's fall that occurred at approximately 3:00 a.m. that morning. He gave an order for medication for the resident's nausea and vomiting and came to the facility to assess Resident #442. The APRN said Resident #442 was stable when he assessed him but issued an order to transfer him to the hospital for further evaluation. Resident #442's representative was at the facility and chose to drive him to a hospital of their choice. The APRN said when a resident has a fall, the nurse is required to conduct a post-fall assessment, notify the resident's primary care physician, initiate neurological checks, document their assessment and physician orders in the resident's medical record. The APRN confirmed LPN Staff A did not notify him or the physician of Resident #442’s fall. On 6/25/25 at 1:45 p.m., a joint interview was conducted with the DON and the ADON to review the process following a resident’s fall and review Resident #442’s fall investigation. The DON and ADON said their investigation verified that LPN Staff A did not document the resident's fall, did not follow post-fall protocol and did not notify the physician or on-coming shift for post-fall management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 4 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide infection control standards for 2 (Residents #83 and #893) of 2 residents reviewed with urinary catheters.The findings included:Review of Infection Control Policies and Practices dated 2001, revised 2018 states the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Bullet # 2 states the objectives or our infection control policies are to (a) prevent, detect, investigate, and control infections in the facility. Bullet #4 states All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.Review of Urinary Catheter Policies and Procedures dated 11/30/2014, revised 9/19/2017 states Foley bag to be covered by a privacy bag to preserve dignity of resident and tubing should be off the floor.1. Review of medical record revealed Resident # 83 was initially admitted to the facility on [DATE], the most recent admission date on 6/5/25 with diagnosis including retention of urine (when the bladder doesn't empty completely), unspecified, other obstructive (blocking) and reflux uropathy (urine flows backwards), and sepsis (serious infection).The admission Minimum Data Set (MDS) Assessment with a date of 6/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.Review of the current physician orders revealed Foley catheter size 16 French (Fr)/30 milliliter (mL) for diagnosis obstructive and reflux uropathy dated 5/14/25. Catheter-bag change as needed dated 5/2/25. Review of the medication administration records (MAR) showed Resident #83 is currently being treated for a urinary tract infection (UTI) identified on 6/22/25 with Levaquin (antibiotic) oral tablet 750 milligrams (mg) once a day for 10 days. Review of care plan initiated 5/15/25 revealed Resident #83 has an indwelling Foley catheter related to obstructive and reflux uropathy. The care plan goal (1) revealed the resident will be/remain free from catheter-related trauma through the review date (2) The resident will show no signs or symptoms of urinary infection through the review date. On 06/23/25 at 10:15 a.m., observed Resident #83 laying in bed. The urinary catheter drainage bag was laying on the floor next to the bed. On 6/23/25 at 10:18 a.m., Certified Nursing Assistant (CNA) Staff F went to the room and said the drainage bag should not be laying on the floor. The CNA said it is an infection control issue because of the germs on the floor. The CNA positioned the urinary drainage bag off the floor by hooking it onto the bedframe. Review of care plan on 6/24/25 revealed Resident #83 has a urinary tract infection related to ESBL (bacteria) in urine. Interventions include contact isolation: wear gowns and mask when changing contaminated linens. Place soiled linens in bags and close bag tightly before taking to laundry. Give antibiotic therapy as ordered. 2. Review of medical record revealed Resident #893 was admitted to the facility on [DATE] with diagnosis including but not limited to urinary tract infection and unspecified dementia. The MDS Assessment with a target date of 6/26/25 revealed a short- and long-term memory problems. Resident is alert to person only.Review of progress note dated 6/21/25 at 2:24 p.m., revealed nursing is reporting today that the resident has not much to void and is concern for potential retention.Review of progress note dated 6/24/25 at 12:14 p.m., revealed the resident developed urine retention over the weekend and Foley was inserted.Review of medical record revealed order 6/22/25 for Foley catheter, diagnosis: urinary retention. Size: 16Fr/5mL.On 6/23/25 at 9:56 a.m., observed Resident #893 with urinary catheter drainage bag without a privacy bag, laying on the floor. *On 6/23/25 at 10:01 a.m., the Director of Nursing (DON) was made aware of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 5 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 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 0690 catheter drainage bag laying on the floor next to the resident's bed. The DON stated, Yeah, I need to get that off the floor.*photographic evidence obtained Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 6 of 6