Inspection·May 11, 2023

F 0636 just been a matter of having enough time to get it done. But I know these residents and the others {Residents #2, #4, #6, #7, #8, #9, #10's names] are past due. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 2 of 5 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 105460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on record review and interview, the facility failed to complete a base line care plan for 1 (Resident #1) of 3 baseline care plans reviewed. Residents Affected - Few Findings include: Review of Resident #1's admission record documented an admission date of 3/20/23 and a discharge date of 3/24/23. Review of Resident #1's clinical record revealed no baseline care plan. During an interview on 5/11/22 at 11:00 AM Staff A, Licensed Practical Nurse, Minimum Data Set (MDS) Coordinator stated, I took the admission assessment and notes from hospice. That is how I got my information for the MDS. Usually, the baseline care plan would be done on day 2 of admission. She [Resident #1] did not have a base line care plan done. Yes, she [Resident #1] should have had the base line care plan and it was not done. During an interview on 5/11/22 at 12:49 PM the Director of Nursing stated, The base line care plan was not done. I do not know why [Resident #1's name] did not have a base line care plan done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 3 of 5 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 105460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605 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 interview the facility failed to ensure that resident medical records were complete and accurately documented for 7 (#2, #11, #12, #13, #14, #15, #16) of 17 resident records reviewed. Findings include: Review of the Treatment Administration Record (TAR) for Resident #2 dated 4/1/23 - 4/30/23 read Wound vac to sacral wound: Change q [every] M-W-F [Monday, Wednesday, Friday] every day shift for Mon, Wed, Fri. There was no documentation on the TAR for Friday, 4/7/23; Wednesday, 4/19/23; or Friday 4/21/23. Review of the TAR for Resident #11 dated 4/1/23 - 4/30/23 read Cleanse area to Left Groin Leptospermum Honey apply Daily and as needed. Cleanse area to left Distal, Medial Shin Leptospermum Honey apply daily and as needed. Cover with ABD Pads. Cleanse area to left Thigh Leptospermum Honey apply Daily and as needed Cover with ABD pads. Stage 3: Cleanse areas to left ischium Leptospermum Homey apply daily and as needed. Cover with ABD pads. Skin prep bilateral heels Q shift, every shift. There was no documentation on the TAR for wound care on 4/5/23, 4/6/23, 4/12/23, 4/16/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, 4/23/23, and 4/25/23. There was no documentation for skin prep bilateral heels on 4/5/23, 4/6/23, 4/12/23, 4/16/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, 4/23/23, and 4/25/23. Review of the TAR for Resident #12 dated 4/1/23 - 4/30/23 read Left Ischium Cleanse left ischial wound with wound cleaner, dry, apply med honey, hydrocolloid foam, cover with border gauze. Cover with island border dressing, every day shift for Left Ischium. There was no documentation on the TAR for wound care on 4/6/23, 4/22/23, 4/23/23, and 4/24/23. Review of the TAR for Resident #13 dated 4/1/23 - 4/30/23 read Cleanse groin wound with wound cleanser, unfold 4 x 4 gauze, cover gauze with zinc ointment and apply to wound daily and PRN every day shift for wound. Cleanse left buttocks wound with wound cleanser, unfold 4 x 4 gauze, cover gauze with zinc ointment and apply to wound daily and PRN every day shift for stage 3 wound. Cleanse left ischium wound with wound cleanser, unfold 4 x 4 gauze, cover gauze with zinc ointment and apply to wound daily and PRN every day shift for wound. Cleanse right buttock with wound cleanser, unfold 4 x 4 gauze, cover gauze with zinc ointment and apply to wound daily and PRN every day shift for stage 4 wound. Cleanse sacral wound with wound cleanser, unfold 4 x 4 gauze, cover gauze with zinc ointment and apply to wound daily and PRN every day shift for wound. There was no documentation on the TAR for wound care for the groin, left buttocks, left ischium, right buttock, or sacral wounds for 4/2/23, 4/6/23, 4/7/23, 4/17/23, 4/21/23, and 4/22/23. Review of the TAR for Resident #14 dated 4/1/23 - 4/30/23 read Skin prep to right heel area and right great toe. Leave open to air. Please apply pillows to offset pressure. There was no documentation on the TAR for skin prep to right heel area and right great toe on 4/17/23, 4/21/23 and 4/22/23. Review of the TAR for Resident #15 dated 4/1/23 - 4/30/23 read Right Distal, Plantar Foot: Clean wound with normal saline, pat dry, apply Leptospermum and cover with a border gauze once daily and PRN as needed every day shift every Mon, Wed, Fri for Right Distal, Plantar Foot Wound Care. Wound Care Sacrum: Clean wound with normal saline, pat dry, apply Leptospermum to the wound bed and cover with a border gauze once daily and PRN as needed for Sacrum Wound every day shift every Monday, Wed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 4 of 5 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 105460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605 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 Friday for Sacrum Wound Care. There was no documentation on the TAR for wound care for the Right Distal, Plantar Foot or Sacrum for 4/5/23, 4/17/23, 4/21/23, and 4/24/23. Review of the TAR for Resident #16 dated 4/1/23 - 4/30/23 read RLE [right lower extremity] wound; cleanse with Dakins and 4 x 4's - pat dry. Apply skin prep to surrounding intact skin. Apply nickel thick collagenase to wound bed and cover with xeroform gauze. Cover with Allevyn dressing. Peel back Allevyn for each skin assessment and for daily cleansing and reapplication of ointment and xeroform gauze every day shift. There was no documentation on the TAR for wound care on 4/15/23, 4/16/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, and 4/25/23. Review of the TAR for Resident #17 dated 4/1/23 - 4/30/23 read Cleanse left buttock wound with NS apply xeroform and dry dressing once a day. Cleanse left buttock wound with NS, apply leptospermum honey, and dry dressing every day shift. There was no documentation on the TAR for wound care for 4/17/23, 4/20/23, 4/21/23 and 4/22/23. During an interview on 5/11/23 at 6:40 PM the Director of Nursing stated, If there is a blank [on the MAR/TAR], it could be the wound care was not done but maybe they just didn't chart it. If they didn't document, I can't say it was done. If it was not done, the record should give the reason. But, if it is just blank as these are, then I can't say whether it was done or not. During an interview on 5/11/23 at 7:15 PM Resident #13 stated, They [the facility nurses] are supposed to change the dressing every night. They miss once in a while. Wound care doesn't come often. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 5 of 5