Health inspection·August 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [Resident #198's name] complains of pain at times due to her contractures. I encourage her to move and help her with positioning. During an observation on 8/15/23 at 8:28 AM with Staff C, Registered Nurse (RN), Resident #198 nodded yes when Staff C asked if she had pain. Resident #198 pointed to her leg and nodded when Staff C asked if her whole leg was hurting. During an interview on 8/15/23 at 8:41 AM Staff C, RN, stated, I try to find out why the resident has pain and ways to alleviate the pain. If that does not work, I give them medication for the pain. [Resident #198's name] does not have any pain medication ordered. During an interview on 8/15/23 at 8:41 AM the DON stated, First, staff should try noninvasive, nonpharmacological interventions to help the resident relieve pain. If that does not work, we should have an 'as needed' pain medication ordered to have on hand. During an interview on 8/14/23 at 12:41 PM the MDS Coordinator stated, I do not see that [Resident #198's name] was care planned for pain. Normally we look at reports, orders, [hospital] discharge summary, and the 3008 [Medical Certification For Medicaid Long Term Care Services And Patient Transfer Form] and use all the information to formulate a care plan. Review of the Department of Medicine Hospitalist Service Discharge Summary for Resident #198 with a discharge date of 8/5/23 reads, Hospital Course. Chronic Problems. Leg pain. Appears to be related to movement and contractures. PRN (as needed) lidocaine and Tylenol. Avoiding narcotics if possible given changes to mental status. Review of the admission record documented Resident #198 was admitted on [DATE] with diagnosis that included aphasia, epileptic seizures related to external causes, type 2 diabetes with unspecified diabetic retinopathy with macular edema, chronic obstructive pulmonary disease, gastroparesis, cerebrovascular disease, blindness right eye, low vision left eye, major depressive disorder, repeated falls, and essential hypertension. Review of the physician's orders for Resident #198 documented no pain medication or pain monitoring. Review of the comprehensive person-centered care plan for Resident #198 documented no developed care plan for pain management. Review of the facility policy and procedure titled Pain Management Guideline, last reviewed 4/27/23 reads, Policy: The center strives to improve patient/resident comfort and minimize pain in order to help a resident attain or maintain his or her highest practical level of well-being. Process: Pain Evaluation: Identify if a resident is experiencing pain using either the resident's self-report pain (utilizing a 0-10 scale) or for those patient/residents who cannot self-report, use the nonverbal clinic indicators. Treatment: Develop patient centered interventions (pharmacologic and non-pharmacologic) to manage pain. Document the interventions on the care plan. Review of the facility policy and procedure titled Comprehensive Care Plans last reviewed 4/27/23 reads, Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 2 of 9 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 08/16/2023 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 0656 identified in the resident's comprehensive assessment. 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: 105460 If continuation sheet Page 3 of 9 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 08/16/2023 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 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. During an interview on 8/13/23 at 10:30 AM Resident #248 stated, They don't take care of my colostomy like they should. It has busted because they don't empty it. Residents Affected - Few During an observation on 8/13/23 at 10:30 AM Resident #248's colostomy bag contained a medium amount of liquid brown stool, was inflated, and appeared to be completely full. Review of the Department of Medicine Hospitalist Medicine History and Physical for Resident #248 dated 7/16/23 reads . s/p [status post] diverting sigmoid colostomy on 5/28/23. Review of the Admission/readmission Data Collection dated 8/8/23 reads, J. Gastrointestinal. 1. Bowel. 1) Always Continent. 2. Bowel Elimination Pattern. 2) At least one movement every three days. 6. Presence of. Colostomy not checked. Review of the care plan for Resident #248 documented no developed care plan for bowel or colostomy care. Review of the Daily Skilled Nurse's Note dated 8/10/23 for Resident #248 read, Section G. 4. no ostomy noted. Review of the Daily Skilled Nurse's Note dated 8/12/23 for Resident #248 read, Section G. 4. no ostomy noted. Review of the Daily Skilled Nurse's Note dated 8/14/23 for Resident #248 read, Section G. 4. no ostomy noted. Review of the Daily Skilled Nurse's Note dated 8/15/23 for Resident #248 read, Section G. 4. no ostomy noted. Review of the physician's orders from 8/8/23 through 8/14/23 documented no order for colostomy care. During an interview on 8/15/23 at 1:53 PM the DON stated nurses will chart completion of colostomy care on the treatment record. The care for the colostomy should also be noted in the resident's care plan. The skilled nursing notes indicates there is not a colostomy. There is no information on the colostomy in the care plan. That is incorrect. The resident should be care-planned for a colostomy and there should be a physician's order so that it will be on the treatment record and the nurses can record the care. If it is not ordered or charted or in the care plan, we cannot know whether or not it was done. Review of the policy and procedure titled Colostomy/Ileostomy Care, last reviewed 4/27/23, reads, Documentation. The following information should be recorded in the resident's medical record: 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual(s) who provided the colostomy/ileostomy care. 6. The signature and title of the person recording the data. Based on observation, interview, and record review the facility failed to follow standard quality (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 4 of 9 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 08/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of care for pain management for 1 of 3 residents, Resident #198 and failed to provide colostomy care for 1 of 3 residents, Resident #248. Findings include: 1. During an observation on 08/13/23 at 10:25 AM Resident #198 was lying in bed. Resident #198 touched her right leg and when asked if she was in pain, she put her thumb up and nodded. During an interview on 8/13/23 at 10:26 AM, Staff B, Certified Nursing Assistant (CNA), stated, [Resident #198's name] complains of pain at times due to her contractures. I encourage her to move and help her with positioning. During an observation on 8/15/23 at 8:28 AM with Staff C, Registered Nurse (RN), Resident #198 nodded yes when Staff C asked if she had pain. Resident #198 pointed to her leg and nodded when Staff C asked if her whole leg was hurting. During an interview on 8/15/23 at 8:41 AM Staff C, RN, stated, I try to find out why the resident has pain and ways to alleviate the pain. If that does not work, I give them medication for the pain. [Resident #198's name] does not have any pain medication ordered. During an interview on 8/15/23 at 8:41 AM the DON stated, First, staff should try noninvasive, nonpharmacological interventions to help the resident relieve pain. If that does not work, we should have an 'as needed' pain medication ordered to have on hand. Review of the Department of Medicine Hospitalist Service Discharge Summary for Resident #198 with a discharge date of 8/5/23 reads, Hospital Course. Chronic Problems. Leg pain. Appears to be related to movement and contractures. PRN (as needed) lidocaine and Tylenol. Avoiding narcotics if possible given changes to mental status. Review of the admission record documented Resident #198 was admitted on [DATE] with diagnosis that included aphasia, epileptic seizures related to external causes, type 2 diabetes with unspecified diabetic retinopathy with macular edema, chronic obstructive pulmonary disease, gastroparesis, cerebrovascular disease, blindness right eye, low vision left eye, major depressive disorder, repeated falls, and essential hypertension. Review of the physician's orders for Resident #198 documented no pain medication or pain monitoring. Review of the comprehensive person-centered care plan for Resident #198 documented no developed care plan for pain management. Review of the facility policy and procedure titled Pain Management Guideline, last reviewed 4/27/23 reads, Policy: The center strives to improve patient/resident comfort and minimize pain in order to help a resident attain or maintain his or her highest practical level of well-being. Process: Pain Evaluation: Identify if a resident is experiencing pain using either the resident's self-report pain (utilizing a 0-10 scale) or for those patient/residents who cannot self-report, use the nonverbal clinic indicators. Treatment: Develop patient centered interventions (pharmacologic and non-pharmacologic) to manage pain. Document the interventions on the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 5 of 9 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 08/16/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 8/13/23 at 10:17 AM Resident #37 was lying in bed sleeping with her oxygen concentrator (O2) set on 3 Liters per minute (3 L/m), nasal cannula was in place. Residents Affected - Few During an observation on 8/14/23 at 12:58 PM Resident #37 was lying in bed watching television. The oxygen concentrator was set on 3 L/m, nasal cannula was in place. Review of the admission record documented Resident #37 was admitted to the facility on [DATE] with diagnoses that included embolism, and thrombosis of deep veins on left lower leg, and chronic obstructive pulmonary disorder. Review of Resident #37's physician's orders documented no orders for oxygen. Review of the Quarterly Minimum Data Set (MDS), Comprehensive Assessment for Resident #37 dated 7/13/23 read No for oxygen. During an interview on 8/15/23 at 1:00 PM, the DON verified Resident #37 has been on oxygen and she could not locate a physician's order. Based on observation, interview, and record review, the facility failed to ensure residents received the necessary respiratory care and services in accordance with professional standards of practice for 2 of 3 resident reviewed for oxygen administration, Resident #53 and #37. Findings include: 1. During an observation on 08/13/23 at 10:11 AM Resident #53 was lying in bed with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 08/14/23 at 8:25 AM Resident #53 was lying in bed with oxygen being administered via nasal cannula at 2.5 liters per minute. Review of Resident #53's physician's orders documented no orders for oxygen. Review of the admission record documented Resident #52 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease. During an interview on 8/15/23 at 8:51 AM the Director of Nursing (DON) stated, [Resident #53's name] is on oxygen and does not have [physician's] orders in the system. Review of the facility policy and procedures titled Oxygen Therapy, last reviewed 4/27/23, reads, Policy: In the event that a resident requires the use of oxygen to manage a medical condition, The Company will offer assistance as ordered by the resident's physician. Only enrichers, concentrators, and liquid oxygen will be used. Oxygen therapy must be reviewed by the nurse on a regular basis and all staff members offering assistance with oxygen must be properly trained. Procedure: 1. The nurse will organize the oxygen therapy as ordered by the resident's physician. 7. Adjust the flow of oxygen as ordered by the physician. Make certain that the flow meter is turned to zero when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 6 of 9 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 08/16/2023 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted daily. Residents Affected - Many Findings include: On 8/13/23 at 8:55 AM, upon entrance to the facility, nurse staffing hours were not posted and readily available for residents and visitors. During an interview on 8/13/23 at 11:15 AM the Administrator stated, 'The hours should be posted in the front lobby. On 8/13/23 at 11:15 AM nurse staffing hours could not be located in the lobby. During an interview on 8/13/23 at 11:20 AM the Business Office Manager stated it was the duty of the MDS (Minimum Data Set) Coordinator to have staffing information posted and readily available with the correct information at the beginning of each shift. A review of the policy and procedures titled, Nurse Staffing Posting Information last review on 11/17/22 read, Policy. It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines. 1. The Nurse Staffing Sheet will be posted on a daily basis .2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information will be: a. presented in a clear and readable format. b. In a prominent place readily accessible to residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 7 of 9 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 08/16/2023 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 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. 2. During an observation on 8/13/23 at 10:15 AM Resident #38 had a small clear medicine cup containing a white powdery substance on the bedside table. During an observation on 8/14/23 at 1:15 PM Resident #38 had a small clear medicine cup containing a white powdery substance on the bedside table. During an interview on 8/15/23 at 10:17 AM Resident #38 stated that the cup contained medication that staff puts on her foot fungus. Review of the Medication Administration Record dated 8/1/23 - 8/31/23 for Resident #38 read antifungal external powder 2%, apply every shift to toes on Left foot. Administration note: apply a full brush to the affected area around the nail and underneath the nail tips every shift for anti-fungal. During an interview on 8/14/23 at 2:17 PM the DON stated that her expectations are medications are never to be left at bedside. During an interview on 8/16/23 at 9:43 AM Staff A confirmed she should not have left the medication at the resident's bedside.at bedside. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 2 out of 4 hallways reviewed for unattended medication. Findings include: 1. During an observation on 8/13/23 at 10:04 AM, Resident #18's room was empty, and a bottle of eye drops was observed on top of the bed side table. Review of Resident #18's physician orders revealed no self-administration orders. Review of Resident #18's Comprehensive Care Plan revealed no interventions for medication self-administration. During an interview on 8/15/23 at 8:52 AM the Director of Nursing (DON) stated, [Resident #18's name] should not have any medication at bedside as she is unable to administer. Review of the facility policy and procedure titled Medication Storage, last reviewed on 4/27/23 reads, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines. 1. General Guidelines. a. All drugs and biologicals will be store in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 8 of 9 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 08/16/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure titled Administering Medications, last reviewed on 4/27/23 reads, Policy Statement. Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation. 27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Plan Team, has determined that they have the decision-making capacity to do so safely. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 9 of 9