Inspection·January 9, 2025

F 0584 regular basis. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/7/2025 at approximately 9:00 AM, Resident #87's room had debris, napkins and crumbs on the floor. Residents Affected - Some During an interview on 1/8/2025 at 3:15 PM, the Environmental Service Manager stated, My expectation whether I am here or not, the resident rooms and floors are the first thing that my staff should be sweeping. Review of the facility policy and procedure titled General Hospitality Services Policies dated 11/30/2024 read, Policy: To provide clean, contamination-free surroundings for residents, visitors, and personnel. A clean environment is essential in preventing transmission of infection in the facility. Procedure . 1. Resident Rooms: Routine cleaning is to be done on a daily basis. Floors are to be dust mopped, then wet mopped daily with a disinfectant solution. Dusting of furniture is to be done every day. Mop water is to be changed when it is dirty (at least every three rooms). Wastebaskets are to be emptied daily, wiped with a disinfectant, and plastic liners replaced . Safety: Needed repairs; leaky faucets; toilets; light bulb; etc., are to be reported to the Maintenance Supervisor for attention and repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 2 of 15 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 01/09/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 4 residents reviewed, Resident #81. Residents Affected - Few Findings include: Review of Resident #81's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with the diagnoses that included sepsis (unspecified organism), cellulitis of right lower limb, urinary tract infection, infection and inflammatory reaction due to other urinary catheter, local infection of the skin and subcutaneous tissue, resistance to vancomycin, malignant neoplasm of uterine, and diarrhea. Review of Resident #81's physician order dated 11/25//2024 showed it read, Rifaximin Oral Tablet 550 MG [milligram] (Rifaximin), Give 1 tablet by mouth two times a day for Bowel. Review of Resident #81's MDS dated [DATE] showed the resident was not receiving antibiotics under Section N - Medications. During an interview on 1/8/2025 at 12:21 PM, the Assistant Director of Nursing (ADON) stated, I see the resident is on antibiotic. This assessment is not accurate. During an interview on 1/8/2025 at 12:50 PM, Staff H, Registered Nurse (RN), MDS Coordinator, stated, This is not an accurate assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 3 of 15 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 01/09/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 2 of 3 residents who were diagnosed with serious mental disorder, Residents #18 and #77. Findings include: Review of Resident #18's Level I PASRR dated 12/24/2024 showed no mental illness documented in Section I: PASRR Screen Decision-Making. Review of Resident #18's admission record showed the resident was admitted on [DATE] with diagnoses that included depression (onset date of 12/24/2024), anxiety disorder (onset date of 12/24/2024), and bipolar disorder (onset date of 12/24/2024). Review of Resident #18's clinical records showed no documentation that Resident #18's diagnoses of depression, anxiety disorder, and bipolar disorder had been included on an updated Level I PASRR. Review of Resident #77's Level I PASRR dated 4/22/2024 showed no mental illness documented in Section I: PASRR Screen Decision-Making. Review of Resident #77's admission record showed the resident was admitted on [DATE] with diagnoses that included schizoaffective disorder (onset date of 4/26/2024), and adjustment disorder with anxiety (onset date of 10/31/2024). Review of Resident #77's clinical records showed no documentation that Resident #18's diagnoses of schizoaffective disorder and adjustment disorder with anxiety had been included on an updated Level I PASRR. During interview on 1/8/2025 at 9:32 AM, the Director of Nursing confirmed Resident #18's and Resident #77's mental health diagnoses had not been included on their preadmission screening and resident reviews. She confirmed a revised PASRR that documented Resident #18's and Resident #77's mental health diagnoses had not been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 4 of 15 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 01/09/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received nail care for 1 of 3 residents reviewed for ADLs (Activities of Daily Living), Resident #12 (Photographic evidence obtained). Residents Affected - Few Findings include: Review of Resident #12's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis affecting right dominant side, dysarthria following cerebral infarction, speech and language deficits following cerebral infarction, and contracture of muscle, unspecified sites. During an observation on 1/6/2025 at 9:40 AM, Resident #12 was lying in bed with contractures to both hands. Resident #12's nails were overgrown and curling with a brown substance under nails. Resident #12's nails were pressing inside of the palms on both hands. During an interview on 1/6/2025 at 9:40 AM with Resident #12, when asked if she wanted her nails clean and trimmed, she shook her head yes. Review of Resident #12's care plan dated 12/27/2024 showed it read, Interventions/Tasks: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. During an observation on 1/7/2025 at 8:52 AM, Resident #12's nails were overgrown and curling with a brown substance under the nails. Resident #12's nails were pressing inside of the palms on both hands. During an interview on 1/7/2025 at 8:53 AM, Staff A, Certified Nursing Assistant (CNA), stated, I have not cut her nails, but I have not had her in a long time. During an interview on 1/7/2025 at 9:00 AM, Staff B, Licensed Practical Nurse (LPN), stated that Activities staff and Certified Nursing Assistants were to keep residents' nails trimmed and confirmed that Resident #12 needed her nails trimmed and cleaned. During an interview on 1/8/2025 at 1:37 PM, Staff I, Restorative CNA, stated that he had told the CNAs multiple times that Resident #12's nails needed to be cleaned and cut because they were pressing into her palms. During an interview on 1/8/2025 at 8:52 AM, the Director of Nursing (DON) stated, [Resident #12's name] nails need to be trimmed and cleaned, and this is to be done with showers, bed baths or any time that is needed. Review of the facility policy and procedure titled Care of Nails with the last review date of 11/19/2024 read, Procedure . May soak hand in basin half full with warm water if needed; Trim fingernails; Clean nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 5 of 15 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 01/09/2025 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** Based on observation, interview, and record review, the facility failed to ensure residents received wound care in accordance with professional standards of practice for 1 of 4 resident reviewed for wound care, Resident #87. Residents Affected - Few Findings include: Review of Resident #87's admission record showed the resident was admitted on [DATE] with the diagnoses that included local infection of the skin and subcutaneous tissue, cutaneous abscess of groin, type 2 diabetes mellitus, polyneuropathy, and necrotizing fasciitis. Review of Resident #87's hospital discharge documentation dated 12/6/2024 showed a wound care order that read, Cleanse wound with [name of the wound cleanser] solution. Fluff gauze and moistened with [name of the wound cleanser] solution loosely pack into wound. Change dressing BID [twice a day] and PRN [as needed] if soiled. Review of Resident #87's physician order dated 12/9/2024 showed it read, Referral to [the local hospital's name] Burn Clinic, DX [diagnosis]: Wound to R [Right] groin wound. Review of the Wound Care Provider Physician notes dated 12/13/2024 for Resident #87 read, Initial Wound Evaluation & Management Summary . Dressing Treatment Plan, Primary Dressing(s), Xeroform gauze apply once daily for 30 days, Secondary Dressing(s), Gauze island with bordered dressing apply once daily for 30 days. Review of Resident #87's after visit summary from the local hospital's burn unit dated 12/17/2024 read, Algidex Ag: is an autolytic debriding agent (breaks down dead tissue, but leaves good skin alone). This gauze stays in place for 3 days. Every 3 days, remove all dressings. Your first dressing change will be on 12/21/24. Wash wound with mild soap (like Dove or Ivory), rinse and pat dry. Apply the Algidex Ag to wound, cover with double layer of petroleum gauze and then dry gauze or Telfa Pad. Review of the Wound Care Provider Physician notes dated 12/20/2024, read, Signing off on patient [Resident #87] who remains in the facility. Patient followed at outside center. Review of Resident #87's physician order dated 12/17/2024 read, Order Summary: Right [NAME]- wash with mild dove or ivory, apply Algidex ag cover with double xeroform and then dry gauze or telfa pad every other day and PRN [as needed] every shift every 3 day(s) for wound care . Order Status: Discontinued. During an interview on 1/7/2025 at 11:35 AM with Staff D, Licensed Practical Nurse (LPN), Unit Manager, when asked about the sequence of orders, she stated the original wound care orders were initially from the local hospital upon discharge. During an interview on 1/7/2025 at 11:35 AM, Staff E, LPN, Wound Care Nurse, stated, [Resident #87's name] wound care orders came from [the Wound Care Provider Physician]. The physician saw [Resident #87's name] after admission and changed the orders because of the depth of the wound had improved. When [the Wound Care Provider Physician] did not follow the resident any longer, I got an order from the NP [Nurse Practitioner]. I did not follow the wound for the resident. The NP did give me a verbal wound care order for every other day with the xeroform. I was reviewing my notes, and the orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 6 of 15 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 01/09/2025 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 on Saturday [1/4/2025] and I thought I must have made a mistake. I changed the order according to my notes. The order is still not correct for what is written from [the Wound Care Provider Physician]. What I should have done was asking the resident if she had any information from the appointment and call the wound care center for clarification. I did not do that. During an interview on 1/7/2025 at 1:30 PM, the Director of Nursing (DON) stated, My expectation is for the nurse to get an updated order after going to a physician appointment. Review of Resident #87's weekly non-pressure skin condition notes for right side groin wound showed no wound measurement documented on 12/20/2024, 12/24/2024, and 1/4/2025. During an interview on 1/9/2025 at 11:00 AM, Staff E, LPN, Wound Care Nurse, stated, I did not document the size of the wound or if there was no signs and symptoms of infection. During an interview on 1/9/2025 at 11:10 AM, the DON stated, My expectation is for the wound to be documented weekly per the wound care policy. Review of the facility policy and procedures titled Physician Orders with the last review date of 11/19/2024, showed it read, Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical records. Review of the facility policy and procedure titled Non-Pressure Skin Condition Record with the last review date of 11/19/2024, showed it read, Policy: To document the presence of skin impairment/new skin impairment, not related to pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc. One site will be recorded per page. Procedure . 4. Enter the date, size, drainage information description of the wound edges and the peri-wound area . 7. Each week the non-pressure ulcer skin condition is to be evaluated and the information recorded until resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 7 of 15 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 01/09/2025 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** 3) During an observation on 1/6/2025 at 10:53 AM, Resident #18's nebulizer mask was on the floor in his room. Residents Affected - Some During an observation on 1/6/2025 at 1:53 PM, Resident #18's nebulizer mask was on the floor in his room. During an observation on 1/7/2025 at 10:00 AM, Resident #18's nebulizer mask was on the floor in his room. During an interview on 1/7/2025 at 10:00 AM, Staff J, LPN, stated, It [Resident #18's nebulizer mask] does not belong on the floor. It belongs in a plastic bag. During an interview on 1/7/2025 at 10:40 AM, the Director of Nursing (DON) stated, My expectation is for the nurses to keep mask in plastic bags. 4) Review of Resident #10's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included encephalopathy, atherosclerotic hearth disease of native coronary artery, essential (primary) hypertension, shortness of breath, and anxiety disorder. Review of Resident #10's physician order dated 12/23/2023, showed it read, Oxygen at 4 liters/minute via nasal cannula as needed. During an observation on 1/6/2025 at 9:56 AM, Resident #10 was receiving oxygen via nasal cannula at the rate of 2.5 liters/minute. During an observation on 1/7/2025 at 10:10 AM, Resident #10 was sitting upright, receiving oxygen via nasal cannula at the rate of 2.5 liters/minute. During an observation on 1/7/2025 at 3:28 PM, Resident #10 was sitting upright, receiving oxygen via nasal cannula at the rate of 2.5 liters/minute. During an interview on 1/7/2025 at 3:28 PM, Resident #10 stated, I use my oxygen all the time. I think it's at three. When asked if she changes the rate, she stated, No. I can't even get out of the bed. During an observation on 1/8/2025 at 8:10 AM, Resident #10 was receiving oxygen via nasal canula at the rate of 2.5 liters/minute. During an interview on 1/8/2025 at 8:20 AM, Staff B, LPN, confirmed that Resident #10 was receiving oxygen at 2.5 liters/minute and stated that the physician order for oxygen was written for 4 liters as needed. During an interview on 1/8/2025 at 9:00 AM, the DON stated, I expect the orders to be followed, and the rate should be set at 4 liters [for Resident #10]. 5) During an observation on 1/6/2025 at 9:58 AM, Resident #17's nebulizer unit, tubing, and mask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 8 of 15 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 01/09/2025 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 were on the resident's bedside table. There was no date on the tubing. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/7/2025 at 10:42 AM, Resident #17's nebulizer unit was on the resident's bedside table. There was no date label on the tubing and no bag holding the mask and tubing. Residents Affected - Some During an interview on 1/7/2025 at 2:42 PM, the DON stated, All masks and tubing for oxygen, nebulizers or CPAPs [Continuous positive airway pressure machines] should be in a bag and dated. Review of Resident #17's physician order dated 6/12/2024 showed it read, DuoNeb Solution 0.5-2.5 (3) MG [milligram]/3 ML [milliliter] (Ipratropium-Albuterol) 3 ml inhale orally two times a day for wheezing. During an observation on 1/8/2025 at 12:25 PM, Resident #17's nebulizer unit was sitting on his bedside table with the mask and tubing attached. There was no label, and the tubing and mask were not in a bag. During an interview on 1/8/2025 at 12:54 PM, Staff G, LPN, stated, I gave him [Resident #17] a nebulizer treatment this morning. The nebulizer tubing should be dated and in a bag. 6) During an observation on 1/6/2025 at 10:27 AM, Resident #30 was receiving oxygen at the rate of 4 liters per minute. During an observation on 1/7/2025 at 9:02 AM, Resident #30 was receiving oxygen at the rate of 4 liters per minute. Review of Resident #30's physician order dated 8/19/2024, showed it read, Oxygen at 2 L/min [liter per minute] via nasal cannula continuous, every shift for sob [shortness of breath], Notify mdO2<93%. During an interview on 1/8/2025 at 12:54 PM, Staff G, LPN, stated, His [Resident #30] oxygen is ordered for 2 liters a minute. I will go and check the rate on the concentrator. Review of the facility policy and procedure titled Oxygen Therapy with the last review date of 11/19/2024, showed it read, 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 . 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. Review of the facility policy and procedure titled Departmental (Respiratory Therapy)- Prevention of Infection with the last review date of 11/19/2024, showed it read Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff . Steps in the Procedure . Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol . 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as ordered for 3 of 8 residents reviewed, Residents #4, #10, and #30, and failed to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 9 of 15 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 01/09/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some respiratory masks were properly stored for 3 of 8 residents reviewed, Residents #17, #18 and #83 (Photographic evidence obtained). Findings include: 1) During an observation on 1/6/2025 at 9:33 AM, Resident #4 was receiving oxygen at the flow rate of 3.5 liters per minute. During an observation on 1/6/2025 at 1:15 PM, Resident #4 was receiving oxygen at the flow rate of 3.5 liters per minute. During an observation on 1/7/2025 at 9:43 AM, Resident #4 was receiving oxygen at the flow rate of 3.5 liters per minute. Review of Resident #4's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified asthma with (acute) exacerbation, and unspecified diastolic (congestive) heart failure. Review of Resident #4's physician order dated 9/20/2025 showed it read, Respiratory: Oxygen- 2 L [Liter] continuous every shift notify md O2<93% [notify medical doctor if oxygen saturation is less than 93%]. During an interview on 1/7/2025 at 10:13 AM, Staff K, Registered Nurse (RN), confirmed that the flow rate was set incorrectly for Resident #4 and stated that Resident #4 should have his oxygen flow rate set at 2 liters, and a resident's flow rate should be checked at the beginning of their shift. 2) During an observation on 1/6/2025 at 10:50 AM, Resident 83's nebulizer mask was stored on the bedside table with no bag on it. During an observation on 1/7/2025 at 9:37 AM, Resident 83's nebulizer mask was stored on the bedside table with no bag on it. During an interview on 1/7/2025 at 10:03 AM, Staff J, Licensed Practical Nurse (LPN), stated that the mask was supposed to be stored in a bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 10 of 15 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 01/09/2025 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide laboratory services to meet the needs of the residents for 2 of 5 residents reviewed for unnecessary medications, Residents #20 and #35. Residents Affected - Few Findings include: 1) Review of Resident #20's admission record showed the resident was most recently admitted on [DATE] with the diagnoses that included unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder, recurrent, unspecified; and other seizures. Review of Resident #20's Medication Regimen Review for September 2024 for Depakote Oral Tablet Delayed Release 250 mg (milligram) (Give 1 tablet by mouth two times a day for mood and stability) showed the Consultant Pharmacist requested specifying the need and frequency of Depakote and Ammonia levels for the order for labs ordered on 6/18/2024. Review of Resident #20's consultation note authored by the Psychiatric Services Provider dated 6/18/2024 showed it read, HPI [History of Present Illness] General . Plan of care to start Depakote 250 mg [milligram] PO [by mouth] BID [twice daily] for mood instability. Add Depakote and Ammonia levels in 7 days and Q [every] 3 months. Review of Resident #20's physician orders revealed no orders to obtain either a Depakote or an ammonia level. Review of Resident #20's test results revealed no laboratory results for either a Depakote or an ammonia level. During an interview on 1/8/2025 at 4:10 PM, the Psychiatric Services Provider stated, We have been having issues with getting the ammonia levels. I think it might have something to do with it being a send out lab. Our Medical Director, [Medical Director's Name] has recommended just getting Depakote levels every three months. If the Depakote level is abnormal or the patient is symptomatic, then we get the ammonia level. During an interview on 1/9/25 at 10:45 AM, the Director of Nursing (DON) stated, The psych nurse can enter orders, but not labs. The process is that they email their notes which are then integrated into PCC. Currently they are not being translated to the right people [nursing]. The vendor is supposed to talk to the unit manager. 2) Review of Resident #35's admission record revealed the resident was admitted on [DATE] with the diagnoses that included hyperlipidemia; essential (primary) hypertension; unspecified diastolic (congestive) heart failure; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Alzheimer's disease, unspecified; and major depressive disorder, recurrent, unspecified. Review of Resident #35's Medication Regimen Review for August 2024 for Atorvastatin Calcium Tablet 80 MG (Give 1 tablet by mouth at bedtime related to hyperlipidemia) showed the Consultant Pharmacist requested lipid panel for assessing if the medication was warranted and how frequently needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 11 of 15 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 01/09/2025 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 0770 Level of Harm - Minimal harm or potential for actual harm Review of Resident #35's physician order dated 6/23/2022 showed it read, Lipid Panel every night shift every 180 day(s) for monitoring . Order Status Active . Start Date: 09/13/2022. Review of Resident #35's medical records revealed no lipid panel results documented since January of 2024. Residents Affected - Few During an interview on 1/8/2025 at 12:35 PM, the DON stated, The expectation is that we follow physician orders for labs. We did change companies because we were having some issues, but that's no excuse. Review of the facility policy and procedure titled Monthly Drug Regimen Review with the last review date of 11/19/2024, showed it read, Procedure: To ensure the requirement is met for monthly drug regimen review the ED [Executive Director]/DON should implement the following process . If follow up for consultant pharmacist recommendations are not completed within the specified time frame this should be reported to the Medical Director for follow up with the attending physician as indicated. Review of the facility policy and procedure titled Physician Orders with the last review date of 11/19/2024, showed it read, Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record . Routine Orders . The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date the order as soon as practicable after it is provided to maintain an accurate medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 12 of 15 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 01/09/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food items were stored in accordance with professional standards (Photographic evidence obtained). Residents Affected - Few Findings include: 1) During an observation while conducting a tour of the kitchen on 1/6/2025 at 9:30 AM, there was a brown buildup on the floor of the Emergency Food Storage room under a food storage crate, located over a floor drain. During an interview on 1/6/2025 at 9:30 AM, the Food Services Manager stated, I don't know what that is. I have been here for 7 months, and it hasn't happened since I have been here. It may have been the sewer drain overflowed. We don't come back here very often. During an observation on 1/8/2025 at 8:35 AM, ceiling vents located in the emergency food storage room and over the food preparation area in the kitchen had a dark substance extending around the perimeter of the vents. The area around two of the vents also had areas of cracked and peeling white material. During an interview on 1/8/2025 at 8:45 AM, the Maintenance Director stated, If that [the brown buildup over the floor drain] was from the drain backing up, it's dry now. No one reported it to me. We will have to pull down those [ceiling] vents and paint the ceiling. Review of the facility's Freezer Temperature Log for January 2025 revealed documentation of temperatures above 32 degrees Fahrenheit (freezing): 64 degrees Fahrenheit on 1/4/2025; 61 degrees Fahrenheit on 1/5/2025; and 38 degrees Fahrenheit on 1/8/2025. No corrective actions were documented on the log. During an interview on 1/8/2025 at 1:08 PM, the District Manager for Food and Nutrition Services stated, We moved all of the food out of the back room [the emergency food supply room]. If I had known there was a drain in there, I would have moved the food then. We don't want to take any risks. I believe they are going to snake the drain. I checked all of the food in that [the reach-in] freezer, and it was still frozen. Some had blocks of ice, apparently from when the freezer had gone through defrost. We moved all of it to a different freezer, and we are having that one repaired. The expectation is when the temperature is not within range, that the food is checked and either moved or discarded. Review of the facility policy and procedure titled Maintenance with the last review date of 11/19/2024 showed it read, Policy: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will follow all policies regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 13 of 15 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 01/09/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff used proper personal protective equipment (PPE) during medication pass for the residents on enhanced barrier precautions and failed to ensure staff performed hand hygiene during wound care to prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: 1) During an observation on 1/8/2025 at 9:52 AM, Staff F, Licensed Practical Nurse (LPN), prepared medications for Resident #500 and entered the room. There was a signage reading, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. The resident had a gastrostomy tube (feeding tube). Staff F donned gloves and administered the medication using the feeding tube without donning on a gown. During an interview on 1/8/2025 at 9:55 AM, Staff F, LPN, stated, I did miss the gown. During an interview on 1/8/2025 at 12:21 PM, the Assistant Director of Nursing (ADON) stated, My expectation is for the staff to follow the enhanced barrier precaution policy wearing the gown. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 11/19/2024, showed it read, Policy: Enhanced Barrier Precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDRO's) among residents by utilizing gloves and gowns for high contact resident care activities. Definitions: Indwelling medical device- includes but is not limited to central lines, urinary catheter, feeding tube, tracheostomy and ventilator. High contact care activity- provide opportunities for transfer of MDRO to staff hands and clothing. High contact care activities include: dressing, bathing/showering, transferring, providing hygiene, such as brushing teeth, combing hair and shaving, changing linens, incontinent care, toileting, device care or use, such as central line, urinary catheter, feeding tube, tracheostomy or ventilator, wound care. 2) During an observation on 1/9/2025 beginning at 9:50 AM, Staff E, LPN, Wound Care Nurse, proceeded to provide wound care to Resident #87. Prior to starting wound care, Staff E washed her hands with soap and water at the sink and had all supplies at bedside prior to wound treatment. Staff E donned a pair of gloves and proceeded to rinse the groin wound with a washcloth of clean rinse water. After rinsing the wound, Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene. Staff E applied the calcium alginate to the wound and then removed the gloves. During an interview on 1/9/2025 at 10:10 AM, Staff E, LPN, Wound Care Nurse, stated, I thought I cleansed my hands after removing gloves after cleaning the wound. I know I should have washed hands every time I remove the gloves. During an interview on 1/9/2025 at 10:12 AM, the Director of Nursing (DON) stated, The expectation is for staff to wash hands prior to donning gloves and wash hands again after doffing gloves and before donning another pair of gloves. This process should be followed regardless of performing clean or dirty functions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 14 of 15 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 01/09/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled Personal Protective Equipment- Gloves with the last review date of 11/19/2024, showed it read, Policy Statement: Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Policy Interpretation and Implementation .8. Wash your hands after removing gloves. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105460 If continuation sheet Page 15 of 15