Inspection·January 20, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure a minimum data set (MDS) assessment was completed in a timely manner for 1 of 4 residents reviewed for timely submission of the MDS, Resident #116. Residents Affected - Few Findings include: Review of Resident #116's MDS records showed the facility had completed an admission MDS on 9/7/2022. Further review of the records did not reveal a completed Quarter 1 MDS on 12/8/2022 when Resident #116's Quarter 1 MDS was due. Resident #116's Quarter 1 MDS was 27 days overdue on 1/18/2023. During an interview on 1/18/2023 at 12:57 PM, the MDS Coordinator verified Resident #116's Quarter 1 MDS had not been completed in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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** 4. Review of the admission record for Resident #239 revealed the resident was admitted on [DATE] with diagnoses including but not limited to mycoses (fungus that invades the tissues), wound of right arm, and cutaneous abscess of right upper limb. Residents Affected - Some During an observation on 1/17/2023 at 9:00 AM, Resident #239 had a PICC in the right upper arm dated 1/16/2023 (photographic evidence obtained). During an interview on 1/17/2023 at 9:00 AM, Resident #239 stated, Yes, the nurses change the PICC line dressing every week. During an observation on 1/18/2023 at 12:00 PM, Resident #239 had a PICC in the right upper arm dated 1/16/2023. During an observation on 1/19/2023 at 9:15 AM, Resident #239 had a PICC in the right upper arm dated 1/16/2023. Review of the physician order for Resident #239 dated 1/10/2023 reads, Fluconazole in Sodium Chloride Intravenous Solution 400-0.9 mg /200 ML-% (Fluconazole in NaCl) use 400 mg intravenously one time a day for Fungemia until 02/06/2023 23:59 [11:59 PM]. Review of the physician order for Resident #239 dated 1/6/2023 reads, Change PICC line dressing q [every] week and PRN. Observe site and report to MD [Medical Doctor] any significant changes one time a day every 7-day(s) for PICC line dsg [dressing] management Alert MD to any S/S [signs/symptoms] of infection or excessive bleeding at site. Review of the physician order for Resident #239 dated 1/6/2023 reads, IV-PICC RUA [Right Upper Arm], monitor site Q shift for signs/symptoms of infection and/or infiltration every shift. Review of the Medication Administration Record (MAR) for January 2023 revealed no documentation of PICC line dressing changes. Review of the nursing progress notes from the admission date of 1/6/2023 to 1/20/2023 revealed no documentation of PICC line dressing changes. During an interview on 1/19/2023 at 9:30 AM, the DON stated, Dressings should be changed every 48 hours with the gauze underneath the dressing. Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 of 7 residents reviewed for central venous access devices (Residents #131, #107, and #239) and for 1 of 4 residents reviewed for gastrostomy tube (Resident #113). Findings include: 1. During an observation on 1/17/2023 at 9:25 AM, Resident #131 was sitting up at bed side with a single lumen midline. The dressing was dated 1/10/2023 and was covered with a transparent dressing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 with gauze under the dressing. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/17/2023 at 9:25 AM, Resident #131 stated, Staff have not changed my IV [intravenous] dressing in a long time. The staff do not take care of it. Residents Affected - Some Review of the admission record for Resident #131 revealed he was admitted to the facility on [DATE] with the diagnoses including but not limited to a history of osteomyelitis (bone infection), type 1 diabetes mellitus with foot ulcer, cardiac arrest, hereditary and idiopathic neuropathy, and sepsis, resistance to multiple antibiotics, and enterocolitis due to clostridium difficile. Review of the physician order for Resident #131 dated 1/16/2023 reads, Vancomycin HCl [hydrochloride) Oral Suspension 50 MG [milligrams]/ML [milliliters] give 5 ml by mouth every 6 hours for CDIFF [Clostridium difficile] for 5 days. Review of the Treatment Administration Record (TAR) for January 2023 for Resident #131 reads, Order date 12/19/2022. Change central line catheter site dressing every week with transparent dressing in the morning every Mon [Monday]. Review of the TAR for January 2023 for Resident #131 reads, Order date 12/19/2022. Change central line catheter site dressing PRN [Pro Re Nata] as needed. Review of the TAR for January 2023 for Resident #131 reads, Order date 12/19/2022. Change needleless access device on central line catheter in the morning every Mon. Review of the TAR for January 2023 for Resident #131 reads, Order date 12/19/2022. Observe central line catheter site during dressing changes in the morning every Mon. During an interview on 1/17/2023 at 11:34 AM, the Director of Nursing (DON) confirmed Resident #131's midline dressing was dated 1/10/2023. 2. During an observation on 1/17/2023 at 9:40 AM, Resident #107 was sitting at the edge of her bed with a single lumen PICC (peripherally inserted central catheter) on her right upper arm, with gauze under the transparent dressing dated 1/14/2023. During an interview on 1/17/2023 at 9:40 AM, Resident #107 stated, I am very concerned about my catheter dressing. Staff will not change my dressing and at times it has had blood under the dressing. They have not changed it in a timely manner. Not too long ago, I had a red line from the site. I'm concerned because that can lead to infection. Review of the admission record for Resident #107 revealed she was admitted to the facility on [DATE] with the diagnoses including but not limited to osteomyelitis of vertebra (bone infection), morbid (severe) obesity due to excess calories, urinary tract infection, other cirrhosis of liver, chronic obstructive pulmonary disease, and severe sepsis with septic shock. Review of the physician order for Resident #107 dated 12/16/2022 reads, Change central line catheter site dressing every week with transparent dressing every day shift every Fri [Friday]. Review of physician order for Resident #107 dated 1/5/2023 reads, Ceftriaxone Sodium Solution Reconstituted 2 GM [gram] use 2 gram intravenously one time a day for Discitis [a condition where the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 spaces between the spinal bones becomes irritated and inflamed] until 01/19/2023 23:59 [11: 59 PM]. Level of Harm - Minimal harm or potential for actual harm Review of the physician order for Resident #107 dated 12/16/2022 reads, Normal Saline Flush Solution (Sodium Chloride Flush) Use 5 ml intravenously every 12 hours for minimum flush of PICC non-valved catheter Flush each PICC non-valved lumen. Residents Affected - Some During an interview on 1/17/2023 at 11:10 AM, the DON confirmed Resident #107's PICC dressing was dated 1/14/2023. During an interview on 1/17/2023 at 2:47 PM, the DON stated midline and PICC line dressings should have been changed after 48 hours since there was gauze underneath the dressing. Review of the facility policy and procedure titled 005-N: Midline Dressing Changes last reviewed on 12/28/2022 reads, Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines . 4. Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with a TSM dressing and change the dressing every 48 hours. 3. During an observation on 1/17/2023 at 9:27 AM, Resident #113 was lying in bed in a semi-Fowlers position (a standard patient position in which the patient is seated in a semi-sitting position (45-60 degrees) and may have knees either bent or straight) with Jevity 1.5 feeding running at 70 ml/hr (hour) and auto flush 35 ml running continuously. During an observation on 1/18/2023 at 8:51 AM, Resident #113 observed lying in bed in a semi-Fowlers position with Jevity 1.5 feeding running at 70 ml/hr and auto flush 35 ml running continuously. Review of the admission record for Resident #113 revealed the resident was admitted to the facility on [DATE] with the diagnoses including but not limited to compression of brain, cerebral edema, traumatic subdural hemorrhage with loss of consciousness of unspecified duration subsequent encounter, hydrocephalus, moderate protein calorie malnutrition and tracheostomy status. Review of the physician order for Resident #113 dated 1/13/2023 reads, Enteral Feed Order One time a day Enteral 1- feeding: Administer Jevity 1.5 continuous per g-tube [gastrostomy tube] Rate: 70 mls/hour, auto flush with 50 ml/hr water starting at 0000 [12:00 AM] to 2000 [8:00 PM]. During an interview on 1/18/2023 at 1:35 PM, Staff D, Registered Nurse (RN), Unit Manager, confirmed Resident #113's auto flush was running at 35 ml/hr and had an active physician's order for 50 ml/hr. During an interview on 1/18/2023 at 1:48 PM, the DON stated that nurses were expected to follow physician orders. Review of the facility policy and procedure titled Care and Treatment of Feeding Tubes last reviewed on 12/28/2022 reads, Policy Explanation and Compliance Guidelines. 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its calorie value, volume, duration, mechanism of administration, and frequency of flush. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services in accordance with professional standards of practice for 5 of 8 residents reviewed for respiratory care (Residents #30, #81, #113, #390, #392). Residents Affected - Some Findings include: 1. During an observation on 1/17/2023 at 9:13 AM, Resident #390 was lying in bed wearing a nasal cannula with oxygen running at 2 liters per minute. No time and date were noted on tubing. During an interview on 1/17/2023 at 9:13 AM, Resident #390 stated that she has used oxygen since she was admitted to the facility. During an observation on 1/18/2023 at 10:25 AM, Resident #390 was sitting in his wheelchair with oxygen running at 2 liters per minute via nasal cannula. Review of the admission record for Resident #390 revealed the resident was admitted to the facility on [DATE] with the diagnoses including but not limited to other orthopedic aftercare, fracture of orbital floor, left side, subsequent encounter for fracture with routine healing, maxillary fracture, unspecified side, subsequent encounter for fracture with routine healing, 2-part displaced fracture of surgical neck of left humerus, subsequent encounter for fracture with routine healing, unspecified fracture of left lower leg, subsequent encounter for closed fracture with routine healing, pedestrian on foot injured in collision with car, pick-up truck or van in traffic accident, and nicotine dependence. Review of the physician orders for Resident #390 showed no order for administration of oxygen at a specific rate or oxygen tubing change. During an interview on 1/18/2023 at 12:47 PM, Staff D, Registered Nurse (RN), Unit Manager, confirmed the oxygen was running at 2 liters per minute. During an interview on 1/18/2023 at 12:51 PM, Staff D, RN, Unit Manager, confirmed there was no active order in the system for Resident #390 to receive oxygen. 2. During an observation on 1/17/2023 at 9:40 AM, Resident #392 was resting with her eyes closed. Oxygen tubing was lying coiled on the floor with no date behind oxygen machine and passive nebulizer treatment mask on top of bedside table with no plastic bag and no date on tubing. During an observation on 1/18/2023 at 8:03 AM, Resident #392 was lying in bed. Oxygen tubing was lying coiled on the floor with no date behind oxygen machine and passive nebulizer treatment mask on top of bedside table with no plastic bag and no date on tubing. During an interview on 1/18/2023 at 8:03 AM, Resident #392 stated, I use oxygen at nighttime when I need it. I use the nebulizer mask for treatments the nurse gives me. Review of the admission record for Resident #392 revealed the resident was admitted to the facility on [DATE] with the diagnoses including hemiplegia and hemiparesis following cerebral infraction (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 affecting left dominant side, polyneuropathy, unspecified, type 2 diabetes mellitus with unspecified complications, peripheral vascular disease, unspecified, acute kidney failure, chronic pain syndrome, and chronic obstructive pulmonary disease. Review of the physician orders for Resident #392 showed no order for administration of oxygen at a specific rate or oxygen tubing change. Review of the physician order for Resident #392 dated 1/16/2023 reads, Albuterol Sulfate Nebulization Solution (2.5 MG [milligrams]/3ML [milliliters]) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath related to Chronic Obstructive Pulmonary Disease, Unspecified. Record review of the physician order for Resident #392 dated 1/16/2023 reads, Change neb [nebulizer] tubing (label and date tubing) and bag cover every week every night shift every Sun [Sunday]. Review of the Medication Administration Record for Resident #392 revealed staff initials on 01/18/2023 for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath related to Chronic Obstructive Pulmonary Disease, Unspecified. During an interview on 1/18/2023 at 12:44 PM, Staff D, RN, Unit Manager, confirmed oxygen tubing was on the floor without date or bag and nebulizer mask was on the bedside table with no date or bag. Staff D stated, Tubing should be dated and bagged when not used. Nebulizer treatment mask should be cleaned and bagged after each use. [Resident #392's name] no longer received oxygen. Resident #392 corrected Staff D and stated that she used oxygen at nighttime when she needed it. During an interview on 1/18/2023 at 12:54 PM, Staff D, RN, Unit Manager, confirmed Resident #392 had no active orders for oxygen as needed. During an interview on 1/18/2023 at 1:00 PM, the Director of Nursing (DON) stated, Oxygen tubing and passive nebulizer masks should be stored in bags once treatment is finished. Tubing should be changed, and bags should be labeled. Staff are expected to follow physician orders. 3. During an observation on 1/17/2023 at 9:27 AM, Resident #113 was lying in bed resting calmly with oxygen running at 5 liters per minute via trach collar, and the tubing was not dated. During an observation on 1/18/2023 at 8:51 AM, Resident #113 was lying in bed resting with eyes closed with oxygen running at 5 liters per minute via trach collar, and the tubing was dated 1/18/2023. Review of the admission record for Resident #113 revealed the resident was admitted to the facility on [DATE] with the diagnoses including but not limited to compression of brain, cerebral edema, traumatic subdural hemorrhage with loss of consciousness of unspecified duration subsequent encounter, hydrocephalus, moderate protein calorie malnutrition and tracheostomy status. Review of the physician order for Resident #113 dated 1/13/2023 reads, Change O2 tubing (label and date tubing) and bag cover every week every night shift every Wed [Wednesday], Sun. Review of the physician order for Resident #113 dated 1/13/2023 reads, Oxygen at 4 liters/min (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 [minute] via [specify delivery system] Trach Collar. Humidification: [specify] Yes, every shift. Level of Harm - Minimal harm or potential for actual harm Review of the physician order for Resident #113 dated 1/13/2023 reads, Oxygen at 4 liters/min via [specify delivery system] Trach Collar. Humidification: [specify] Yes as needed. Residents Affected - Some During an interview on 1/18/2023 at 12:46 PM, Staff D, RN, Unit Manager, confirmed that Resident #113's oxygen was running at 5 liters per minute. During an interview on 1/18/2023 at 12:48 PM, Staff D, RN, Unit Manager, confirmed that Resident #113 had an active order in the system for oxygen at 4 liters per minute and the resident's oxygen should have been running at 4 liters per minute. During an interview on 1/18/2023 at 1:00 PM, the DON stated that staff were expected to follow physician orders for oxygen administration. Review of the facility policy and procedure titled Oxygen Administration last reviewed on 12/28/2022 reads, Policy Explanation and Compliance Guidelines. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control . 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: a. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . c. Keep delivery devices covered in plastic bag when not in use. 4. Review of the admission record for Resident #30 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease with acute exacerbation and shortness of breath. During an observation on 1/17/2023 at 10:50 AM, Resident #30's oxygen was set at 3.5 liters per minute and the attached nasal cannula tubing was lying across oxygen machine. The tubing was not dated. During an interview on 1/17/2023 at 10:50 AM, Resident #30 stated, I do not touch the oxygen setting but it should be set at 3 liters. I only use oxygen at night. I put it on if I need to. During an observation on 1/18/2023 at 9:23 AM, Resident #30 was sitting in her wheelchair. Oxygen tubing was lying on oxygen machine tubing. The tubing was dated 11/17/2023. The rate of oxygen flow was 3.5 liters per minute. Oxygen was not being administered to Resident #30. Review of the physician order for Resident #30 dated 12/19/2022 reads, O2 [oxygen] via Nasal cannula at 3 LPM [liters per minute] every shift. Review of the Medication Administration Record for Resident #30 for January 2023 revealed oxygen was administered each day and each shift, except for 1/4/2023 and 1/5/2023 day shift and 1/14/2023 evening shift. During an interview on 1/18/2023 at 9:23 AM, Resident #30 stated, I used oxygen last night while I was sleeping but removed it when I woke up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 During an interview on 1/18/2023 at 12:33 PM, Staff E, RN, Unit Manager, confirmed that oxygen was set at 3.5 liters, was not being administered to Resident #30, and the physician order for Resident #30 was for continuous oxygen via nasal cannula at 3 LPM every shift. Staff E stated, [Resident #30's name] uses oxygen only if needed. 5. Review of the admission record for Resident #81 revealed the resident was readmitted to the facility on [DATE] with diagnoses including but not limited to systemic lupus erythematosus, rheumatoid arthritis with rheumatoid factor, and pneumonia. During an observation on 1/17/2023 at 9:55 AM, Resident #81's nebulizer tubing was lying on the floor and was not dated. During an observation on 1/17/2023 at 1:10 PM, Resident #81's nebulizer tubing was lying across the nebulizer machine and was uncovered. During an observation on 1/18/2023 at 9:22 AM, Resident #81's nebulizer mask and tubing was uncovered and undated and was lying across the nebulizer machine. Review of the Medication Administration Record (MAR) for Resident #81 for January 2023 reads Order date 12/04/2022. Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml, 3 ml inhale orally via nebulizer every 6 hours for SOB [shortness of breath]. Give every 6 hours while awake. All treatments were administered from 1/1/2023 through 1/17/2023. Review of the MAR for Resident #81 revealed that nebulizer treatment was administered on 1/1/2023 through 1/16/2023, daily at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. Review of the physician orders for Resident #81 revealed no orders for tubing change. During an interview on 1/18/2023 at 12:33 PM, Staff E, RN, Nurse Manager, confirmed that Resident #81's nebulizer tubing was not dated and was not in a bag or container. He stated, Nebulizer tubing are changed and dated on Sunday nights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with professional standards in 4 of 6 medication carts (300 hall cart, 400 hall cart, south front cart and 5 acute cart) and failed to ensure medications were secured (photographic evidence obtained). Findings include: 1. On [DATE] at 8:45 AM, during an observation of the 5 acute cart with Staff A, Licensed Practical Nurse (LPN), there were one unopened Levemir flex touch pen and three Aplisol injectables that required refrigeration and expired on [DATE], [DATE] and [DATE], respectively. During an interview on [DATE] at 8:45 AM, Staff A, LPN, stated that the Levemir flex touch pen was unopened, and three Aplosol injectables should have been in the refrigerator and not in cart. 2. On [DATE] at 9:00 AM, during an observation of the 400 hall cart, there were two Timolol eye drops, one opened Ciprodex ear drops, and one opened Polymyxin eye drops, which were unlabeled. During an interview on [DATE] at 9:00 AM, Staff B, LPN, stated that two Timolol and Polymyxin eye drops were unlabeled, and Ciprodex ear drops should have been dated with open date once the medication was opened. 3. On [DATE] at 9:20 AM, during an observation of the 300 hall cart with Staff C, LPN, there were one unopened Novolog Flexpen, and two opened Novolin R insulin vials that were undated. On [DATE] at 9:25 AM, during an observation of the south front cart with Staff C, LPN, there were one Levemir flex touch pen, two Humalog Kwik pens, one Lantus Solostar, one Novolog Flexpen, two Timolol eye drops, and one Prednisolone Acetate Suspension 1% eye drops that were not labeled with an opened date. During an interview on [DATE] at 9:25 AM, Staff C, LPN, stated that all medications on the 300 hall cart should be dated once opened regardless of what they are, and the Levemir pen, two Humalog Kwik pens, Lantus Solostar, Novolog Flexpen, and two Timolol eye drops on south front cart should be dated once opened. 4. On [DATE] at 10:00 AM, during an observation of Resident #51's room, there was a bottle of Fluticasone nasal spray at the resident's bedside. On [DATE] at 10:10 AM, during an observation of Resident #23's room, there were a bottle of 0.9% Sodium Chloride, Iodoform packing strip, and wound cleanser spray at the resident's bedside. On [DATE] at 3:30 PM, during an observation of Resident #51's room, there was a bottle of Fluticasone nasal spray at the resident's bedside. On [DATE] at 3:35 PM, during an observation of Resident #23's room, there were a bottle of 0.9% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 Sodium Chloride, Iodoform packing strip, and wound cleanser spray at the resident's bedside. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 2:47 PM, the Director of Nursing (DON) stated, My expectation is for all nurses taking the cart over and when receiving medication, the nurses need to ensure that any meds that needs refrigeration be refrigerated. If the nurses open a medication, insulins or drops, the open date needs to go on the on the medication. I can see the dates on the injections. I did not expect this. No medications should be left at bedside.5. During an observation on [DATE] at 9:50 AM, Resident #32 was lying in his bed covered with blanket talking on his cell phone. On the bed side table next to resident, there were drinks and a medication cup containing medications. Residents Affected - Some During an interview on [DATE] at 9:50 AM, Resident #32 stated, I requested a cup with ice and the nurse went to get it for me. He just left them [medications in cup] there just now to get me the ice. Review of the facility policy and procedure titled Medication Storage last reviewed on [DATE], 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 manufacture'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 biologics will be stored 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 medications or locked in the medication storage area/cart . 6. Refrigerated Products: a. All medication requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. Review of Polaris Medication Storage updated in 9/2021 revealed the expiration dates of 28 days for Humalog Kwik Pen Lantus and Novolog insulin pens, and Timolol eye drops; 42 days for Levemir Flexpen insulin pen, and Levemir and Novolin R insulin vials; Discard unused portion after therapy is completed (approx. 7 days) for Ciprodex ear drops. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 foods and beverages were stored in a safe and sanitary manner. Residents Affected - Some Findings include: During the tour of the facility main kitchen with the Certified Dietary Manager (CDM) on 1/17/2023 beginning at 9:15 AM, there were an opened bag of raw chicken breast, an opened bag of raw beef patties, and an opened box of omelets stored in the walk-in freezer exposing the food items to drying out and freezer burn. In the main food preparation/production area, there were three serving scoops, two serving ladles, and two serving spoons observed in a utensil storage drawer that had a buildup of food residue on them. The utensil storage drawer had numerous food particles and crumbs in two of three storage drawers used for clean utensil storage. During an interview on 1/17/2023 at 9:30 AM, the CDM acknowledged the open bags of food items stored in the walk-in freezer and stated they should have been closed after the needed items were removed from the bags of raw foods. The CDM verified the dirty utensils stored in the utensil drawer as well as food particles and crumbs that were scattered throughout the drawer. On 1/18/2023 at 6:37 AM, during the tour of the kitchen, there were beef patties stored without a label and not in the original packaging that designated the name or use by date. The ice machine had a black substance around the door of the ice machine. During an interview on 1/18/2023 at 6:37 AM, the CDM confirmed the beef patties were undated and unlabeled, not in the original packaging, and there was a black substance around the door of the ice machine. On 1/19/2023 at 11:53 AM, during an observation of the North Hall nourishment room, there were two containers of Med Pass that were opened and not dated. On 1/19/2023 at 11:57 AM, during an observation of the Sub Acute Hall nourishment room, there were two thawed nutritional supplements with no thawed date or use by date stored in the refrigerator, and a container of Med Pass that was opened and not dated. During an interview on 1/19/2023 at 12:00 PM, the Regional Dietary Director acknowledged opened and undated food items stored in the nourishment room refrigerators and confirmed that the thawed nutritional supplements stored in the refrigerators did not have a thawed-on date. Review of the nutritional supplement use instructions displayed on the nutritional supplement carton showed the instructions to store the frozen thaw at or below 40 degrees Fahrenheit and use the thawed product within 14 days. Review of the facility policy and procedure titled Food Storage/Cold dated October 2019 and reviewed on 1/20/2023 reads, Policy Statement: It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code. Action Steps . 5. The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing (X3) DATE SURVEY COMPLETED A. Building 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 labeled and dated and arranged in a manner to prevent cross contamination. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled Sanitation Inspection dated 1/2022 reads, Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects . 4. Sanitation inspection will be conducted in the following manner . b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. 5. Inspections will be conducted but limited to the following areas: a. Dry storage b. Freezer c. Refrigerator d. Dish room e. Pot wash f. Main production area g. Food preparation area h. General dietary observations. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the admission record for Resident #239 revealed the resident was admitted on [DATE] with diagnoses including but not limited to mycoses (fungus that invades the tissues), wound of right arm, and cutaneous abscess of right upper limb. During an observation on 1/17/2023 at 9:00 AM, Resident #239 had a PICC in the right upper arm dated 1/16/2023 (photographic evidence obtained). During an observation on 1/18/2023 at 12:00 PM, Resident #239 had a PICC in the right upper arm dated 1/16/2023. During an observation on 1/19/2023 at 9:15 AM, Resident #239 had a PICC in the right upper arm dated 1/16/2023. Review of the Medication Administration Record (MAR) for January 2023 revealed no documentation of PICC line dressing changes. Review of the nursing progress notes from the admission date of 1/6/2023 to 1/20/2023 revealed no documentation of PICC line dressing changes. During an interview on 1/20/2023 at 9:34 AM, the DON stated, Staff are expected to document and sign off when they perform the task. 4. Review of Resident #76's medical record revealed an emergency temporary guardianship appointed by the court and an order to suspend durable power of attorney (DPOA) on 10/20/2022. Resident #76's medical record did not reflect that proper changes were made to the resident's medical record related to the removal of the DPOA information under the contacts listed for Resident #76. During an interview on 1/19/2023 at 12:00 PM, the Administrator stated, I don't see where there were any changes made. During an interview on 1/20/2023 at 09:07 AM, the Business Office Manager stated, The daughter should not be on there [the medical record] as the DPOA. Review of the facility policy and procedure titled Documentation in Medical Record last reviewed on 12/28/2022 reads, Policy: Each resident's medical record shall contain an accurate representation of actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for 4 of 7 reviewed residents (Residents #76, #107, #131, and #239). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. During an observation on 1/17/2023 at 9:25 AM, Resident #131 was sitting up at bed side with a single lumen midline. The dressing was dated 1/10/2023 and was covered with a transparent dressing, with gauze under the dressing. Residents Affected - Few During an interview on 1/17/2023 at 9:25 AM, Resident #131 stated, Staff have not changed my IV [intravenous] dressing in a long time. The staff do not take care of it. Review of the admission record for Resident #131 revealed he was admitted to the facility on [DATE] with the diagnoses including but not limited to a history of osteomyelitis (bone infection), type 1 diabetes mellitus with foot ulcer, cardiac arrest, hereditary and idiopathic neuropathy, and sepsis, resistance to multiple antibiotics, and enterocolitis due to clostridium difficile. Review of the Treatment Administration Record (TAR) for January 2023 for Resident #131 reads, Order date 12/19/2022. Change central line catheter site dressing every week with transparent dressing in the morning every Mon [Monday]. Documentation on the TAR showed no initials on 1/2/2023 to indicate a dressing change and recorded initials confirming the dressing change was completed on 1/9/2023 and 1/16/2023. Review of the TAR for January 2023 for Resident #131 reads, Order date 12/19/2022. Change needleless access device on central line catheter in the morning every Mon. Documentation on the TAR showed no initials on 1/2/2023 to indicate the needleless access device was changed and recorded initials confirming the needleless access device was changed on 1/9/2023 and 1/16/2023. Review of the TAR for January 2023 for Resident #131 reads, Order date 12/19/2022. Observe central line catheter site during dressing changes in the morning every Mon. Documentation on the TAR showed no initials on 1/2/2023 to indicate the catheter site was observed during dressing change and recorded initials confirming the catheter site was observed during dressing change on 1/9/2023 and 1/16/2023. 2. During an observation on 1/17/2023 at 9:40 AM, Resident #107 was sitting at the edge of her bed with a single lumen PICC (peripherally inserted central catheter) on her right upper arm, with gauze under the transparent dressing dated 1/14/2023. Review of the admission record for Resident #107 revealed she was admitted to the facility on [DATE] with the diagnoses including but not limited to osteomyelitis of vertebra (bone infection), morbid (severe) obesity due to excess calories, urinary tract infection, other cirrhosis of liver, chronic obstructive pulmonary disease, and severe sepsis with septic shock. Review of the physician order for Resident #107 dated 12/16/2022 reads, Change central line catheter site dressing every week with transparent dressing every day shift every Fri [Friday]. During an interview on 1/17/2023 at 11:10 AM, the Director of Nursing (DON) confirmed Resident #107's PICC dressing was dated 1/14/2023. Review of Medication Administration Record (MAR) for Resident #107 revealed no documentation of dressing change on 1/14/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105465 If continuation sheet Page 15 of 15