Health inspection·November 6, 2020

F 0655 Level of Harm - Minimal harm or potential for actual harm not transcribed or written on the baseline care plan. She confirmed the IDT's failure to ensure the compression stocking and ice pack to the left knee were on the baseline care plan and implemented by the nursing staff could lead to Resident #250 having pain, discomfort and swelling to his left knee and leg. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 2 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain hygiene for 1 (Resident #57) of 3 residents reviewed who required assistance with activities of daily living and incontinence care. Residents Affected - Few The findings included: On 11/4/20 at 8:35 a.m., Resident #57 was observed lying in bed. She was alert and oriented. Her room had a strong odor of urine. Resident #57 said despite her requests her brief had not been changed since 11:00 p.m., the night before. She said the night shift often did not come in to check on her at night and she was often left in briefs soaked in urine until the morning. She said she was uncomfortable lying in the wet brief. On 11/4/20 at 8:35 a.m., at the time of the interview, Certified Nursing Assistant (CNA) Staff P was observed in the room preparing to provide incontinent care to the resident. With Resident #57's permission, CNA Staff P was observed changing the resident's brief. The brief was saturated with urine. The urine had soaked through the brief into the incontinent pad on the bed. Review of the clinical record revealed Resident #57 was incontinent of bowel and bladder. On 11/5/20 the CNA documentation (Documentation Survey Report) was reviewed. From 10/2020 and 11/2020 there was no documentation Resident #57 was checked or changed during the night shift from 10/2/20 through 10/14/20, and on 10/22/20, 10/29/20, 10/30/20, 11/2/20, 11/2/20 and 11/4/20. On 11/4/20 at 10:25 a.m., during an interview with CNA Staff P said many times Resident #57 was soaked through her brief in the morning. She said on 11/2/20 she had reported to Registered Nurse (RN) Staff S that Resident #57 was soaked through her brief in the morning and Resident #57 had told the CNA she had not been changed during the night. On 11/4/20 at 2:30 p.m., during an interview, RN Staff S said she has been working at the facility for approximately 1 week. RN Staff S confirmed she was told by CNA Staff P the resident was not changed during night shift 11/2/20 and was very wet in the morning. RN Staff S said the night shift had a lot of agency CNAs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 3 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to demonstrate effective coordination to ensure 1 (Resident #62) of 1 resident with a surgical incision received appropriate follow up care. This failure could cause delayed wound healing and infection and resulted is a higher level of care. Residents Affected - Few The findings included: On 11/2/20 at 10:25 a.m., Resident #62 was observed in a wheelchair at the doorway of his room and was heard calling for help. The resident had a dressing to the right hip saturated with bloody drainage. The drainage was dripping from the wound, running down his leg onto the floor. Two puddles of bloody drainage were observed on the floor next to the wheelchair. Resident #62 stated he had staples to that area from a hip procedure in September. A review of clinical record for Resident #62 revealed an admission assessment dated [DATE] indicating the resident had a wound with wound vac to the right medial hip with staples intact. (Staples are generally placed for 7-10 days). On 11/2/20 the Nurse Practitioner (NP) documented in a progress note Reason for Visit: Patient seen today for assessment of right hip incision site. Currently has an area with mild dehiscence (splitting or bursting open of a wound), drainage and redness, afebrile. Several staples removed on well healed area today Needs ortho [orthopedic] F/U [follow up] ASAP [as soon as possible]. On 11/2/20 at 11:45 a.m., during an interview Resident #62 reported some of the staples were removed that morning. On 11/3/20 at 3:07 p.m., Registered Nurse (RN) Staff H said Resident #62 had purulent (pus filled, indicating infection) drainage from the right hip incision and was sent to the hospital. RN Staff H said the process was if a resident was admitted from the hospital with staples and had no orders to remove the staples, the nurse would be responsible to contact the surgeon or the Nurse Practitioner (NP) and obtain orders. RN Staff H she said she completed the initial skin assessment for Resident #62 and verified the staples had been in place since admission on [DATE]. RN Staff H verified Resident #62 was not scheduled for the necessary follow up care with the orthopedic surgeon. On 11/5/20 at 12:55 p.m., during an interview the NP, she said when residents come from hospital, they should have orders to follow up on when to remove staples. The NP said if orders were not included, hopefully someone would catch that, but she would not be aware of the lack of orders unless nursing brought that to her attention. The NP said she did not see Resident #62 on 11/2/20 when he was sent out. She said she relied on the assessment of the RN Supervisor and RN Staff H. She also stated she had been out for several weeks and would have to reference her notes on Resident #62. She said on Monday (11/2/20) the Resident's incision site was draining, red and was warm to touch (signs of infection). A review of the hospital emergency department notes dated 11/3/20, revealed Resident #62 was being evaluated for moderate, progressive worsening of the right hip wound. On 11/4/20, Resident #62 underwent a surgical debridement to the right hip wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 4 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The wheelchair seating pocket guide from the National Pressure Injury Advisory Panel (NPIAP) notes The number one factor in common among all wheelchair users is impaired mobility . A number of contributing or compounding factors are associated with pressure injuries; the primary of which is impaired mobility . Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. Residents Affected - Few Source: https://cdn.ymaws.com/npiap.com/resource/resmgr/events/NPIAP_Permobil_WC_Seating_Po.pdf A review of the clinical record revealed Resident #55 was admitted from the hospital on 8/13/19 with a pressure areas on the left and right buttocks which were documented as resolved on 9/6/19. The most recent quarterly MDS assessment dated [DATE] noted Resident #55 had impaired cognition, generalized weakness and required extensive physical assistance of 2 persons for transfer. Resident #55 was only able to stabilize with staff assistance when moving from a seated to standing position. The assessment also noted the resident was frequently incontinent of bowel, always incontinent of bladder and was at risk of developing a pressure ulcer. The assessment indicated the resident had a pressure reducing device for his chair. The most recent Braden Scale for predicting Pressure Sore Risk evaluation dated 10/30/20 noted Resident #55 was at moderate risk for developing a pressure ulcer. The resident made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. The care plan revised on 7/1/20 noted the resident has a potential for pressure injury development related to activities of daily living deficits. The interventions in the care plan did not include a pressure reducing device to the wheelchair. On 11/2/20 at 10:45 a.m., Resident #55 was observed in a wheelchair in his room. Resident #55 was not able to answer questions but was attempting to get out of the wheelchair while complaining his bottom hurts. On 11/2/20 at 12:05 p.m., Resident #55 remained in the wheelchair in his room. He continued to complain his bottom and neck hurt while attempting to get up. Observation of the wheelchair failed to reveal the presence of a pressure reducing or relieving cushion. On 11/3/20 at 2:22 p.m., observation of Resident #55's skin with Certified Nursing Assistant (CNA) Staff Y and Unit Manager Staff A revealed mild redness to the right buttock. On 11/3/20 at 2:38 p.m., during an interview CNA Staff Y said she had been taking care of Resident #55 since his return from the hospital on [DATE]. She said she relied on the information on the Kardex (CNA information) and would use whatever intervention was listed on the Kardex. She said Resident #55 had not had a pressure reducing cushion in his wheelchair since at least 10/30/20. The CNA Kardex failed to include a pressure reducing cushion listed as a preventive measure for Resident #55. On 11/3/20 at 3:38 p.m., during an interview the Director of Nursing (DON) said the pressure ulcer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 5 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0686 prevention interventions for Resident #55 included barrier cream, pressure reducing cushion in the wheelchair and repositioning. Level of Harm - Actual harm Residents Affected - Few On 11/3/20 at 4:22 p.m., the DON verified Resident #55 did not have a pressure reducing cushion in his wheelchair. She said: I don't know if it matters, but we found his wheelchair in the other room with a nice cushion. 3. A clinical record review revealed Resident #3 was admitted to the facility on [DATE] with right sided weakness and a wound to the right plantar area. The admission data collection form completed by a RN noted the resident was alert and oriented to person, place, and time. Resident #3 was incontinent of bowel and had excoriation to the perineal area. The facility determined Resident #3 had a potential for impairment to skin integrity related to diagnoses of peripheral vascular disease, obesity, weakness and developed a care plan with the goal to minimize the risk for skin breakdown. The care plan was updated on 8/12/20 to note area to the upper left buttock and on 8/24/20 to note pressure ulcer to gluteal fold and upper left buttock. An event report completed on 8/12/20 noted pressure ulcers to the left gluteal fold and left buttock measuring respectively 1.5 x 0.7 x 0.7 and 0.1 x 0.5 x 0.1 centimeter. On 10/13/20 when RN Staff Q documented the left gluteal fold, the pressure ulcer measured 0.3 x 0.1 x 0 centimeter. There was no weekly measurement of the pressure ulcer on 10/20/20. On 10/27/20 RN Staff Q documented the left gluteal fold pressure ulcer measured 0.6 x 0.5 x 0.1 centimeter. On 11/2/20 at 2:59 p.m., during an interview Resident #3 said he developed a pressure ulcer at the facility. He said he did not know if it was getting better. On 11/4/20 at 12:50 p.m., observation of the pressure ulcer with Resident #3's permission revealed a stage II pressure ulcer to the left gluteal fold and left buttock. RN Staff Q applied treatment as ordered but did not measure the wounds. On 9/10/20 the Registered Dietician (RD) documented in a nutrition consult note Resident with two stage II pressure ulcers under treatment . Recommend add Prostat 30 ml [milliliters] once daily and add Zn-220 [zinc] one tablet daily to support wound healing. The clinical record lacked documentation the facility followed through on the RD's recommendation and administered the supplements to support the healing of the pressure ulcers acquired at the facility. On 11/5/20 at 3:07 p.m., during an interview the Director of Nursing (DON) said the RD sent her dietary recommendations to her via email. She verified and printed the RD's recommendation dated 9/10/20 for Resident #3 that read Add Zinc-220 one tablet daily and add Prostat 30 ml daily. The DON said she usually called the Advanced Practice Registered Nurse (APRN) to discuss the recommendations but could not find documentation the APRN was notified of the dietician's recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 6 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0686 On 11/5/20 at 3:28 p.m., during an interview RN Staff Q said she was responsible to measure the resident's wounds every Tuesday but did not do it this week. She said, before it was a line, now it is bigger. Level of Harm - Actual harm Residents Affected - Few On 11/5/20 at 3:45 p.m., the DON said the facility used to have weekly wound meetings where they would discuss residents with wounds. She said sometimes she looked at the wounds herself but could not remember the last time she made wound rounds. The DON admitted they had not had a wound meeting in a while. Based on observation, record review, facility policy and procedure review, and interview, the facility failed to implement timely preventive measures and failed to alter the plan of care to include offloading of the area when a pressure ulcer developed for 1 (Resident #62) of 2 residents reviewed who developed a pressure ulcer at the facility. This lack of interventions resulted in Resident #62 developing an unstageable pressure ulcer. The facility also failed to coordinate the care and ensure 2 (Resident #55 and #3) received the necessary interventions to prevent the development of pressure ulcers and assist in wound healing. The findings included: The facility policy WC-100, Clinical Guideline Skin and Wound (effective 4/1/17) documented to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of / prevention of pressure injury. The policy included, Licensed Nurse to complete skin evaluation weekly. 1. Review of the clinical record showed Resident #62 was admitted on [DATE]. The Minimum Data Set (MDS) assessment (tool used to assess and plan care) dated 9/20/20, documented Resident #62 had no pressure injuries, and noted the resident was at risk for pressure ulcers/injuries. Review of skin assessments documented on 9/24/20 and 10/7/20 stated skin to be intact. Subsequent weekly skin assessments were not documented. Review of physician orders dated 10/28/20 for Resident #62 included to apply skin prep to right heel topically every shift. On 11/2/07 at 11:45 a.m., Resident #62 was observed in his room. He was observed to have a reddened area to the right heel, with an approximate 2.0 centimeter round blackened area to the center. On 11/3/20 at 10:22 a.m., Resident #62 was observed sitting in a wheelchair in his room. During an interview at this time, he said he was not doing well. The resident complained of pain to his right heel and said it was leaking a lot. On 11/3/20 at 3:07 p.m., in an interview Registered Nurse (RN) Staff H stated they have been doing skin prep to Resident #62's heel. RN Staff H said she assessed the resident's right heel last week when brought to her attention by physical therapy. RN Staff H said at that time, the right heel was intact, and no fluid was noted. RN Staff H said she did not document a skin assessment then, but the nurse assigned to Resident #62 should have charted it. On 11/5/20 at 8:55 a.m., in an interview Occupational Therapy Assistant (OTA) Staff V stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 7 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0686 Level of Harm - Actual harm Residents Affected - Few noticed the resident was walking on the ball of his foot last week and appeared to be in pain. OTA Staff V said he removed Resident #62's right sock and the heel looked different. OTA Staff V said he reported his observation to the nurse caring for the resident. On 11/5/20 at 9:10 a.m., in an interview Physical Therapy Assistant (PTA) Staff W stated he observed Resident #62 limping last week and informed the assigned nurse. PTA Staff W stated he did not notice any drainage but believed the heel was reddened. On 11/5/20 at 9:18 a.m., in an interview RN Staff B said she administered medications to Resident #62 on 11/2/20 but did not assess the condition if his skin. On 11/5/20 at 10:18 a.m., in an interview RN Staff H said she was somewhat familiar with resident #62 but did not do the initial skin assessment. RN Staff H said the resident only had a surgical site on admission. RN Staff H said at the time Resident #62 was transferred to hospital, he did have not fluid filled area on right heel. RN Staff H said the nurse assigned to the hallway should be assessing the residents daily. On 11/5/20 at 12:55 p.m., during an interview, the Nurse Practitioner stated she was unaware that Resident #62 had a pressure ulcer and would have to reference her previous assessment. A review of the hospital emergency department admission record for 11/3/20 revealed Resident #62 had a round silver dollar sized blister that is scabbed over to the right heel. A nursing clinical note dated 11/4/20 noted right heel with an unstageable pressure injury. Stable eschar (dead tissue) to wound bed, no signs and symptoms of infection noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 8 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/2/20 at 9:45 a.m., Resident #91 was observed siting in bed. Resident #91's left hand was contracted. At time of observation Resident #91 said he was paralyzed on the left side. He said he was supposed to have something on his hand, but he did not want to wear it. Resident #91 said they did not provide any type of therapy. He said he would like to have therapy. Resident # 91 was not wearing a splint on his left hand at time of observation. Record review revealed Resident #91 was admitted to facility on 6/28/11. The resident had a diagnosis of hemiplegia and hemiparalysis following cerebral infarction affecting left non-dominant side. The MDS assessment dated [DATE] indicated Resident #91 had moderately impaired cognition based on a score of 12 on the Brief interview for mental status (BIMs). The Kardex (Certified Nursing information) noted under adaptive devices left hand splint as ordered. Review of the care plan for Resident #91 revealed an activities of daily living (ADLs) plan most recently revised on 9/21/20. The care plan included provision for the resident to have left hand splint as ordered. On 11/4/20 at 1:18 p.m., during an interview LPN Staff A said Resident#91 refused the splint. LPN Staff A said they did not offer restorative. The facility had stopped when Covid-19 began. On 11/4/20 at 1:28 p.m., during an interview the Therapy Supervisor (TS) said Resident# 91 refused to wear his splint. He was discharged from therapy on 9/14/20. The TS provided an occupational therapy discharge summary indicating Resident#91 refused to wear a splint. She said restorative therapy was a nursing service and the facility was responsible to provide the services. She said the facility stopped providing restorative services since COVID-19 started around the end of March or beginning of April. On 11/4/20 at 1:23 p.m., Resident#91 said he did not like to wear a splint. He said it was very uncomfortable. Resident #91 said he wished they had done some kind of hand therapy, massage or something but they never offered him anything. On 11/4/20 at 1:29 p.m., the Director of Nursing (DON) said they discontinued restorative services when the COVID-19 crisis began, and she did not have any new orders for restorative. She said they provided maintenance program exercise as part of the activities of daily living (ADL) care for residents. She was not able to show documentation on the electronic clinical record Resident #91 received a maintenance exercise program. 4. Review of Resident Census and Conditions of Residents (CMS-672) dated 11/2/20 showed the facility had 11 residents with contractures and 18 residents receiving rehabilitative services. 2. On 11/2/20 at 3:40 p.m., Resident #3 was observed in bed. The resident said he suffered a stroke and was not able to move his right arm or leg. Resident #3's right hand was closed into a fist. The right 5th finger was curled toward his palm. Resident was not able to straighten the finger. He said he used to wear a splint at night, but it went missing. He said the facility had not replaced the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 9 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0688 splint and they were not providing treatment to maintain the range of motion of his right hand. Level of Harm - Minimal harm or potential for actual harm Review of the occupational therapy (OT) evaluation dated 7/17/20 revealed documentation of Resident #3's range of motion and strength was impaired for the right shoulder, right wrist, and right hand. Residents Affected - Some The last OT progress report dated 9/26/20 noted Resident #3 was compliant with Plan of Treatment. Maximum improvement is yet to be attained. Patient's condition is improving as a result of skilled therapy services and Patient's progress has been slower than initially anticipated due to change in medical condition and unable to bring patient out of room . Continued OT services are necessary in order to maximize (I) [independence] w/ADLs [ with activities of daily living] . The recommended level of skilled therapy is required due to the following complexities and comorbidities that impact treatment: Impairments to multiple areas of the body. Multiple diagnoses and Severity of functional limitations. On 11/4/20 at 11:17 a.m., during an interview the Director of Rehab (DOR) said Resident #3 was receiving OT for his upper extremities up until he was transferred to the COVID-19 unit. She said all therapy services stopped on 10/15/20. She said the facility had a good restorative program until COVID-19 hit. She said since the pandemic the facility had stopped providing restorative therapy to the residents. On 11/4/20 at 11:29 a.m., during an interview the OT said Resident #3 was admitted to the facility this past July and received occupational therapy that included passive and active range of motion. He said Resident #3 was not motivated to continue with the exercises when the therapist was not around. The OT said they abruptly discharged the resident from therapy on 10/15/20 when he tested positive for COVID-19 and was transferred to the COVID-19 unit where he remained for 10 days. The therapist said they did not coordinate with nursing to provide any services to maintain the range of motion of his right upper extremity. The OT said Resident #3's right hand was getting tight. He said Resident #3 needed the therapy, but they were waiting to hear for insurance verification before providing services. On 11/4/20 at 12:10 p.m., during a second interview Resident #3 said his right hand had been getting worse since he's been at the facility and had not been able to wear a splint. He said he tried to push on his right hand with his left hand to mimic the splinting, but it is not working. He said since therapy dropped him when he had COVID-19 he had not received any treatment for his hand. On 11/4/20 at 12:16 p.m., during an interview the Director of Nursing (DON) said the facility had a restorative program up until COVID-19 started. She said the residents who came down with COVID-19 while receiving therapy received specific range of motion only if the therapist obtained a physician's order for a maintenance program. They would follow the physician's order, provide the range of motion specified in the order and the CNAs would document in the electronic medical record. On 11/4/20 at 12:24 p.m., during an interview RN Staff Q said the facility did not do anything different during the COVID-19 pandemic for residents with limited range of motion. She said as far as she was concerned only the restorative CNA was responsible to do range of motion. On 11/4/20 at 12:27 p.m., during an interview CNA Staff P said Resident #3 was totally dependent on staff for activities of daily living. She said she provided care every day such as bathing, changing incontinent briefs and catheter care. CNA Staff P said no one had told her she needed to do range (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 10 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0688 of motion for the resident. She said if they had asked her to do it, she would have. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to provide appropriate services and interventions for the management of contractures for 3 (Resident #3, #91, and #94) of 3 residents sampled with a limitation in range of motion (ROM). This had the potential to cause pain and worsening of the contracture. The facility had 11 residents with contractures. Residents Affected - Some The findings included: A review of the facility policy N-904, Contractures, Prevention (revised 8/22/17) documented, to prevent contractures for those residents who no longer have full use of their extremities. Each resident must be evaluated for the need of contracture prevention procedures on admission, readmission and as needed. The policy specified some residents may have braces or splints, be sure to follow the physician's order regarding the schedule of when to put these on and off. 1. During random observations on 11/2/20, 11/3/20, 11/4/20, and 11/5/20 revealed Resident #94's left hand closed in a fist. Resident #94 was not able to open his hand (contracted condition) and did not have a splint in place. A review of the clinical record for Resident #94 revealed a Minimum Data Set (MDS) assessment completed on 10/5/20 documented Resident #94 had impairment on one side for functional limitation in ROM. The record contained a physician order dated 9/21/20 to apply elbow and left-hand splint to be placed on during the day, and off at bedtime. A review of Occupational Therapy (OT) recommendations, dated 1/22/20 documented Resident #94 had a contracture of the left wrist and required daily Passive Range of Motion (PROM) and placement of splint in order to reduce the risk of further medical complications that may result from impairments. A review of treatment administration records found Resident #94 did not receive PROM exercises for 19 days, and the splint was not applied 12 days in October 2020. On 11/3/20 at 3:21 p.m., during an interview Registered Nurse (RN) Staff H said Resident #94 regularly refused PROM and splint application. RN Staff H said the resident's refusal should be documented in the clinical record. RN Staff H said if the resident refused to apply the splint the Certified Nursing Assistant (CNA) was expected to notify the nurse. On 11/4/20 at 8:40 a.m., during an interview Resident #94 said staff used to regularly place splint, but he has not had the splint placed for several weeks. Resident #94 said his wrist felt better when the splint was placed. On 11/4/20 at 8:47 a.m., during an interview RN Staff H said Resident #94's splint should be in the closet but sometimes it was moved. RN Staff H entered room and said she normally found the splint in the top drawer of the bedside table. RN Staff H looked in bedside table and then closet. RN Staff H located splint in the dresser and unsuccessfully attempted to apply it to the resident's left hand. She said she would get therapy. On 11/4/20 at 8:55 a.m., during an interview Occupational Therapy Assistant (OTA) Staff P said staff was trained to do PROM. He confirmed he did not have documentation of staff training. OTA Staff P said the splint is preventative, not restorative. OTA Staff P placed the splint after performing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 11 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0688 PROM. Resident #94 told RN Staff H and OTA Staff P no one had attempted to apply the splint in weeks. Level of Harm - Minimal harm or potential for actual harm A review of the CNA Care Kardex for Resident #94 instructed to provide gentle PROM to the left arm and apply left hand splint. Residents Affected - Some On 11/4/20 at 8:59 a.m., during an interview CNA Staff O said she was assigned to provide care to Resident #94 but was unaware the resident used a splint. CNA Staff O said she had not received instruction on how to apply the splint or how provide passive range of motion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 12 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to accurately assess the risk for falls, failed to coordinate care and implement interventions to minimize the risk of avoidable fall and fall related injuries for 1 (Resident #55) of 1 resident with a history of multiple falls. The findings included: Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had impaired cognition, generalized weakness, unsteady balance. The resident was not steady for surface to surface transfer and required extensive physical assistance of 2 for bed mobility and transfers. Review of the facility's event log revealed Resident #55 sustained a fall on 1/24/20, 5/7/20 and 6/28/20, when attempting to transfer without assistance. The current care plan noted the resident's risk for falls included a deficit in activities of daily living, hearing deficit and weakness. The goal was to minimize the risk for falls. The fall interventions included a wheelchair alarm as of 5/3/19 (to alert staff of unassisted transfer attempts), bed in low position and bilateral floor mats as of 12/27/19 (help prevent injury from potential falls). As of 8/14/19 the care plan specified to keep Resident #55 in line of sight when in wheelchair and not to leave the resident in wheelchair in the room. On 10/27/20 Resident #55 was discharged to the hospital with return anticipated. Upon return to the facility on [DATE] the nurse completed a fall risk evaluation indicating Resident #55 was at low risk for falls. The fall risk evaluation was inaccurate and noted Resident #55 had no history of falling within the last 6 months. On 11/2/20 at 10:45 a.m., Resident #55 was observed in a wheelchair in his room. The resident was not within line of sight of the staff. Resident #55 was not able to answer questions but was attempting to get out of the wheelchair while complaining his bottom hurts. On 11/2/20 at 12:05 p.m., Resident #55 remained in his wheelchair in his room and not within line of sight of staff. He continued to complain his bottom and neck hurt while attempting to get up. The wheelchair did not have an alarm as per the care plan to notify staff of unassisted transfers. On 11/2/20 at 12:45 p.m., and 11/3/20 at 10:11 a.m., Resident #55 was observed in bed. No fall mats were on the floor to minimize the risk of injury in case of a fall. On 11/3/20 at 2:38 p.m., during an interview Certified Nursing Assistant (CNA) Staff Y verified Resident #55 did not have the fall mats or the chair alarm. She said she relied on the [NAME] (CNA information) to get her information and would use whatever was listed on the [NAME]. Review of the [NAME] revealed a clip alarm listed as a safety intervention. The [NAME] did not direct the CNA to place a fall mat while the resident is in bed. On 11/3/20 at 3:24 p.m., during an interview the Director of Nursing said Resident #55 should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 13 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete floor mats and a clip alarm. She verified the fall evaluation completed on 10/30/20 was inaccurate and did not reflect Resident #55's fall history. She said the nurse who completed the evaluation was brand new to the facility and wouldn't have known Resident #55 had a history of falls. On 11/4/20 at 1:30 p.m., during an interview the MDS Coordinator explained upon return to the facility they completed a brand-new assessment for payment purposes only. She said there was no need for a new care plan unless there was a significant change with the resident. She said in the case of Resident #55 there was no change in condition. He remained at high risk for falls and the precautions remained the same. Event ID: Facility ID: 105507 If continuation sheet Page 14 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and record review the facility failed to ensure a dietary recommendation was implemented and the facility received ongoing communication from the dialysis facility and the Registered Dietitian, for 1 (Resident #70) of 3 residents reviewed who received dialysis services. Residents Affected - Few The findings included: On 11/4/20 a review of Resident #70's medical record revealed his last admission date to the facility was 8/27/20. Resident #70 had a diagnosis of End Stage Renal Disease and was receiving hemodialysis on Tuesdays, Thursdays, and Saturdays. The Dialysis Communication Record (DCR) form sent to the dialysis center with Resident #70 had a section for the nursing facility to fill out prior to dialysis and upon return from dialysis by facility staff. The form did not contain a section for the dialysis center to document regarding the dialysis care and services for that day. Further review of the medical record revealed there was no documentation from the dialysis center informing the facility of Resident #70's dialysis treatment and any pertinent information. The Registered Dietitian (RD) wrote a progress note on 10/3/20 stating Resident #70's lab work from the dialysis center noted his Albumin 2.2 (low), Potassium 3.6 and Phosphorus 1.7 (low). Recommendation to remove renal restriction from the diet due to low phosphorous level. She documented she would continue to monitor monthly. Review of Resident #70's monthly physician's orders for the month of November 2020, noted he was on a carbohydrate control diet/renal diet with double protein portions. On 11/4/20 at 12:05 p.m., in an interview with Licensed Practical Nurse (LPN) Staff DD a she said they were required to fill out the DCR form and send it to the dialysis center with all their dialysis residents. When the resident returned from the facility, they were required to fill out the bottom of the form with the resident's vital signs, their pain level, and assess the dialysis access site. She said the dialysis center did not send back any information or call the facility with any information on how the dialysis treatment went that day and any pertinent information. On 11/4/20 at 12:30 p.m., in an interview LPN Staff A confirmed Resident #70 went to the dialysis center 3 days a week for hemodialysis. She said the nurses were required to send a DCR form to the dialysis center with pertinent information and fill out the bottom of the form with the resident's vital signs, their pain level, and assess the dialysis access site when the resident returned from dialysis. She said after reviewing Resident #70's DCR form, the facility nurses did not consistently document they had assessed Resident #70's vital sign, pain level, and dialysis assess port when he returned from the dialysis center. She further said the dialysis center did not communicate with the facility regarding Resident #70's dialysis treatment and any pertinent information that day. On 11/4/20 at 1:00 p.m., in a phone interview with the dialysis center Administrative Assistant, she confirmed Resident #70 came to their facility dialysis center every Tuesday, Thursday and Saturday for hemodialysis. She said the dialysis center did not communicate with the nursing home regarding any of Resident #70 dialysis treatments. She said if the facility had asked them, they would have sent information to the nursing home about Resident #70's condition during treatment and any pertinent information. On 11/4/20 at 2:10 p.m., in an interview the RD confirmed she had written a progress note on 10/13/20 stating Resident #70's phosphorus level was 1.7 and the normal phosphorus level range was 3.5 to 5.5. She said she discussed Resident #70's lab work with the dialysis center RD and determined to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 15 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discontinue Resident #70's renal diet. She said since she was not at the facility, she emailed the Director of Nursing (DON) on 10/14/20 to recommend the facility remove the renal restrictions from Resident #70's diet. She confirmed after reviewing Resident #70's medical record the renal restrictions were not discontinued on 10/14/20 as she requested. She said she normally visited the facility 2 times during the week and was unaware the DON had not obtained an order to discontinue the renal diet. Removing the renal restrictions from Resident #70's diet would assist in reaching normal lab values which was noted as a low phosphorus level of 1.7, resulted on 10/13/20. On 11/4/20 a review of Resident 70's dialysis treatments from 10/1/20 to current, received on 11/4/20 from the dialysis center, revealed the dialysis nurse wrote on 10/3/20 and 10/6/20 Resident #70's lung sounds were diminished. On 11/5/20 at 2:10 p.m., in an interview the DON she said she was unable to find any documentation in Resident #70's medical record the dialysis center had communicated with the facility their ongoing assessment of Resident #70's condition during treatments, monitoring for complications and implementing appropriate interventions. She said the dialysis center refused to communicate with the facility regarding Resident #70's condition during his dialysis treatments but was unable to find any documentation the facility had requested any information as required. She said the dialysis center did not inform the facility Resident #70's lung sounds were diminished on 10/3/20 and 10/6/20. The DON said the RD emailed her on 10/14/20 requesting they discontinue the renal restrictions on Resident #70's diet due to his low phosphorus level of 1.7. She said they did not discontinue Resident #70's renal restrictions on his diet as requested by the RD on 10/14/20 and was unaware Resident #70's phosphorus level was 1.7 on 10/13/20. She confirmed the nursing home, dialysis center and the RD did not have ongoing communication and collaboration regarding Resident #70's dialysis care and services as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 16 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, record review and interview the facility failed to ensure timely reordering of medications resulting in 2 (Resident #93 and #94) of 2 residents reviewed for not receiving several doses of necessary medication as ordered. Resident #93 may have missed ordered medication for more than 2 months. The findings included: 1. Review of the clinical record revealed Resident #93 had an order for the antidepressant medication Sertraline 50 milligrams 1 tablet by mouth daily for major depressive disorder. The medication was scheduled to be given in the morning. On 11/2/20 and 11/5/20 Registered Nurse (RN) Staff B documented in the Medication Administration Record (MAR) she did not administer the Sertraline as ordered to Resident #93. On 11/5/20 at 10:25 a.m., during an interview RN Staff B said the Sertraline had not been available since she worked on 11/2/20. She said she searched the medication cart and the Sertraline was still not available therefore she did not administer it to the resident. Review of the MAR on 11/6/20 at 9:20 a.m., revealed Agency Licensed Practical Nurse (LPN) Staff X placed her initials on the MAR indicating she administered the Sertraline as ordered to Resident #93. On 11/6/20 at 9:45 a.m., during an interview LPN Staff X said she administered all morning medications to Resident #93 at approximately 9:12 a.m. as ordered, including the Sertraline. On 11/6/20 at 9:50 a.m., Resident #93 approached LPN Staff X and requested her morning medications. LPN Staff X poured 5 different pills in a cup and administered to the resident. She did not administer Sertraline. On 11/6/20 at 10:00 a.m., LPN Staff X verified she documented Resident #93's medications were administered including the Sertraline (even though the medication was not available). Further review of the MAR for 11/2020 revealed on 11/1, 11/3 and 11/4 the nurses documented they administered the Sertraline to Resident #93 in the morning as ordered. Review of the pharmacy shipment summary showed on 8/26/20 the pharmacy delivered 30 tablets of Sertraline 50 milligrams. There was no refill for September, October or November 2020. The facility's emergency medication kit did not include Sertraline. On 11/6/20 at 10:30 a.m., during an interview the Director of Nursing (DON) verified the emergency kit did not include Sertraline. She said since the last shipment was on 8/26/20 she did not know where the nurses found the Sertraline, they documented they administered to Resident #93. She said she would have to investigate. 2. Review of the clinical record revealed Resident #94's physician's orders included Torsemide 20 milligrams (water pill) 1 tablet by mouth daily for heart failure and antidepressant medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 17 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0755 Venlafaxine 150 milligrams 1 tablet by mouth daily for major depressive disorder. Level of Harm - Minimal harm or potential for actual harm Review of the MAR for 11/2020 showed on 11/2, 11/5 and 11/6 the nurses documented they did not administer the Torsemide or Venlafaxine as ordered. Residents Affected - Some On 11/5/20 at 10:25 a.m., during an interview RN Staff B said she worked on 11/2/20 and 11/5/20 but did not administer the medications as ordered to Resident #94. She said the Torsemide and the Venlafaxine were not available on 11/2 and were still missing from the cart. Further review of the MAR revealed on 11/1, 11/3 and 11/4 the nurses placed their initials on the MAR indicating they administered the medications as ordered. On 11/6/20 at 9:45 a.m., during an interview LPN Staff X said she couldn't find the Venlafaxine or the Torsemide therefore did not administer them to the resident as ordered. The facility's emergency medication kit did not include Torsemide or Venlafaxine. Review of the pharmacy shipment summary showed the last shipment of Torsemide (30 tablets) was on 9/27/20 at 2:41 a.m., and the last shipment of Venlafaxine (30 tablets) was on 9/27/20 at 2:41 a.m. On 11/6/20 at 10:30 a.m., during an interview the DON verified the emergency kit did not include Sertraline, Venlafaxine or Torsemide. She said she did not know where the nurses found the Sertraline, Torsemide or Venlafaxine that they documented they had administered to the residents. She said she would have to investigate. The DON said she could not locate a policy addressing timely reordering of medications but typically the nurses should reorder when they have approximately 5 doses left. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 18 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review, and interview, the facility failed to provide a medical reason for the increase of a psychotropic medication, and failed to implement person-centered, non-pharmacological approaches for 1 (Resident #62) of 5 residents reviewed for unnecessary medications. Psychotropic medications are used to alter mood, perception, emotion and behavior. The findings included: Review of the facility's policy and procedure N-1255, Medication Management-Psychotropic Medications (revised 3/23/18) specified residents would not be given psychotropic medications unless necessary to treat condition as diagnosed and documented in clinical record. It showed that behaviors and side effects would be monitored using a behavior monitoring flow chart. Review of the clinical record indicated Resident #62 was admitted on [DATE] and had a diagnosis of depression and generalized anxiety disorder. Resident #62 was taking Quetiapine (an antipsychotic ) 25 milligrams (mg) once daily prior to his admission. The clinical record showed a physician order dated 9/18/20 for Quetiapine to be increased from 25 mg once daily to 25 mg twice daily. The clinical record contained no documentation of behavioral symptoms to warrant the increase and the facility did not initiate the behavior monitoring until 9/22/20. Resident #62 had an initial psychiatric evaluation conducted on 9/23/20 which noted the resident was oriented to person, place, time, and situation. His mood was documented as normal and behavior cooperative. The clinical record showed a pharmacy consultation report dated 9/23/20 recommending a gradual dose reduction of the antipsychotic medication. The record documented the recommendation was declined by the Nurse Practitioner (NP), describing Resident #62 as impulsive and requiring a sitter. A NP progress note dated 9/23/20 recorded Resident #62 had a pleasant mood observed. On 3 subsequent progress notes by the NP, Resident #62 was documented as having a pleasant mood observed. On 11/04/20 at 12:49 p.m., during an interview the Director of Nursing (DON) confirmed there was no documentation Resident #62 had behavioral problems or required a sitter. The DON confirmed no documentation was found in Resident #62's clinical record to justify the increase in dosage of Quetiapine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 19 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 facility policy & procedure review, the facility failed to perform hand hygiene after direct contact with 4 residents (#69, #18, #28, and #56) observed to receive care; failed to handle medications in a sanitary manner for 2 (#57 and #18) of 4 residents observed receiving medications; and failed to follow current infection control standards and, failed to conduct an assessment to identify areas where waterborne organisms can grow. The failure to follow proper infection prevention techniques and CDC guidelines increases the risk of transmitting COVID-19 and other harmful organisms to residents in the facility. Residents Affected - Few The findings included: 1. The facility's policy for Handwashing/Hand Hygiene (revised August 2019) read This facility considers hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation specified to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; After contact with a resident's intact skin; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . On 11/4/20 at 10:00 a.m., Certified Nursing Assistant (CNA) Staff CC was observed measuring the blood pressure and pulse oximetry for Resident #69. CNA Staff CC left the room without performing hand hygiene and entered Resident #18's room. She took the Resident 18's blood pressure and pulse oximetry and then left the room without performing hand hygiene and went to Resident #28's room. CNA Staff CC measured Resident #28's blood pressure and pulse oximetry, and left the room without performing hand hygiene and went to Resident #56's room. CNA Staff CC was observed donning a pair of gloves without performing hand hygiene and said she was going to assist the resident to change her incontinent brief. On 11/4/20 at 10:15 a.m., during an interview CNA Staff CC verified she had been going from room to room to measure residents' vital signs without performing hand hygiene. Staff CC said she was not even thinking about washing her hands since she was not touching the residents. 2. On 11/4/20 at 8:15 a.m., Registered Nurse (RN) Staff Q was observed to prepare and administer 5 oral medications to Resident #57. RN Staff Q poured a pill in her bare hand, transferred it into a small medication cup, and administered it to the resident. On 11/4/20 at 8:30 a.m., RN Staff Q verified she poured the pill into bare her hand and administered a potentially contaminated medication to Resident #57. RN Staff Q said she was aware she should not touch the pills with her bare hands. On 11/5/20 at 9:58 a.m., RN Staff Q was observed preparing to administer medications to Resident #18. RN Staff Q poured the pills in her bare hand and placed them in a medication cup, and administered the pills to the resident. On 11/5/20 at 10:05 a.m., RN Staff Q verified she poured the resident's oral medications in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 20 of 21 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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 hand before placing them in the medication cup. Level of Harm - Minimal harm or potential for actual harm 3. Review of the Center for Medicare and Medicaid Survey and Certification memo (Ref S&C 17-30) to Skilled Nursing Facilities revised on 6/9/17 revealed Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. Residents Affected - Few The facility's policy and procedure for Legionella Water Management Program, (Revised July 2017) states, the purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread and reduce the risk of Legionnaire's disease. On 11/4/20 at 11:06 a.m., the Maintenance Director said he had been the facility Maintenance Director for less than a week and was not aware of the possible areas in the water system where legionella bacteria could grow. On 11/5/20 at 2:20 p.m., the Regional Nurse Consultant verified the facility did not have documentation of a facility assessment to identify potential areas of concern where legionella or other opportunistic water pathogens could grow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 21 of 21