Health inspection·October 22, 2025

F 0584 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm A used washcloth was observed on the floor under the sink. room [ROOM NUMBER]: Residents Affected - Some The wall behind the beds had large areas patched, not painted. The shared bathroom had 4 unlabeled, uncovered wash basins stacked up and stored on the bathroom floor. room [ROOM NUMBER]: The wall behind the bed by the window had multiple large gouges. An unlabeled wash basin and an unlabeled emesis basin were stored uncovered on the toilet tank. room [ROOM NUMBER]: Unlabeled, uncovered wash basins were stored on the shared bathroom floor. room [ROOM NUMBER]: An unlabeled wash basin and unlabeled emesis basin were observed stored uncovered on the toilet tank of the shared bathroom. The grout around the toilet was dirty with a large accumulation of black and brown substance. room [ROOM NUMBER]: The grout around the toilet of the shared bathroom was dirty with a large accumulation of black and brown substance. room [ROOM NUMBER]: The top drawer of the nightstand was broken. The shared bathroom had multiple uncovered, unlabeled bed pans and wash basins stacked up on the toilet tank. room [ROOM NUMBER]: The dresser was noted to be in a state of disrepair. The legs appeared gnawed, exposing the underlying material. room [ROOM NUMBER]: The wheelchair armrests in room [ROOM NUMBER] A were torn, exposing the underlying padding material. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 2 of 7 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 10/22/2025 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 0584 Two used urinary catheter drainage bags were observed stored in the shared bathroom handrail with the tubing wrapped around the handrail. Level of Harm - Minimal harm or potential for actual harm Photographic evidence obtained. Residents Affected - Some room [ROOM NUMBER]: The wall across 233 A was damaged with indentation in the drywall above the baseboard. On 10/20/25 at 9:49 a.m., in an interview Resident #6 said she's had ants crawling in her bed. On 10/20/25 at 11:00 a.m., a tour of the [NAME] Unit was conducted with the Infection Preventionist. The Infection Preventionist verified the wash basins, urinals and/or emesis basins were not stored in a sanitary manner in rooms 218, 219, 220, 221, 222, 224, and 226. She said the urinary catheter drainage bag in room [ROOM NUMBER] was not stored in a sanitary manner. The Infection Preventionist said resident's personal care items and the foley catheter drainage bag should be labeled and stored in plastic bags and were an infection control concern. The Infection Preventionist said she has been employed at the facility for three weeks and had not identified these concerns and had not in-serviced the staff on the proper storage of residents' care items. On 10/20/25 at 11:40 a.m., a tour of the [NAME] Unit was conducted with the Maintenance Director. He verified the bed control in room [ROOM NUMBER] B was not working properly and needed to be replaced. He verified the extension cord in room [ROOM NUMBER] B was not hospital graded and should not be used in a resident's room. The Maintenance Director verified the observations made in the residents' rooms on the [NAME] Unit. He said he made daily rounds in the residents' rooms but did not keep a list of repairs to be made. 2. On 10/21/25 at 4:00 a.m., during a tour of the [NAME] Unit the following observations were made: Live crawling insects in the hallway and in room [ROOM NUMBER]. Numerous ants were crawling on the clean linen in the linen cart. During confidential interviews, direct care staff said roaches and ants have been a constant issue at the facility. Review of the facility's pest control log for June 2025, July 2025, 8/2025, 9/2025, and 10/2025 revealed recurrent entries of roaches and ants sightings as follows: 6/17/25: Roaches in the bathroom of room [ROOM NUMBER]. 6/27/25: Roaches and ants in the activities department. 8/19/25: Ants in room [ROOM NUMBER] W. 8/21/25: Ants in room [ROOM NUMBER] A. 8/21/25: Ants in the pantry of the [NAME] Unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 3 of 7 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 10/22/2025 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 0584 9/21/25: Roach in the entry hall of [NAME] Lane. Level of Harm - Minimal harm or potential for actual harm 9/30/25: Roches on/in the dresser in room [ROOM NUMBER] W. 10/17/25: Kitchen-Dishpit Roaches 100 S. Residents Affected - Some Review of the pest control company inspection reports revealed: On 10/14/25 dead roaches and American cockroaches were found in the kitchen storage area. 10/21/25, Issues with roaches in the kitchen and with ants in rooms. On 10/21/25 at 10:10 a.m., in an interview the pest control technician said there was an ongoing problem with ants in residents' rooms due to food in the rooms. He said he started his inspection in the kitchen and found an area with cracks on the floor. He said, I squirted some material in there and forced a roach out. He said the floor of the hallway where the dishwasher is needed to be replaced as it was a hiding place for roaches. On 10/21/25 at 3:53 p.m., in an interview the housekeeping supervisor said she has been employed at the facility since 10/6/25 but has been helping at another facility. She said 2 days ago, she came back to this facility. When she went in the residents' rooms, she noted the rooms, including the windowsills were dusty. She said the grout around the toilets needed to be cleaned. The housekeeping supervisor said she did not make a list of all the rooms that needed to be cleaned. She said she found a check off list for the daily cleaning, but they have not started using them. 3. On 10/21/25 at 4:35 a.m., observation of the kitchen with Dietary Staff U revealed: The floor of the walk-in refrigerator was heavily soiled with large amount of built-up black substance. Photographic evidence obtained A large hole was observed in the wall of the walk-in refrigerator. Photographic evidence obtained The pipes in the walk-in refrigerator had large amount of frost build up. Photographic evidence obtained The seal of the walk-in refrigerator was heavily soiled with a large accumulation of black substance. Photographic evidence obtained. The side wall of the walk-in refrigerator was covered in condensation. Photographic evidence obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 4 of 7 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 10/22/2025 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 0584 A large pool of water was observed on the kitchen floor behind the walk-in refrigerator's door. Level of Harm - Minimal harm or potential for actual harm The walk-in freezer had ice built up and melting ice on the floor behind the door. Photographic evidence obtained Residents Affected - Some On 10/21/25 at 4:05 p.m., in an interview the Dietary Manager was asked about processes in place to clean and make necessary repairs to kitchen equipment. The Dietary Manager replied that he was working on repairing the areas observed. He said the kitchen staff was responsible for the cleaning listed on the daily cleaning list posted. The floor and the door of the walk-in refrigerator should be cleaned weekly. He said the daily cleaning list was posted but there was no log for staff to sign that the cleaning was completed. Review of the cleaning schedule provided by the Dietary Manager revealed on Thursdays the evening cook was responsible to clean the walk-in refrigerator and freezer. On Thursdays, the morning aide 1 was responsible to clean the refrigerator and freezer doors and walls thoroughly. When asked about training and competency of staff for safe food handling during tray line, the Dietary Manager said he started working at the facility in July 2025 and Dietary Aide Staff W was already employed. The Dietary Manager provided a list of in-services for Dietary Aide Staff W which showed a date of hire of 5/4/24. On 2/25/25, 4/10/25, Staff W scored 100 on a Glove usage inservice Quiz. On 3/5/35 and 8/12/25, Staff W scored 100 on a Time and Temperature inservice Quiz. 4. On 10/20/25 at 9:10 a.m., during a tour on [NAME] and [NAME] Halls the following was observed: room [ROOM NUMBER]: A wash basin was stored on the floor of the shared bathroom. room [ROOM NUMBER]: The bed sheets had multiple black stains and food crumbs. An open urinal was wedged in the handrail of the bathroom. room [ROOM NUMBER]: An unlabeled and uncovered wash basin was stored on top of the toilet tank of the shared bathroom. Photographic evidence obtained. room [ROOM NUMBER]: An unlabeled, uncovered wash basin was stored on top of the toilet tank of the shared bathroom. room [ROOM NUMBER]: An unsecured tube of Arthritis Relief Cream and unlabeled, uncovered wash basins were stored on top of the toilet tank of the shared bathroom. room [ROOM NUMBER]: An unlabeled, unbagged wash basin was stored on the toilet of the shared bathroom. Photographic evidence obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 5 of 7 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 10/22/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]: Flying insects were observed in the room. An unlabeled oxygen tubing was on the floor at the foot of the bed. Photographic evidence obtained. room [ROOM NUMBER]: Three unlabeled wash basins were stacked on the toilet tank of the shared bathroom. Photographic evidence obtained. room [ROOM NUMBER] A: The left arm rest of the wheelchair was missing. The four alcohol-based hand sanitizer dispensers mounted on the walls of the [NAME] and [NAME] units were empty and not functioning. Photographic evidence obtained. On 10/21/25 at 3:00 p.m., observation of the [NAME] Hall communal shower room with Licensed Practical Nurse (LPN) Staff E revealed two shower stalls. The shower head was missing from one of the stalls. An opened bottle of body wash and shampoo was stored in a rusted metal holder in the shower room. Photographic evidence obtained. LPN Staff E said, Well, this one works when asked about the missing shower head. She did not reply when asked about the opened bottle of body wash and shampoo stored in the rusted metal holder. On 10/21/25 at 3:12 p.m., observation of the communal shower room of the [NAME] Hall with LPN Staff E revealed two shower stalls. One of the showers was not functioning. The pipe was protruding from the wall and was missing the shower head. In an interview during the observation, LPN Staff E said, Obviously the staff are not using that shower. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 6 of 7 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 10/22/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, residents, staff and contractor's interview, the facility failed to have an effective pest control program to ensure a pest free environment in residents' rooms and in the kitchen of the food serving establishment.The findings included:On 10/20/25 at 9:05 a.m., during a tour of the [NAME] Unit, a live brown insect was observed crawling on the bathroom floor of room [ROOM NUMBER].On 10/20/25 at 9:49 a.m., in an interview Resident #6 said she's had ants crawling in her bed.On 10/21/25 at 3:50 a.m., in an interview Registered Nurse (RN) Staff BB said ants were an issue at the facility. During the interview, multiple ants were observed crawling on the wall at the nurse's station next to the [NAME] Unit.On 10/21/25 at 4:00 a.m., during a tour of the [NAME] Unit the following observations were made:Live crawling insects in the hallway and in room [ROOM NUMBER].Numerous ants were crawling on the clean linen in the linen cart.During confidential interviews, direct care staff who routinely work during the night shift said roaches and ants have been a constant issue at the facility.During a confidential interview during the night shift on 10/21/25 a direct care staff said recently 13 roaches were killed on their assigned unit.Review of the facility's pest control log for June 2025, July 2025, 8/2025, 9/2025, and 10/2025 revealed recurrent entries of roaches and ants sightings as follows:6/17/25: Roaches in the bathroom of room [ROOM NUMBER].6/27/25: Roaches and ants in the activities department.8/19/25: Ants in room [ROOM NUMBER] W.8/21/25: Ants in room [ROOM NUMBER] A.8/21/25: Ants in the pantry of the [NAME] Unit.9/21/25: Roach in the entry hall of [NAME] Lane.9/30/25: Roches on/in the dresser in room [ROOM NUMBER] W.10/17/25: Kitchen-Dishpit Roaches 100 S.Review of the pest control company inspection reports revealed:On 10/14/25 dead roaches and American cockroaches were found in the kitchen storage area.10/21/25, Issues with roaches in the kitchen and with ants in rooms.On 10/21/25 at 10:10 a.m., in an interview the pest control technician said there was an ongoing problem with ants in residents' rooms due to food in the rooms. He said he started his inspection in the kitchen and found an area with cracks on the floor. He said, I squirted some material in there and forced a roach out. He said the floor of the hallway where the dishwasher is needed to be replaced as it was a hiding place for roaches. On 10/22/25 at 10:30 a.m., a tour of the kitchen was conducted with the Kitchen Manager. The flooring tiles next to the sink and dishwasher were lifting, creating an open space between the tiles and the floor underneath. The Kitchen Manager verified the pest control technician found the roach underneath the flooring.Review of the facility's survey history revealed noncompliance identified during the last recertification survey completed on 3/13/24 included the facility failure to maintain an effective pest control program. On 10/22/25 at 1:00 p.m., in an interview the Administrator verified pest control remained a concern. The program in place has not been effective to contain common household pests. On 10/22/25 at 2:00 p.m., a brown insect was observed crawling on the bathroom floor in room [ROOM NUMBER]. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105507 If continuation sheet Page 7 of 7