Inspection visit

Health inspectionMarch 16, 2023

Q: What happened during the March 16, 2023 survey of AVIATA AT WEST PALM BEACH?

This was a inspection survey of AVIATA AT WEST PALM BEACH on March 16, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at AVIATA AT WEST PALM BEACH on March 16, 2023?

Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

AVIATA AT WEST PALM BEACHCMS #10555812 citations on this visit

12 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document the accuracy of code status for 1 of 28 sampled residents reviewed for code status (Resident #43). The findings included: Review of Resident #43 electronic records revealed the resident was admitted [DATE] with a diagnosis to include Dementia, Cerebral Vascular Accident, Type II Diabetes, Aphasia, Hemiplegia and Hemiparesis, Adult Failure to Thrive, Atrial Fibrillation, and Convulsions. Review of the resident's quarterly MDS (Minimum Data Set) dated 01/31/23 revealed the resident has a BIMS (Brief Interview for Mental Status) of 7, indicating his cognition was severly impaired. Review of the resident's MAR (Medication Administration Record) documented Resident #43 is a Full Code, which indicated if this resident's heart stopped beating or he stopped breathing, all resuscitation procedures would be provided to keep them alive. Review of the physicians' orders dated 07/13/20 documented the resident is a full code and there was also a Do Not Rescusitation order (DNRO) dated 10/17/22. Review of the resident's care plan documented a DNR care plan. Review of Resident #43 paper chart revealed a yellow paper, titled, Do Not Rescusitate, signed and dated 10/17/22 by the resident's Power of Attorney (POA). During an interview on 03/15/23 at 9:00 AM with Staff K, LPN (Licensed Practical Nurse), she stated she has worked here for 3 weeks. The surveyor asked her if a resident had an emergency or was found in cardiac arrest how would they know if they are a full code or DNR. She stated that another nurse will go to check the paper chart for DNR status and she would check the EMR (electronic medical record). She stated she would check the resident's wrist band for code status. the surveyor asked her to go into resident rooms to check wristbands, and all 3 residents did not have a wristband on. During an interview on 03/15/23 at 9:10 AM with Staff C, LPN, stated that she has been working in facility for 4 years. She was asked about knowing if resident was a DNR or full code and how they would handle code status in an emergency. She stated that as soon as she calls a code blue (cardiac arrest), another nurse is supposed to go to the paper chart to confirm resident's code status; and we go to the paper chart first. During an interview on 03/15/23 at 11:55 AM with Director of Nursing (DON), she was asked how they handle an resident emergency such as a code and knowing if a resident is a full code or DNR. She stated that they check the electronic chart in PCC (Point Click Care) or the paper chart but it is usually the electronic chart. She was asked to show the surveyor where to find it. She pulled up a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 32 Event ID: 105558 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0578 Level of Harm - Minimal harm or potential for actual harm resident which happened to be Resident #43. She said he is a full code. She was then asked to pull up his orders and to review them. She saw that it showed that he has an order for full code and has a DNR order. She stated I will get that corrected right away. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 2 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment in 3 of 4 units, including the laundry room; and failed to ensure an environment free of accident hazards by not securing disposable razors at the bedside for 1 of 28 sampled residents (Resident #42). The findings included: Observations during the survey on 03/13/23 through 03/16/23, revealed the following concerns on 3 of 4 units. A tour of the facility was completed on 03/16/23 at 1:41 PM with the Maintenance Director and the Plant Ops (Operations) Assistant who acknowledged the concerns below during the tour: 1. room [ROOM NUMBER]: There was rust around the light switch cover by inside the room by the door; and there was paint peeling on the back wall behind the bed. room [ROOM NUMBER]: There was paint peeling on the wall, caulking needs to be done under chair railing, wall behind bed had paint peeling, two tone paint on wall behind bed, A/C (air conditioner) unit base was cracked, wood baseboard was chipped and the pipes under the bathroom sink are rusty. room [ROOM NUMBER]- The over the bed table laminate peeling/chipped you can see the cork underneath. Bathroom ceiling tiles over the shower stall have black stains/soot, the shower curtain rod is rusted and stained, the wood door entering the room is chipped and has what looks like red paint on the edge of the door and metal frame of the door. The bed frame, which is wood is peeling away from cork. room [ROOM NUMBER]: The bathroom wall behind the toilet has paint peeling away from wall, where the ceiling meets the wall there are brown stains/rust, wall in bedroom all scuffed up and needs painting, wood closet scuffed. room [ROOM NUMBER]: The wardrobe closet with handle is missing; there was a window pane that has a crack across the entire window (Maintenance Director stated he has a new window on order). room [ROOM NUMBER]: The bathroom door is warped and does not close completely; the caulking around the pipes are needed behind sink; shower head on the floor in shower (no hook to hang it); and splotches of caulking observed on wall by bathroom in main room. room [ROOM NUMBER]: There were drip stains and caulking peeling away from the wall by the sink in main room. room [ROOM NUMBER]: The bathroom had white splotches of caulking on two walls that are different colors than the paint; Shower head was on floor in shower stall and no hook to hang it. room [ROOM NUMBER]: The side bedrails have rust on them and there is no cord for pull light. room [ROOM NUMBER]: The bathroom was dirty and there was paint peeling off the wall. 2. During a tour conducted on 03/15/23 at 12:15 PM of the soiled utility room and laundry room with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 3 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 the Assistant Director of Nursing and the Director of Laundry Services, the soiled utility room had unbagged PPE (Personal Protective Equipment) in uncovered trash bins. The biohazard bin (Red) had unbagged PPE, red biohazard bags untied, and an overhead light above the red biohazard trash bins not working. In the dryer portion of the laundry room, there was a pedestal fan covered with dust and the inside drum of the middle dryer had melted debris. Residents Affected - Few 3. Review of the facility's policy, titled, Grooming Activities, with an effective date of 11/30/14, included: Grooming activities are provided to assist the residents in meeting their physical needs as well as self-esteem need. Grooming activities shall be offered daily. Grooming activities shall include, but are not limited to: Shaving. A grooming basket shall contain supplies and be utilized to supplement the resident's own grooming items. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE] with a most recent readmission date of 04/05/22 with the following diagnosis: Paraplegia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented Resident #42 had a Brief Interview for Mental Status of 15, which indicated that he was cognitively intact. Review of Section G of the MDS dated [DATE] documented Resident #42 had a bed mobility self-performance of extensive assistance with support of one-person physical assist, transfer self-support of total dependence with support of two plus persons physical assist, dressing self-performance of extensive assistance with support of one person physical assist, eating self-performance of independent with support of setup help only, toilet use self-performance of extensive assistance with support of one-person physical assist, personal hygiene with self-performance of extensive assistance with support of one person physical assist. Review of the Care Plan for Resident #42 dated 11/25/18 with a focus on ADLs (Activities of Daily Living) self-care performance deficit: 'Resident has a history of frontal subdural collection. Non-ambulatory, able to wheel wheelchair independently. Requires staff assistance with self-care. Goals were to continue to maintain independent dining with setup assistance. Resident will receive appropriate staff support with (bathing, dressing, grooming, toileting, transfers , and mobility) through the next review Interventions included: Assist resident with dressing and grooming. Encourage to attempt washing face, washing hands, drying upper body, donning and removing of simple items of clothing. Requires at times assistance for completion of oral hygiene and care. At times perform independently. Provide setup and allow to complete as much as within his capabilities. Offer assistance if need it.' During an observation conducted on 03/13/23 at 10:37 AM, Resident #42 had 2 disposable razors in plain view on his bedside table which were located next to his bed. Photographic Evidence Obtained. During an interview conducted on 03/13/23 at 10:38 AM with Resident #42, when asked if he shaves himself, he replied 'yes'. He stated he can do things for himself if it is the front of his upper body. When asked what he does with the razors when he is finished with them, he stated he tells the nurse and she puts the razor in a sharps container for disposal. During an observation conducted on 03/14/23 at 9:20 AM, Resident #42 continued to have 2 disposable razors on his overbed table next to his bed. During an interview conducted on 03/14/23 at 2:05 PM with Staff B, Certified Nursing Assistant (CNA), when asked if residents can have sharp items at bedside she said, 'I don't think so if they are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 4 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 - Few not alert and oriented'. When asked if a resident is alert and oriented, could that resident have any sharp objects at the bedside, she said, 'I don't think so because we have to keep the residents safe'. When asked if she saw a sharp object at a resident's bed side, what would she do, she said she would take it away from the resident and tell the nurse. During an interview conducted on 03/14/23 at 2:20 PM with Staff A, Licensed Practical Nurse (LPN), when asked are residents ever allowed to keep sharp objects at the bedside, she stated that residents are not allowed to have any sharp objects at the bedside. If a resident had a sharp object at bedside, she would assess why and take it away and let her supervisor know. During an interview conducted on 03/14/23 at 2:30 PM with Staff C, LPN, when asked if residents can have any sharp objects at the bedside, she stated 'no'. She said if we see any sharp objects at the bedside, we have to take the sharp object out of the room. She stated, sometimes family come and bring residents various items. She said that both the nurses and the CNAs observe for any sharp objects at the resident's bedside every time they enter a resident's room. During an interview conducted on 03/14/23 at 2:50 PM with the Director of Nursing, when asked are residents ever allowed to keep sharp objects at the bedside, she said 'no, never'. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 5 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 of 2 sampled residents reviewed for Preadmission Screening and Resident Review (PASARR) was screened for a mental disorder or intellectual disability prior to admission (Resident #41). Residents Affected - Few The findings included: Resident #41 was first admitted to the facility on [DATE]. On 10/26/21, the resident to a hospital for lethargy and fever. Resident #41 was re-admitted on [DATE] under Hospice services. At the time of re-admittance, Resident #41 had diagnoses that included Coronary Artery Disease, Anxiety Disorder, Major Depressive Disorder, Schizophrenia and Psychosis. The Quarterly Minimum Data Set (MDS) assessment, dated 02/17/23, documented Resident #41 had a Brief Interview for Mental Status (BIMS) of 11, indicating minor cognitive impairment. The resident's Mood was documented as showing little interest or pleasure in doing things; feeling down, depressed or hopeless; having sleep issues; and feeling tired or having little energy. There were no behaviors were noted during the assessment period. Resident #41 required extensive to total assist for most of her Activities of Daily Living (ADLs), except for eating which required limited assistance. Review of Resident #41's medication orders showed Resident #41 received daily antipsychotic, antidepressant and anti-anxiety medications. On 03/13/23 during record review, a Level I Preadmission Screening and Resident Review (PASSAR) was found in Resident #41's electronic record. This Level I PASSAR had been completed on 04/19/19, one year prior to the resident's admission to this facility. This Level I PASSAR indicated that a Level II should have been completed due to the resident having Mental Illness (Depressive Disorder and Schizophrenia) and having 1) serious difficulty interacting appropriately and communicating effectively with other persons, 2) having a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or has been dismissed from employment; received psychiatric treatment more intensive than outpatient care; 3) due to the mental illness, the resident has experienced an episode of significant disruption to the normal living situation for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials; and 4) has also exhibited actions or behaviors that may make them a danger to themselves or others. Per Section IV of the PASSAR, Individual may not be admitted to a Nursing Facility. Use form and required documentation to request a Level II PASSRR evaluation because there is a diagnosis of or suspicion of serious mental illness. On 03/15/23 at 10:54 AM, an interview was conducted with the MDS coordinator. She confirmed that the only PASSAR on file was the PASSAR dated 04/19/19. No new Level I PASSAR was found to have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 6 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0645 completed at the time of the admission on [DATE] or at the time of re-admission on [DATE]. Level of Harm - Minimal harm or potential for actual harm Even though the facility failed to have a Level I PASSAR completed at the time of admission, it must also be noted that even though the facility did accept the PASSAR completed a year prior to admission [DATE]), they did not follow up on the recommendation of the Level I PASSAR to have a Level II PASSAR completed for Resident #41 prior to admission. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 7 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, clinical record review and interview, the facility failed to identify, report and treat skin conditions in a timely manner for 1 of 1 sampled resident reviewed for skin conditions (Resident #25); and the facility failed to follow physician's orders for medication administration for 1 of 5 sampled residents (Resident #10) during medication administration observation. Residents Affected - Few The findings included: Facility policy, titled, Skin Evaluation, last revised 04/01/17 documents A Licensed Nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas and skin problems. Procedure: a Licensed Nurse will complete a total body evaluation on each resident weekly and document the observation on the skin evaluation form. If the resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. The Licensed Nurse will document the observation on the skin evaluation form. Observations conducted on 03/13/23 at 1:12 PM; on 03/14/23 at 8:42 AM and on 03/14/23 at approximately 3:00 PM revealed Resident #25 had redness, rash like skin condition to his left leg and left elbow. The areas on the left elbow had small open areas of raw skin and the left leg had two spots of red rash to the mid-thigh and left lower leg. Clinical record review conducted on 03/13/23 revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Dysphagia and Cerebrovascular Accident. Physician's orders dated 08/03/20 documents weekly skin sweeps. Weekly skin check documentation dated 03/13/23 documents skin is intact. The assessment completed the same date, as the first observation, failed to capture the resident's skin condition. Minimum Data Set assessment (MDS) assessment with reference date of 12/08/22 documents the resident was assessed as moderately impaired for skills of daily decision making and had no skin tears, no pressure wounds and had a lesion to the foot. Care Plan initiated on 03/09/22 documents the resident has the potential for skin impairment and the interventions included pressure relieving devices and topical medication as ordered. Further review of the record failed to provide documentation of the resident's current skin conditions. Observation of Resident #25 conducted on 03/15/23 at 2:25 PM, revealed the resident sitting in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 8 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dining room. The resident was wearing long pants. The Director of Nursing (DON) was asked to check the resident's left leg and elbow and confirmed the presence of the skin conditions and stated the resident had seen a dermatologist in the past and was going to obtain the consultation report and that the issue may be ongoing. The DON also explained the aides are to report skin changes to the nurses. Dermatology consult dated 01/16/23, provided to the surveyor on 03/16/23 documents the resident's rash had resolved. New physician's order dated 03/15/23 documents a new treatment for Resident #25, Clotrimazole 1% topical cream apply to sides of nose and left elbow twice a day for 7 days. Interview with Staff F, Certified Nursing Assistant, conducted on 03/16/23 at 12:20 PM revealed the resident has an ongoing rash on his groin, and sometimes has red patches like rash to his body. If she notices any changes in skin, she would report to the nurse and confirmed the red rash like areas to the elbow and leg are new to her. 2. Review of the facility's policy, titled, Administering Medications, with a revised date of April 2019, included: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication (med) checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE]. The diagnoses included: Cerebral Palsy, Pain in Unspecified Joint, and Muscle Spasm. Review of Section C of the MDS dated [DATE] documented that Resident #10 had a Brief Interview for Mental Status of 15, indicating he was cognitively intact. Review of the Physician's Orders showed that Resident #10 had an order dated 11/16/22 for Baclofen oral tablet 10mg, give 1 tablet by mouth bid (twice daily) for muscle spasm. During a med pass observation conducted on 03/14/23 9:35 AM with Staff A, Licensed Practical Nurse (LPN), using med cart 3 for Resident #10 she placed the following medications in a medication cup: Baclofen 10mg ([2 tabs] 1 tab from 2 different blister packs for the same resident) Potassium Chloride Extended Release 10 meq (milliequivalent) Sertraline 100 mg (milligram) Furosemide 20 mg Lisinopril 10 mg Phenytoin Sodium Extended 100 mg Bisacodyl 5 mg (2 tabs) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 9 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 Natural Vegetable Laxative (Senna) 8.6 mg (2tabs) Level of Harm - Minimal harm or potential for actual harm The total number of pills was 11. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview conducted on 03/14/23 at 9:50 AM with Staff A, when asked the number of pills she had in the medication cup, she responded 11. When Staff A was asked what the order for Baclofen for Resident #10 is, she stated the order is for Baclofen 10mg give 1 tablet by mouth bid (twice daily) for muscle spasm. When Staff A was shown the 2 blister packs of Baclofen 10mg for the same resident, she stated she should only have put 1 Baclofen 10 mg tablet in the medication cup. She removed 1 of the Baclofen 10 mg tablets from the medication cup and put it in the drug buster bottle to dispose of it. Event ID: Facility ID: 105558 If continuation sheet Page 10 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer and adequately document tube feedings as ordered by the physician for 1 of 1 sampled resident reviewed for tube feeding (Resident #28). The findings included: Review of the facility's policy, titled, Enteral Feeding -Enteral Nutrition Pump, with a revision date of 11/12/18, included: Nurses administer enteral feeding when volume control is indicated and as ordered by physician. Review of the facility's policy, titled, Physician Orders, with a revision date of 03/03/21 included: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Review of the facility's policy, titled, Medication Administration Via Enteral Tube, with a revised date of 03/06/19, included: Document on the Nurse's Notes any problems encountered and any measures taken. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Diagnoses included: Parkinson's Disease, Type 2 Diabetes Mellitus, Major Depressive Disorder, Gastrostomy Status, and Apraxia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #28 had a Brief Interview for Mental Status of 9, indicating he had moderate cognitive impairment. Review of Section G of the MDS dated [DATE] documented that Resident #28 had a bed mobility self-performance of extensive assistance with support of one person physical assist, transfer self-support of extensive assistance with support of two plus persons physical assist, dressing self-performance of extensive assistance with support of one person physical assist, eating self-performance of extensive assistance with support of one person physical assist, toilet use self-performance of extensive assist with support of one person physical assist, personal hygiene with self-performance of extensive assistance with support of one person physical assist. Review of the Physician's Orders showed that Resident #28 had an order dated 03/13/23 for two times a day for continuous Glucerna 1.5, 75 ml/hr (milliliters/hour) x 20 hours (Total volume 1,500 ml/day) from 2:00 PM to 10:00 AM. Review of the Care Plan for Resident #28 dated 03/07/23 with a focus on Feeding Tube: resident requires tube feeding: swallowing problem. Goals were to maintain adequate nutritional and hydration status AEB (As Evidenced By) weight stable, no s/sx (signs/symptoms) of malnutrition or dehydration through next review dat. Resident will remain free of side effects or complications related to tube feeding through next review date. Insertion site will be free of s/sx of infection through the review date. Interventions included: The resident needs (assistance) with tube feeding and water flushes. See MD orders for current feeding orders. Registered Dietician (RD) to evaluate quarterly and as needed (PRN). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 11 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Nursing Notes and Assessments for Resident #28 from 03/14/23 to 03/15/23 revealed no documentation by a nurse or the dietician. During an observation conducted on 03/14/23 at 7:30 AM of Resident #28 resting in bed with eyes open, upon closer observation, the resident had tube feeding, Glucerna 1.5 (formulary type) labeled as being started on 03/14/23 at 5:15 AM and was infusing via pump at 75 milliliters per hour. The tube feeding was just below the 1,000-milliliter mark out of a 1,000-milliliter capacity bottle. During an observation conducted on 03/14/23 at 2:25 PM of Resident #28 was lying in bed with tube feeding bottle of Glucerna 1.5 (formulary type) labeled as being started on 3/14/23 at 5:15 AM and was infusing at 75 milliliters per hour via an electric pump. The tube feeding bottle was at the 750-milliliter mark out of a 1,000-milliliter capacity bottle. During an observation conducted on 03/15/23 at 7:20 AM of Resident #28 lying in bed with his eyes closed. Upon closer observation, the resident had a tube feeding bottle of Glucerna 1.5 (formulary type) labeled as being started on 03/14/23 at 5:15 AM and was not infusing (tube feeding was connected to an electric pump that was currently off). The tube feeding bottle was at the 450-milliliter mark out of a 1,000-milliliter capacity bottle. (This indicated the resident had received 550-milliliters of tube feeding in 22 hours) During an observation conducted on 03/15/23 at 9:30 AM of Resident #28 lying in bed, upon closer observation, the resident had a tube feeding bottle of Glucerna 1.5 (formulary type) labeled as being started on 03/15/23 at 8:00 AM and was infusing at 75 milliliters per hour via an electric pump. The tube feeding bottle was at the 950-milliliter mark out of a 1,000-milliliter capacity bottle. During an interview conducted on 03/14/23 at 7:35 AM with Staff B, Certified Nursing Assistant (CNA), when asked if she had performed any activities of daily living (ADLs) for Resident #28, she stated she just gave him a bath a little after 7:00 AM. During an interview conducted on 03/14/23 at 2:35PM with Staff C LPN, when asked about continuous tube feedings why some are ordered to be off 10:00 AM and restarted at 2:00 PM, she stated that is what the Registered Dietician or Physician orders and the nurses just follow the orders. When asked if the time that the tube feeding is off is for things like routine care for the resident, she said 'no'. During an interview conducted on 03/14/23 at 2:37 PM with the facility RD/LD (Registered Dietitian/Licensed Dietician) when asked about Resident #28 who was receiving enteral tube feeding, could she explain why the order is written to be 'on at 2:00 PM and off at 10:00 AM', she stated because residents are usually up during those times and tend to ambulate more during those times. When asked if the time the tube feeding is off (10:00 AM to 2:00 PM) is designated for activities of daily living such as bathing, she stated 'no'. During an interview conducted on 03/14/23 at 2:48 PM with the facility's RD/LD, she stated that residents who are receiving enteral tube feeding she does not necessarily go by when the tube feeding is on or off, she goes by the total volume infused. She said the nurses know to give the total feeding volume for the resident who has a enteral tube feeding order. She said the nurse would let her know if the resident did not receive the total volume of feeding for the day. During an interview conducted on 03/15/23 at 7:26 AM with the facility's RD/LD, when asked how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 12 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few often she is in the facility, she stated 2 days a week, and at that time she will check the residents who are receiving enteral tube feeding. During an interview conducted on 03/16/23 at 11:00 AM with Staff C, LPN, when asked if she documents in the electronic medical record (EMR) the total volume a resident receives for tube feeding, she stated 'no'. She stated we just follow the orders as they are written, if it states to stop the tube feeding at 10:00 AM, and restart the tube feeding at 2:00 PM, that is what she does. During an interview conducted on 03/16/23 at 11:15 AM with the facility's RD/LD when it was brought to her attention that the nurse follows the order to stop and start a tube feeding as per the orders and they do not indicate the total volume of tube feeding received by the resident, she stated that the nurse would just communicate the volume to her. She stated Resident #28 had the tube feeding order changed on Monday and she had not checked on the resident this week even though she has been at the facility daily since 03/13/23. She then stated she has been busy this week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 13 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on record review and interview, the facility failed to complete annual performance reviews for 2 of 3 sampled staff members (Certified Nursing Assistants, Staff #H and #I). Residents Affected - Some The findings included: Review of the personnel files provided on 03/16/23 revealed Staff #H, Certified Nursing Assistant, was hired on 05/31/07 and Staff #I, a Certified Nursing Assistant was hired on 07/01/20. Review of the documentation provided revealed no evidence that the Certified Nursing Assistants, Staff #H and #I had annual performance reviews. Interview with Assistant Director of Nursing (ADON) conducted on 03/16/23 at approximately 1:00 PM revealed the facility completes annual evaluations and was asked to provide the most recent performance reviews for Staff #H and #I. The information was not provided. Subsequent interview with the Human Resources Director on 03/16/23 at approximately 2:49 PM revealed nursing is responsible for the completion of the annual evaluations and was not able to provide evidence of completion. Interview with the Administrator during the exit conference revealed the facility will provide evidence of the completed evaluation by the end of the day. The facility has not provided the required documents as of 03/20/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 14 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and interview, the facility staff failed to: Acquire and dispense medications in a timely manner for 1 of 28 residents (Resident #62); and failed to ensure narcotic reconciliation was accurate for 3 of 3 sampled residents (Resident #2, #71, and #68). The findings included: 1. Facility policy, titled, Medication Shortages/Unavailable Drugs, dated 12/01/07, documented: This Section 7.0 sets forth procedures relating to medication shortages and unavailable drugs. PROCEDURE 1. Upon discovery that the Facility has an inadequate supply of a medication to administer to a resident, Facility Staff should immediately initiate action to obtain the medication from the Pharmacy. 1.1 If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take the action specified in Sections 2 or 3 of this Section 7.0, as applicable. 2. If a medication shortage is discovered during normal Pharmacy hours: 2.1 A licensed Facility nurse should call the Pharmacy to determine the status of the order. If the medication has not been ordered, the licensed Facility nurse should place the order or reorder to be sent with the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, the Facility nurse should obtain the medication from the emergency stock supply to administer the dose. 2.3 If the medication is not available in the emergency stock supply, Facility staff should notify the Pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal Pharmacy hours: 3.1 A licensed Facility nurse should obtain the ordered medication from the emergency stock supply. 3.2 If the ordered medication is not available in the emergency stock supply, the Facility nurse should call the Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery. 3.2.2 Use of an emergency (back-up) Third Party Pharmacy. 4. If an emergency delivery is unavailable, the Facility nurse should contact the attending physician to obtain orders or directions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 15 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 5. If the medication is unavailable from the Pharmacy or a Third Party Pharmacy, and cannot be supplied from the manufacturer, the Facility should obtain alternate physician/prescriber orders, as necessary. 6. If the medication is unavailable from the pharmacy due to formulary coverage, contraindication, drug-drug interaction, drug-disease interaction, allergy or other Residents Affected - Few 7. If the Facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, the Facility nurse should notify the nursing supervisor and contact the Facility medical director for orders/direction, making sure to explain the circumstances of the drug product shortage. 8. When a missed dose is unavoidable, the Facility nurse should document the missed dose and the explanation for such missed dose on the Medication Administration Record (MAR) or Treatment. Administration Record (TAR) and in Nurses Notes per Facility Policy. Such documentation should include the following information: 8.1 A description of the circumstances of the medication shortage. 8.2 A description of the Pharmacy's response upon notification. 8.3 Actions Taken. Interview with Resident #62 conducted on 03/13/23 at 10:01 AM revealed the resident is concerned regarding not receiving his sleeping aides (medications) every night. Last night (03/12/23), the nurse told him they ran out of his Restoril and Melatonin. Review of the Controlled Medication Utilization Record, dated 03/04/23 and physician's orders for Restoril 30 mg one capsule at bedtime, indicated the facility received on 03/04/23 seven doses of Restoril. The medication was removed from the inventory from 03/05/23 thru 03/11/23, accounting for the seven pills received. The next delivery of the medication occurred on 03/13/23. There is no evidence the facility had ordered the medication refill timely to ensure the medication was available for immediate use on 03/12/23. Observation of the emergency medication kit on 03/15/23 at 10:30 AM with the Assistant Director of Nursing (ADON) verified the facility had Restoril 15 mg and 30 mg (5 doses) as emergency supplies. There is no evidence the medication was removed on 03/12/23 for Resident #62. Review of the Medication Administration Record dated 03/2023 indicated the resident did not receive the Restoril and Melatonin on 03/12/23. The nurse documented the resident refused. In addition, the record indicated the resident did not receive the Melatonin on 03/08/23. Subsequent interview with Resident #62 on 03/15/23 at 12:42 PM revealed he did not refuse his sleeping pills and that the facility does not have his Melatonin either, and he has not received the Melatonin all last week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 16 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 - Few Observation of the medication cart (400 wing) with Staff E, Registered Nurse, revealed the nurse checked the cart and verified the cart did not have Melatonin, which is a stock item. Interview with Staff J, Licensed Practical Nurse, conducted on 03/15/23 at 3:20 PM confirmed Resident #62 did not receive the prescribed Restoril on one occasion, it was not here, so he did not get it. Staff J confirmed the resident also missed his Melatonin, they did not have it. It was for a couple of days, the staff is not sure how many doses were missed. Interview with the Central Supply staff on 03/16/23 at 10:10 AM revealed the nurses let her know what stock medications are needed and stated an order of Melatonin arrived yesterday. There was no evidence the facility staff followed their procedures to ensure medications are readily available for administration. 2. Facility policy, titled, Inventory Control of Controlled Substances, dated 12/01/07, documented: PROCEDURE 1. With respect to Schedule Il controlled substances: 1. 1 The Facility should maintain separate individual controlled substance records on all Schedule Il drugs in the form of a declining inventory. (See Appendix 11, Controlled Substance Declining Inventory Sheet) 1.1.1.1 Resident name 1.1.1.2 Prescriber name 1.1.1.3 Prescription number 1.1.1.4 Drug name strength, dosage form, dosage 1.1.1.5 Total quantity received by the Facility 1.1.1.6 Date and time of administration 1.1.1.7 Signature of person administering the drug 1.1.2 Facility staff should not enter more than one (1) prescription for a Schedule Il drug on each page of a declining inventory. 1.2 The Facility should ensure that the incoming and outgoing nurses count all Schedule Il controlled substances at least once daily or at the change of each shift, and document the results on a Controlled Drug Count Verification, or Shift Count Sheet (for Narcotics). [See Appendix 12 Facility Verification Shift Count Sheet]. 2. With respect to Schedule Ill - V controlled substances, the Facility should ensure that Facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 17 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 staff count all Schedule Ill-V controlled substances in accordance with Facility policy and Applicable Law. Level of Harm - Minimal harm or potential for actual harm 3. The Facility should ensure that its staff IMMEDIATELY reports suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up. Residents Affected - Few 3.1.1 Upon receipt of such a report, the Facility should ensure that the appropriate Facility personnel confirm the discrepancy and follow Facility policy and Applicable Law regarding documentation of the incident. 3.1.2 The Facility should also conduct an investigation to determine: 3.1.2.1 Whether a dose was in fact administered and, if so, the reason the administration was not charted; and 3.1.2.2 Whether a dose was refused. 4. A Facility representative should regularly check the inventory records to reconcile inventory. 4.1 The Facility should reconcile current and discontinued inventory of controlled substances to the log used in the Facility's controlled drug inventory system (See Section 5.1). 4.2 The Facility should reconcile the current inventory to the controlled drug declining inventory record and to the resident's Medication Administration Record. 4.3 The Facility should regularly reconcile unused controlled substances held in -storage awaiting destruction with the-declining inventory record. a. Record review conducted on 03/14/23 revealed Resident #2 was prescribed Ativan 1 milligram (mg) every eight hours as needed on 11/04/22. Controlled Medication Utilization Record dated 03/03/23 through 03/14/23 indicated the nursing staff removed the Ativan 1 mg on 03/05/23 at 10 PM; 03/07/23 at 9 AM; 03/09/23 at 5 PM; 03/10/23 at 1:05 PM and 03/13/23 at 7 PM. The corresponding medication administration record (MAR) failed to provide evidence the resident received the doses identified above. c. Record review conducted on 03/14/23 revealed Resident #71 was prescribed Tramadol 50 mg every six hours as needed on 03/04/23. Controlled Medication Utilization Record dated 03/05/23 through 03/10/23 indicated the nursing staff removed the Tramadol 50 mg on 03/06/23 at 2 PM and on 03/07/23 at 2 PM from the inventory. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 18 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 The corresponding MAR failed to provide evidence the resident received the doses identified above. Level of Harm - Minimal harm or potential for actual harm d. Record review conducted on 03/14/23 revealed Resident #68 was prescribed Xanax 0.5 mg every eight hours as needed on 02/03/23. Residents Affected - Few Controlled Medication Utilization Record dated 02/17/23 through 03/12/23 indicated the nursing staff removed the Xanax 0.5 mg on 03/03/23 at 8:45 AM; 03/06/23 at 10 PM ; 03/07/23 at 11 PM; 03/08/23 at 11:21 PM and 03/10/23 at 9:48 PM and 03/11/23 at 9:16 PM. The corresponding MAR failed to provide evidence the resident received the doses identified above. Interview with the Assistant Director of Nursing (ADON) conducted on 03/14/23 at 12:30 PM revealed the ADON reviewed the records for Residents #2, #71 and #68, and acknowledged the discrepancies between the controlled medication utilization record and the residents' MARs. The ADON was not able to explain the discrepancies and how the staff is monitored to prevent controlled substances diversion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 19 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the consultant pharmacist failed to identify irregularities for the use of 'as needed' anxiolytic medication for 1 of 7 sampled residents reviewed for unnecessary medications (Resident #3). The findings included: Facility policy, titled, Administering Medications, last revised April 2019, documented Administering Medications: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 28. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. Clinical record review conducted on 03/13/23 revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease. Physician's order dated 01/12/23 documented Lorazepam 0.5 mg every six hours as needed for Anxiety. The order does not have an end date. Minimum Data Set annual assessment with reference date of 12/20/22 documented the resident was assessed as independent with skills of daily decision making; displayed rejection of care and was receiving antidepressant medications. Care Plan dated 02/20/23 documented the resident uses antianxiety medications for anxiety disorder. The interventions included administer antianxiety medications as ordered by physician, monitor side effects, educate resident on risk and benefits, monitor for safety, monitor adverse reactions, monitor of target behavior and document. Review of the pharmacy recommendations: reports dated 01/20/23 and 02/26/23 indicated the consultant pharmacist reviewed the resident's drug regimen and identified no irregularities. Interview with Director of Nursing (DON) on 03/15/23 at 2:08 PM confirmed the physician's order for Ativan did not have a stop date, it is active and is past the recommended 14 days. The DON confirmed the resident has not taken doses and that there is no documentation to validate the extended time frame for use. Interview with the Consultant Pharmacist conducted by phone on 03/16/23 at 9:02 AM revealed all residents are discussed monthly during the Psych review and stated the fact the resident had not taken the medication, would be discussed at the next meeting (March). His practice is to recommend the discontinuation of any as needed medication that has not been taken in sixty days. The Consultant was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 20 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0756 not able to explain why the anxiolytic medication prescribed longer than 14 days with no rationale for the extended use was not identified as an irregularity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 21 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure medication regimen was free of unnecessary medications of 1 of 7 sampled residents (Resident #46), as evidenced by failure to monitor and follow parameters for insulin administration. Residents Affected - Few The findings included: Facility policy, titled, Administering Medications, last revised April 2019, documented: Administering Medications Medications are administered in a safe and timely manner. and as prescribed. Policy Interpretation and Implementation 1. only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. Clinical record review conducted on 03/13/23 revealed Resident #46 was admitted to the facility on [DATE]. Physician's orders dated 09/13/22 documented: Insulin Aspart Subcutaneous Suspension 70/30, inject 25 units subcutaneously in the evening for Diabetes. Hold for blood glucose less than 250. Medication Administration Record dated 02/01/23 through 03/14/23 revealed the nursing staff administer the long acting insulin with blood sugar readings below 250, despite the parameters specified in the physician's order, as follows: 02/04/23, insulin given with blood sugar reading of 191 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 22 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0757 02/06/23, insulin given with blood sugar reading of 152 Level of Harm - Minimal harm or potential for actual harm 02/07/23, insulin given with blood sugar reading of 246 02/10/23, insulin given with blood sugar reading of 151 Residents Affected - Few 02/11/23, insulin given with blood sugar reading of 189 02/14/23, insulin given with blood sugar reading of 190 02/15/23, insulin given with blood sugar reading of 191 02/17/23, insulin given with blood sugar reading of 141 02/18/23, insulin given with blood sugar reading of 200 02/20/23, insulin given with blood sugar reading of 238 02/23/23, insulin given with blood sugar reading of 168 02/26/23, insulin given with blood sugar reading of 194 02/28/23, insulin given with blood sugar reading of 209 03/01/23, insulin given with blood sugar reading of 244 03/02/23, insulin given with blood sugar reading of 228 03/03/23, insulin given with blood sugar reading of 214 03/05/23, insulin given with blood sugar reading of 136 03/07/23, insulin given with blood sugar reading of 221 03/08/23, insulin given with blood sugar reading of 200 03/11/23, insulin given with blood sugar reading of 181 03/12/23, insulin given with blood sugar reading of 145. Interview with Director of Nursing conducted on 03/15/23 at 2:13 PM revealed after reviewing the administration records, the staff did not follow the physician's orders, and confirmed the insulin should have not been given and the order will be clarified with the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 23 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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, policy review and interview, the facility failed to ensure residents receiving PRN (as needed) orders for psychotropic drugs were limited to 14 days unless there was documented rationale in the resident's medical record to indicate the reason for the extended duration, for 3 of 7 sampled residents (Resident #2, #3, #22); and facility staff failed to implement behavior monitoring for Resident #2, who is receiving anti-anxiety medications, including the identification of the target behavior and the provision of non-pharmacological interventions prior to medication use. The findings included: 1. Clinical record review conducted on 03/14/23 revealed Resident #2 was re-admitted to the facility on [DATE] with multiple medical conditions. Minimum Data Set, assessment with reference date 12/11/22 documented the resident was assessed as independent for skills of daily decision making; required extensive assistance with activity of daily living and received antiquity and opioid medications. Care Plan dated 01/28/23 documented Resident #2 was experiencing recent loss of son and Anti-anxiety medication use to reduce anxiety. The interventions included administer medications as ordered, monitor side effects and document and report adverse reactions. Educate the resident about risks and benefits and of toxic symptoms of antianxiety medication given. Physician's order dated 11/14/22 documented Ativan 1 milligram (mg) every 8 hours as needed for anxiety. Psychology consult dated 01/10/23 documented Patient has chronically refused need of psychiatry medications and he continues on his Ativan 1 mg every 8 hrs (hours) as needed per his request. Further review of the record failed to provide evidence of behavior monitoring. There was no evidence of the use of non-pharmacological interventions to aid with anxiety, and there was no documentation of monitoring of side effects and attempts of gradual dose reduction since November 2022. The record failed to provide the rationale for the extended use of the Ativan as needed, since November 2022. The Medication Administration Record (MAR) indicated Resident #2 received Ativan, 28 doses from 03/01/23 thru 03/14/23; and received 65 doses from 02/01/23 thru 02/28/23. Pharmacy Recommendations dated 11/26/22, documented: PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam 1 mg give one tablet every 8 hours as needed. take 1 tablet by mouth every eight hours as needed for anxiety. Recommendations: Please discontinued PRN Lorazepam, tapering as necessary. If the medication cannot be discontinued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 24 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Rationale for recommendation: CMS [Center for Medicare and Medicaid Services] requires that PRN orders for non antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rational for the extended time period and the duration for the PRN order. The physician accepted the recommendation on 01/12/23, the medication was not discontinued, and the prescriber did not document the rationale for the extended use. Interview conducted with the Director of Nursing (DON) on 03/15/23 at 2:00 PM explained the facility documents behavior monitoring on the MAR and confirmed there is no behavior monitoring documentation for Resident #2. In addition, the DON confirmed the pharmacy recommendation was not implemented and stated last night she reached out to the physician to change the medication from PRN to a routine schedule as the resident is taking multiple doses per day. 2. Facility policy, titled, Psychopharmacological Medication Use, dated 12/01/07 documented: POLICY This Section 3.8 sets forth procedures relating to psychopharmacological medication use. PROCEDURE 1. The Facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the SOM, and all other Applicable Law relating to the use of psychopharmacologic drugs. 2. Where a physician/prescriber orders a psychopharmacologic drug for a resident, the Facility should ensure that the physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic drug is necessary to treat one of the specific conditions listed in the SOM. If a physician/prescriber orders a psychopharmacological drug in the absence of a diagnosis of specific behavior listed in the SOM , the Facility should ensure that the ordering physician/prescriber review the medication plan and consider a gradual dose reduction (GDR) of psychopharmacological medications for the purpose of finding the lowest effective dose or of discontinuing the drug unless a GDR is contraindicated 2.1 The physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. 3. Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychopharmacological drugs for organic mental syndrome with agitated or psychotic behavior(s). Clinical record review conducted on 03/13/23 revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 25 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 Physician's order dated 01/12/23 documented Lorazepam 0.5 milligrams every six hours as needed for Anxiety. Medication administration records (MARs) indicated the resident has not received the medication since the prescription date. Residents Affected - Few Minimum Data Set annual assessment with reference date of 12/20/22 documented the resident was assessed as independent with skills of daily decision making; displayed rejection of care and was receiving antidepressant medications. Care Plan dated 02/20/23 documented the resident uses anti anxiety medications for anxiety disorder. The interventions included administer anti anxiety medications as ordered by physician, monitor side effects, educate resident on risk and benefits, monitor for safety, monitor adverse reactions, monitor of target behavior and document. Interview with Director of Nursing on 03/15/23 at 2:08 PM confirmed the physician's order for Ativan did not have a stop date, it is active, and is past the recommended 14 days. The DON confirmed the resident has not taken doses and verified there is no documented rationale to validate the extended time frame for use. 3. Record review for Resident #22 documented the resident was admitted to the facility on [DATE] with diagnoses that included Generalized Anxiety, Chronic Obstructive Pulmonary Disease, Atrial-Fibrillation, Type I Diabetes, Hypertension, Muscle Weakness, Bipolar II Disorder. She has a Care Plan for anti-anxiety medications related to adjustment issues, and anxiety disorder. The interventions included administering anti-anxiety medications as ordered by a physician. Review of the physician's orders included Alprazolam Intensol oral concentrate 1 mg/ml 1 ml PO (oral) start date 02/23/23 and end date indefinite. Review of the Pharmacy reviews for the past 6 months did not show documentation of concern of an indefinite 'prn' order of the Alprazolam. It only documented it was reviewed during the facility's behavior management committee meeting. Review of the physician note on 02/06/23 documented an order of Xanax to be changed to 1mg every 8 hours as needed. On 02/23/23, a physician note documented the resident has a tendency to pocket pills and take them later. The physician changed Alprazolam order to a liquid form. Reviewed physician notes for 02/06/23, 02/15/23, 02/18/23, 02/23/23 and 02/27/23 revealed the physician would document a 14 day PRN order but then the next order would document indefinite. This was noted on several orders. There is no documentation for a rationale in the resident's record indicating extending the PRN order past the 14 days. During an interview on 03/16/23 at 10:50 AM with the Director of Nursing (DON), she stated she is familiar with anxiety meds having to be ordered only for 14 days. The DON was asked to pull up the resident's order for Xanax. She acknowledged that they show end date as indefinite for order. She stated that the physician is the one who wrote the orders for Xanax. The pharmacist should have caught the mistake. The DON called the physician but there was no answer on 03/16/23 at 11:05 AM. She was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 26 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 FORM CMS-2567 (02/99) Previous Versions Obsolete asked if she could print the previous discontinued orders of the Alprazolam (Xanax); and she said she couldn't figure out how to do that. She stated that each order going back to May of 2022 shows indefinite for orders for the Xanax. During an interview on 03/16/23 at 11:10 AM with the Pharmacist, the Pharmacist stated: 'I am aware of not doing PRN Xanax for more than 14 days. It is discussed in a meeting part of resident's psych addressed in meeting. Does not have to be 14 days if reviewed for a longer duration. I did comment on the PRN antianxiety greater than 14 days, it was addressed on 02/27/22 and 11/26/22. On 02/06/23, the order reads give every 8 hours as needed times14 days. It did fall in the review I had done prior in that month, since they changed that order. Original date was 02/06/23 but signed 02/08/23. Event ID: Facility ID: 105558 If continuation sheet Page 27 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interviews, the facility failed, in accordance with accepted professional standards and practices, to maintain medical records on 3 of 28 sampled residents that are complete and accurately documented (Residents #20, #53, and #64). The findings included: 1a. Upon review of the March 2023 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for Resident #20, it was noted that staff initials and charting codes were missing for the following medication administrations and treatments: a) 03/03/23 at 9:00 AM Enoxaparin Sodium Pre-Filled Injection Syringe 60 mg. b) 03/03/23 at 6:00 PM Lacosamide 100 mg for seizures Lasix 40 mg for Congestive Heart Failure Potassium Chloride Oral Solution 15 ml for Congestive Heart Failure. c) 03/04/23 at 5:00 AM Enteral Feeding (Isosource 1.5, 480 ml per day). d) 03/07/23 at 9:00 AM Bisacodyl EC Tablet Delayed Release 5 mg Oxygen Saturation not recorded Lisinopril 10 mg for Hypertension Enoxaparin Sodium Pre-Filled Injection Syringe 60 mg. Ivabradine HCI 5 mg for Congestive Heart Failure Senna-S 8.6-50 mg for Constipation. e) 03/07/23 in AM Lexapro 10 mg for Depression. f) 03/07/23 in PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 28 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 Pepcid 20 mg for GERD [Gastroesophageal Reflux Disease]. Level of Harm - Potential for minimal harm g) 03/08/23 at 9:00 PM Enoxaparin Sodium Pre-Filled Injection Syringe 60 mg. Residents Affected - Some Enteral Feeding (Isosource 1.5, 480 ml per day). 1b. On 03/02/23 and 03/07/23 at 12:00 Noon, and 03/03/23 at 6:00 PM, there was no documentation for the following: a) Ipratropium-Albuterol Inhalation Solution 0.5 - 2.5 (3) MG/3 ML 3 ml; b) Number of minutes of Nebulizer Administration; c) Resident tolerance of Nebulizer treatment; d) Checking lung sounds post Nebulizer Administration e) Recording sputum color f) Recording sputum Production. 1c. On 03/07/23, 03/11/23 and 03/12/23 in PM, the Blood Pressure and Pulse were not recorded on eMAR at time of providing Metoprolol Tartrate 100 mg for Hypertension to document if medication was given according to parameters (hold for Systolic <110 and Diastolic Blood Pressure <60, Heart Rate below 60). 1d. On 03/01/23, 03/05/23, and 03/07/23 during Day shift, and 03/08/23 during Evening shift, Vital signs were not recorded (Blood Pressure, Temp, Pulse, Respiration, O2 sats, Pain Level). 1e. On 03/01/23, 03/02/23, 03/05/23, and 03/07/23 Day shift, and 03/08/23 Evening shift, there was no documentation for the following: a) monitoring of behaviors, b) checking for elevated head of bed at 45 degrees, c) checking Tube Feeding placement, d) Enteral tube flush with 30 cc's of water after medications, e) checking for residual, f) Oxygen saturation, g) monitoring for medication side effects, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 29 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 h) non-medication intervention attempts. Level of Harm - Potential for minimal harm 1f. On 03/01/23, 03/02/23, 03/05/23, 03/07/23, and 03/12/23 Day shift, and 03/07/23 and 03/08/23 Evening shift, there was no documentation for the following: Residents Affected - Some a) checking for bleeding and bruising related to anticoagulant use; b) aspiration precautions per facility policy; c) elevate bed to 45 degrees; d) stoma Care; e) safety precautions per facility policy; f) call bell in reach; g) suctioning. 1g. On 03/02/23 and 03/07/23 at 12:00 Noon, and 03/08/23 at 6:00 PM, there was no documentation for the following: a) Lungs sounds pre nebulizer administration; b) Pulse and respiration rates pre and post nebulizer administration. On 03/13/23 at 10:20 AM during initial interview, Resident #20 stated she had no concerns with the care being provided. 2a. Upon review of the March 2023 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for Resident #53, it was noted that staff initials and charting codes were missing for the following medication administrations and treatments: 2a. On 03/06/23 at 9:00 AM and 03/08/23 at 5:00 PM Prostat 30 ml twice daily (9:00 AM and 5:00 PM) 2b. On 03/04/23, 03/07/23, and 03/08/23 at 9:00 PM Clean mask daily at bedtime. On 03/13/23 at 10:22 AM, Resident #53 confirmed he received his medication daily. 3. Upon review of the March 2023 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for Resident #64, it was noted that staff initials and charting codes were missing for the following medication administrations and treatments: 3a. On 03/12/23 and 03/13/23 at 6:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 30 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 Victoza Subcutaneous Solution Pen-Injector 18 mg/3 ml; inject 3 ml. Level of Harm - Potential for minimal harm 3b. On 03/09/23 and 03/12/23 at 6:30 AM Humalog Injection Solution per sliding scale; Residents Affected - Some Novolog Injection Solution 12 units before meals. 3c. On 03/01/23 and 03/10/23 Day shift, there was no documentation for the following: a) monitoring for behaviors; b) monitoring for pain; c) monitoring outcome of preventions; d) monitoring side effects of medications; e) non-medication interventions attempted. 3d. On 03/01/23, 03/02/23, and 03/05/23 Day shift, and 03/07/23 Evening shift, there was no documentation for the following: a) checking for bleeding and bruising related to anticoagulant use; b) applying barrier cream to bilateral under breasts; c) encourage and assist with turning and re-positioning. On 03/14/23 at 9:20 AM, Resident #64 stated meds are often late, but none of her medications have been missed. On 03/16/23 at 2:30 PM, the Director of Nursing acknowledged missing documentation on the eMAR, and she confirmed that nurses are to document for each administration and code the reason if any medication or treatment is not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 31 of 32 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 105558 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at West Palm Beach 5065 Wallis Road West Palm Beach, FL 33415 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 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on record review and interview, the facility failed to complete annual performance reviews for 3 of 3 sampled staff members (Certified Nursing Assistants / CNAs, Staff #G, #H and #I) Residents Affected - Few The findings included: Review of the personnel files provided on 03/16/23 revealed Staff #G, Certified Nursing Assistant (CNA), was hired on 04/01/22; Staff #H, CNA, was hired on 05/31/07 and Staff #I, CNA, was hired on 07/01/20. Review of the documentation provided revealed no evidence that Staff #G, #H and #I had evidence of completing the required continuing competency education of no less than 12 hours per year. Interview with the Assistant Director of Nursing (ADON) conducted on 03/16/23 at approximately 1:00 PM revealed the facility completed abuse and dementia training for the staff. The ADON explained some of the education is completed in classroom setting and some through Relias academy. The ADON was not able to provide evidence of the completion of the required competencies and education for the staff identified above to meet the 12 hour credit requirement or to explain the system to track the staff for compliance with the education requirements. Subsequent interview with the Human Resources Director on 03/16/23 at approximately 2:49 PM revealed nursing is responsible for the completion of the required education and competencies. Interview with the adminstrator during the exit conefernce revealed the facility will provide evidence of the completed evaluation by the end of the day. The facility has not provided the required documents as of 03/20/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 32 of 32

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Citations

12 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0947GeneralS&S Dpotential for harm
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
0730GeneralS&S Bno actual harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0842GeneralS&S Bno actual harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the March 16, 2023 survey of AVIATA AT WEST PALM BEACH?

This was a inspection survey of AVIATA AT WEST PALM BEACH on March 16, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AVIATA AT WEST PALM BEACH on March 16, 2023?

Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·March 16, 2023