Health inspection·May 3, 2023

F 0678 immediately begin CPR. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if the resident responds. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility policy titled, Emergency Equipment Cart with an effective date of [DATE] included the Center will maintain an emergency equipment cart. Procedure: Residents Affected - Few 1. Center will establish an emergency equipment cart that is accessible to nursing stations. 2. Check the emergency cart daily. 3. Restock/replenish the emergency cart following use and as needed. The closed record review for Resident #1 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Diagnoses included: Crohn's Disease, Ileostomy, Malignant Neoplasm of Thyroid Gland, Type 1 Diabetes Mellitus, Hypertension, Phlebitis and Thrombophlebitis of Deep Vessels of Lower Extremity, Malignant Neoplasm of Female Breast, Major Depressive Disorder, and Covid-19. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact. The MDS also revealed the resident required extensive assistance in ADLs (Activities of Daily Living) including bed mobility, transfers, dressing, and personal hygiene. Review of physician's orders for Resident #1 revealed an order dated [DATE] for a Full Code. Review of the care plan for Resident #1 with a revision date of [DATE], and a focus on Advanced Directives: Full Code, with the goal to have advance directives followed. Interventions included: Discuss advanced directives with resident and or resident's representative. Review of the Nursing Progress notes for Resident #1 dated [DATE] included: 12:06 PM patient blood pressure 135/78, pulse 64, temperature 97.0, O2 sat (Oxygen Saturation) 98% room air, blood sugar 141, family member at bedside, patient alert and responsive, no distress noted. 12:10 PM patient family member left the facility. 12:24 PM patient noted to be unresponsive without any pulse. Code Blue called, status verified by two nurses at 12:24 PM CPR initiated and 911 call placed. 911 arrived to facility to take over resident care. 12:25 PM doctor notified. 12:43 PM 911 pronounced the passing of patient. 1:00 PM family member notified. Review of the facility investigation revealed a Code Blue Documentation Nurses Note dated [DATE] revealed: Witnessed- yes. Time Code Blue was called - 12:35 PM. Time CPR started 12:35 PM. Type of Ventilation (blank). Vital Signs 12:35 (PM) BP (Blood Pressure) 0, Pulse 0, Respirations 0, O2 Sat 0, Bedside glucose 121 drawn at 12:24 PM. Resuscitation terminated 12:43 PM. During an interview conducted on [DATE] at 12:20 PM with the Assistant Director of Nursing (ADON), she stated she was assigned to Resident #1 on [DATE]. She stated there was a family member in the resident's room earlier that day. On [DATE] at 12:24 PM she found the resident unresponsive in their room, checked for a carotid pulse, checked for responsiveness, unsure if she checked for an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 2 of 5 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 05/03/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few obstruction in the resident's mouth at this time, and did not see a rise/fall of chest, code blue called. She stated the chart was verified with 2 other nurses that the resident was a full code. Immediately she started chest compressions. The Director of Rehab (DOR), the Unit Manager (UM), and the DON were present. She stated that the Code Blue Documentation Nurses Note was completed by her after the paramedics came in and took over the care of the resident. During the code blue while CPR was performed by the ADON, another staff member in the room was taking notes. When asked if she still had the notes she said no. When asked who was the person taking notes she said she did not remember. When questioned about the code blue documentation nurses note, she stated she had put the incorrect time the code was called, and the CPR was started as 12:35 PM. It should have been 12:24 PM. At 12:35 PM the Executive Director notified the physician. The family was notified at 12:35 PM, and at 1:00 PM they were notified the resident passed. She stated that there was no Ambu-bag located on the crash cart. When asked where back up supplies for the crash cart are kept, she stated in the central supply/clean utility room. When asked if the resident had a non-rebreather mask placed on her during the code blue, she stated she believes it was the unit manager who instructed staff to place a non-rebreather mask with 15 liters of oxygen on the resident. All staff members present in the room were taking turns to do the chest compressions. She stated the paramedics arrived (unsure of the time) and at 12:43 PM the paramedics pronounced the resident deceased . When asked if she was following the CPR standard of practice for healthcare professionals, she said yes, she believed she was except the resident did not receive the 2 breaths because they did not have the Ambu bag available. During an interview conducted on [DATE] at 1:05 PM with the Unit Manager (UM), she stated there was no Ambu bag available, chest compressions were being performed, she checked the resident's airway to make sure there was no obstruction, and a non-rebreather mask was placed on the resident with oxygen at 15 liters. Within approximately 3-5 minutes the resident vomited, the non-rebreather was removed and a nasal canula was applied and the resident and her head was turned to the side, at the time the resident's head was turned to the side by the DOR, the UM had checked the resident's airway and there was no visible obstruction, she did not perform a finger sweep of the resident's mouth as she was continuously providing chest compressions. The paramedics arrived approximately 2-3 minutes later and the paramedics instructed the staff to stop CPR and they applied the AED pads and there was no indication to shock the resident. The paramedics were aware the resident was a full code and did not perform any chest compressions or rescue breathing. When asked if she had followed the standard of practice for CPR for healthcare professionals, she stated yes. When asked if that included rescue breathing, she stated no because we had no Ambu bag, but we did apply oxygen to the resident. During an interview conducted on [DATE] at 1:20 PM with the Director of Nursing (DON), she stated she arrived at the resident's room just after the code blue was called. She and the ADON were looking for the Ambu bag on the crash cart and there was no Ambu bag found on the crash cart. She left the room to look for an Ambu bag in the back up supply room (Clean Utility Room) near the nursing station and no Ambu bag was found. She then looked in the main central supply room and there was no Ambu bag there. The Central Supply Clerk helped her locate an Ambu bag in the back up supply room (Clean Utility Room). She had brought the Ambu bag to the resident's room as the paramedics had arrived at the resident's room. When asked if the staff had followed the standard of practice for CPR for healthcare professionals, she stated yes except for the 2 breaths with an Ambu bag, because there was no Ambu bag available. When asked about the root cause analysis, she stated she identified that the cause was the Ambu bag not present on the crash cart and the backup supply of an Ambu bag was not easily accessible in the back up supply room (Clean Utility Room). She stated there are checks of the crash cart by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 3 of 5 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 05/03/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the UM or the ADON daily and this is signed off on the flow sheet (the flow sheet is located on the crash cart). There is only 1 crash cart for the facility. It is the responsibility of the unit manager/ADON to restock a crash cart after a code. During a telephone interview conducted on [DATE] at 5:30 PM with the Director of Rehabilitation, he stated he was involved in the code for Resident #1. He stated he took over chest compressions briefly when the ADON became fatigued. He left when the UM took over doing chest compression. He stated no rescue breaths were given while he was in the room. He did not see an Ambu bag. Normally the Ambu bag would be used during CPR in a healthcare setting. When asked if he noticed the resident vomiting, he said there may have been some drool coming from the resident's mouth. When asked if the standard of practice for CPR for healthcare professionals was followed, he said yes. When asked if any rescue breathing was provided to the resident during CPR he stated no, the resident had on a non-rebreather mask. An interview and a review of the Emergency Equipment Cart Checklist, was conducted on [DATE] at 11:30 AM with the Unit Manger. When asked about the Emergency Equipment Cart Checklist for the dates of [DATE] and [DATE], she stated that either she or the ADON verifies the Emergency Equipment Cart Checklist is completed (whoever arrives at the facility first). She stated she completed the Emergency Equipment Cart Checklist on [DATE] in the morning. When asked why there were no initials for the Ambu bag on [DATE], she stated I just forgot to initial for the Ambu bag. When asked why there was a check mark instead of her initials for the Ambu bag on [DATE], she stated the Emergency Equipment Cart Checklist was completed by her on [DATE] in the afternoon, after the code blue had been finished, and that she had placed a Ambu bag on the cart. Review of the Fire Rescue report, dated [DATE], revealed the following information: Dispatched at 12:34:54; at Patient at 12:41:00. Primary Impression: Dead on scene, exam/eval only Narrative: Responded to a cardiac arrest . On arrival made contact with nursing staff who were performing CPR. Nursing staff could not give a time frame on last seen responsive, but stated it was greater than 30 minutes. Assessed patient, patient was pulseless, apneic, with fixed and dilated pupils. Placed pads and leads on patient, asystole was confirmed. Patient was pronounced dead on scene. **The Immediate Jeopardy Removal Plan was submitted by the facility and implementation was verified by the survey team on [DATE]. The actions included: An Ad Hoc QAPI (Quality Assurance Performance Improvement) Committee meeting was held with the Medical Director in attendance on [DATE] and [DATE]. Root Cause Analysis was performed with addendum on [DATE] which identified the problem as CPR conducted with missing ambu bag on [DATE], and the root cause was identified as a system failure on checking/restocking the emergency cart. The Performance Plan was implemented that included: -An audit of the facility licensed nurses' CPR certification were reviewed and current as of [DATE]. On [DATE], review of 24 of 24 facility licensed nurses revealed all nurses had a current Basic Life (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 4 of 5 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 05/03/2023 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 0678 Support (BLS). Level of Harm - Immediate jeopardy to resident health or safety -Licensed nurse education to include CPR Policy/Procedure, emergency cart policy and Abuse/Neglect/Exploitation/Misappropriation beginning [DATE]. Residents Affected - Few -Newly hired licensed nurses will receive education upon hire to include CPR Policy/Procedure, abuse/neglect, emergency cart policy. -Mock Code Blue drills initiated on [DATE], with licensed nurses. -Code blue drills will continue with licensed nurses bi-weekly on each shift for 2 months or until QAPI committee determines substantial compliance has been achieved. On [DATE], review of 24 of 24 licensed nurses' education revealed the following: On [DATE] education on Abuse/Neglect/Exploitation/Misappropriation was provided to 85 employees. On [DATE], [DATE] and [DATE], education on location of back up supplies for the crash cart, mock code blue drill, performing effective CPR was provided to 18 out of 24 nurses in person and 6 nurses via telephone. On [DATE] education on location of back up supplies for the crash cart, mock code blue drill, performing effective CPR was provided to nurses that had already received the training on [DATE] or [DATE]. On [DATE], interviews were conducted with 9 of the 24 licensed nurses, including one new hire, who all stated they received education on back up supplies for the crash cart, performing effective CPR, and had attended a mock code blue drill. Review of the schedule for the biweekly mock code blue drills revealed the following: [DATE] night shift, [DATE] day shift, [DATE] day shift, [DATE] night shift, [DATE] day shift, [DATE] night shift, [DATE] night shift, [DATE] day shift, [DATE] day shift, and [DATE] night shift. -The DON/ADON/Designee is to validate the Emergency Cart checklist is completed daily until substantial compliance is met. On [DATE], review of the Emergency Cart checklist from [DATE] to [DATE] revealed each item was initialed for each day. -In addition to the plan implemented on [DATE], during the [DATE] QAPI meeting, the following was added to the plan: The Emergency Equipment Cart was secured on [DATE], and the policy was updated on [DATE]. On [DATE], an observation was made of the Emergency Equipment Cart, and it was secured and contained two Ambu bags (Photographic evidence obtained). The updated policy was reviewed, and it included that the Cart 200 nurse for the 7PM to 7AM shift is designated as Charge Nurse. Duties include checking Emergency Crash Cart to ensure accurate placement and functionality/content of equipment. The Cart 200 nurse will document on the Emergency Cart checklist the findings of the inventory. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105558 If continuation sheet Page 5 of 5