Health inspection·December 2, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Minimum Data Set (MDS) assessment done 10/11/2022 documented this resident was cognitively intact and independent for activities of daily living and ambulating. h) On 11/28/2022 at 1:00 PM, the South Activities' room toilet was noted to have a blanket surrounding it on the floor with fluid on the floor tile. A staff member sitting at the nurse's station was notified by the surveyor. She stated that the toilet was leaking, and they knew about it. i) On 11/29/2022 at 9:02 AM, the resident in room [ROOM NUMBER] stated his toilet has been broken for 5 days. He said maintenance came to fix it, turned the water off and never came back. He stated he has to go next door to use the restroom. The surveyor observed that the toilet did not work, was half full of dark yellow fluid with what appeared to be crystals floating on top. The administrator was notified. Record review of the Minimum Data Set (MDS) assessment done 08/17/2022 documented this resident as cognitively intact and independent for activities of daily living and ambulating. j) On 11/29/2022 at 10:32 AM, the following observations were made in room [ROOM NUMBER]A: The plaster and paint was missing from the ceiling with staining that appears like a leak in the corner above the door; the cover was missing off the cable outlet; the wall next to the bed was damaged without paint; the over-the-bed table was delaminated on the top and rough; outside the door the paint / wallpaper was peeled away from the wall in sheets; and the ceiling tile in the hallway outside the door was stained with what appears to be a leak. Record review of the Minimum Data Set (MDS) assessment done 10/04/2022 documented this resident with moderate cognitive impairment requiring extensive assistance for activities of daily living and mobility. k) On 11/29/2022 at 10:40 AM, the South Activities room toilet was again noted to have a blanket surrounding it on the floor with fluid on the floor tile. The Regional Consultant nurse was notified. l) On 11/30/2022 at 2:00 PM, a resident in room [ROOM NUMBER] approached the surveyor and stated that her toilet had been leaking for 2-3 days and that she uses towels to contain the water. She stated that she was afraid someone would fall and that she reported it a couple of times. She said she ran out of towels and was using paper towels on the floor. The surveyor noted paper towels along the north side of the toilet with a dark stained and partially missing toilet seal along the floor. The Regional Nurse Consultant was notified. Record review of the Minimum Data Set (MDS) assessment done 08/28/2022 documented this resident with moderate cognitive impairment requiring limited assistance for all activities of daily living and mobility. On 12/02/2022 at 12:12 PM, the above findings and photographic evidence were reviewed with the Maintenance Director and walking rounds were completed with the maintenance director who validated the findings. 2. Review of the facility policy, dated 11/30/2014, titled, Laundry Services, documented in part: All processed personal clothing will be returned to the resident in a timely manner. Any lost or destroyed personal clothing will be reviewed by the Executive Director and addressed on a resident concern form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 2 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 - Some Facility policy, dated 11/30/2014, titled, Personal Property-loss or theft documented: An employee receiving a concern regarding lost or missing items from a resident or resident representative will initiate a Complaint/Grievance form or electronic equivalent. Record review of Resident #30 documented and admission date of 08/04/20 with diagnoses that included Parkinson's, Diabetes, Heart Disease and Dementia. A resident Minimum Data Set assessment dated [DATE] documented Resident #30 as severely cognitively impaired requiring extensive assistance to total care for all activities of daily living and documented the resident is not self-mobile requiring extensive assistance for transfer and locomotion in a wheelchair. On 11/28/22 at 11:32 AM, Resident #30's husband stated they keep losing her clothes and had filed a grievance verbally again last week. He said he does not understand why it is an ongoing battle. He placed a laundry basket in her room with signs posted not to take laundry because he washes her clothes. He stated he filed a grievance a while ago, but nothing changed. On 11/28/22 at 11:36 AM, an observation of Resident #30's room revealed a laundry basket labeled with the resident's name and a sign posted stating the family with do the resident's clothes laundry and the basket was for her clothes only. Photographic evidence obtained. On 12/01/22 at 11:02 AM, Resident #30's husband stated he spoke to several people about the missing clothes over three weeks ago. Three pairs of pants and two tops were missing. One of the tops was a Red Sox top that is special to his wife. On 11/30/22, the Grievance logs were reviewed for the months of June 2022 through November 2022 with no documentation of grievances for Resident #30's lost clothes. On 12/01/22 at 11:06 AM, Staff C (Licensed Practical Nurse / LPN) stated she was aware Resident #30 had lost clothes a few times. When it happens, she talks to the Certified Nurse's Assistant (CNA) and the laundry department. She was unaware if Resident #30 was currently missing clothes, but they usually find them in the laundry. On 12/01/22 at 11:37 AM, Staff J, Laundry Worker, stated that if a resident loses clothes, they will bring them to the laundry to try to find them. She stated she was aware that they were looking for a special shirt for Resident #30. She said Resident #30's husband had been there looking for missing clothes in the past but not recently and Social Service keeps track of people that are missing items. On 12/01/22 at 11:54 AM, the Social Service Director stated that they have a policy that they do not replace items lost. If items are missing, the staff tells her verbally and she will initiate a grievance. She stated they had a care plan meeting for Resident #30 today and the resident's husband complained about the missing clothes, and she was going to do a grievance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 3 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the Quarterly MDS (Minimum Data Set) dated 09/08/22 showed Resident #6 required total assistance with bathing. During Resident Council interview, Resident #6, who is also the [NAME] President of the Resident Council stated, It has been months since I have had a shower. The Resident Council President confirmed Resident #6's statement as being true, and that he and Resident #6 have complained to staff about not getting his showers. Resident #6 has a BIMS of 15, noting no cognitive impairment or memory deficit. Upon review of the Resident #6's shower task sheet for November 2022, it was documented that he is supposed to get his showers on Monday, Wednesdays and Fridays by staff working the 11:00 PM - 7:00 AM shift. The task sheet documented that Resident #6 had 10 showers in November (11/07/22 at 5:13 AM, 11/10/22 at 5:27 AM, 11/11/22 at 4:46 AM, 11/14/22 at 5:00 AM, 11/21/22 at 5:31 AM, 11/25/22 at 5:00 AM and 8:21 PM, 11/28/22 at 5:08 AM, and 12/01/22 at 3:55 AM). On 12/02/22 at 9:51 AM, Resident #6 confirmed, I still have had no showers. My roommate (Resident Council President) has complained about it. It makes him upset, too, because I don't get them. I have only had bed baths, no showers. When the resident was asked about the documentation regarding his showers, the resident adamantly denied that any showers had been given. What is written down is not true! I did not have those showers. Based on policy review, interview and record review, the facility failed to respond to grievances in a timely manner for 8 of 24 sampled residents, for Residents #6, #36, #30, #73, #67, #8, #26, and #47. The findings included: Review of the facility policy, titled, complaint/grievance, revision date 10/24/22, indicated the center will support each resident's right to voice a complaint /grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Grievances discovered to meet the definition of abuse, neglect, exploitation, or misappropriation will be handled per the facility's abuse policy. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. The Procedure revealed an employee receiving a complaint / grievance from a resident, family member and/or visitor will initiate a complaint/grievance form. Complaint/grievance forms will be available 24 hours per day 7 days a week in an unsecured common area. Original grievance forms are then submitted to the grievance officer/designee for further action. The grievance officer/designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. The findings of the grievance shall be recorded on the complaint/grievance form. 1. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE]. The quarterly minimum data set (MDS), assessment reference date 09/08/22, recorded a brief interview for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 4 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mental status score (BIMS) score of 15, indicating Resident #6 was cognitively intact. This MDS documented no behavior issue for Resident #6. The quarterly MDS documented Resident #6 had pertinent diagnosis of Depression. Review of the social service progress note, dated 09/08/22, revealed met with Resident (#6) for quarterly interview. The resident continued to be alert with independence in decision making, he scored 15 in his BIMS. On 11/28/22 at 10:34 AM, an interview was conducted with Resident #6, who stated another resident (Resident #5) had used a derogatory word directed at his sexual orientation in which Resident #6 felt verbally abused by. Resident #6 continued to add that Resident #5, had also verbally abused the staff. He further added Resident #5 had caused him to lose his favorite Certified Nursing Assistant (CNA) due to verbal abuse, and the CNA had resigned. Resident #6, further stated a CNA, Staff L, came into his room to provide care, she walked in the room with her cell phone hooked to her neck, talking on the phone, Staff L provided the entire care, in which the whole time she was on the phone. Resident #6 voiced, Staff L was unprofessional, and totally disrespectful towards him. Resident #6 stated Staff L had long nails, was dressed inappropriately, the way she dresses exposed her skin, you can see her buttocks. He explained that Staff L had a childish attitude, as if she doesn't care about her job. Resident #6 revealed he had voiced all these concerns to the former Director Of Nursing (DON). On 11/30/22, review of the last 6 months grievance log, lacked documented evidence of Resident #6's concerns. On 11/30/22 at 10:45 AM, an interview was held with the Social Service Director (SSD), who revealed that on 10/13/22, she was out sick and when she returned to work on 10/18/22, the staff had informed her that Resident #5 had verbally abused Resident #6, regarding a derogatory statement Resident #5 had made towards Resident #6's sexual orientation. The SSD voiced, she was informed the concern was reported to the former DON, and the former DON did not initiate a grievance, report it, or investigate the concern. When the SSD spoke to the current DON about the concern, the current DON revealed it was too late to do anything about the concern as it happened a month ago. The SSD confirmed there was no grievance written about the concern. The SSD voiced she will initiate a grievance today (11/30/22) and start an investigation. 2. Review of Resident #36's record revealed he was re-admitted to the facility on [DATE] with diagnoses that included: High Blood Pressure, Respiratory Failure, Anxiety Disorder and Depression. The annual MDS assessment, reference date 10/30/22, recorded a BIMS score of 15, indicating Resident #36 was cognitively intact. This MDS documented no mood or behavior issue for Resident #36. On 11/28/22 at 10:35 AM, an interview was conducted with Resident #36, who voiced a CNA, Staff H, had used a derogatory word directed at his sexual orientation in which Resident #36 felt verbally abused, belittled, humiliated, and disregarded. Resident #36 explained, Resident #6 (his roommate) had been sitting in the chair for 2 and half hours and wanted to go to bed. Resident #6 had his call light on, when Staff H finally arrived in the room Resident #36 tried to advocate for Resident #6 and told Staff H, 'my roommate had the call light on for over 2 hours waiting to go to bed.' Subsequently, Staff H, used a derogatory word towards his sexual orientation, and stated you need to mind your business, you don't pay my salary. Resident #36 voiced that he had written and provided a letter to the former DON about the concern. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 5 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #36 showed the letter to the surveyor. The letter read: 10/18/22 to (DON), on Monday evening my roommate [Resident #6] and I went out for dinner, we returned to Woodlake at 7:30 pm, the CNA I know as Q [Staff H] came in and asked [Resident #6] if he was ready for bed, he had already taken off his shirt and was looking for his body wash, she said 'I'll be back'. She returned with a night gown and linens, put them on the bed and again said 'I'll be back'. By 8:30 PM, she had not come back, Resident #6 put on the call light to remind her [Staff H] that he was still waiting. He fell asleep with no shirt about to fall out of his wheelchair. [Staff H] returned at 9:45 PM she said again are you ready for bed? I said he's had the call light on for over an hour. Staff H said why are you so concern about [Resident #6]? Are you, his girlfriend?! I said he is my vice president, my roommate, and my friend! Staff H said mind your own business, you don't pay my salary! I said as a matter of fact, I do! She jerked the curtain closed and I said excuse me, I will get out of your way. And I left the room and went to the front desk and asked who was in charge, there were a few CNAs standing around the front desk and they said no one was in charge, try your nurse. Staff E was my nurse, and he came to the front and told me to calm down as I was struggling to breath and obviously had high blood pressure. When I told Staff E that Staff H had asked if I was (Resident #6's) girlfriend, one of the female CNAs laughed out loud! I said do you think that's funny? She did not respond. (Staff M) was at the desk, and I asked him, (Staff M) you know I'm not a troublemaker, I don't overreact. He said that's true. Staff E said talk to the DON tomorrow. I went back to my room; Staff H was gone, and Resident #6 was in bed. This is unacceptable and a shame on Woodlake. Thank you! Signed by Resident president. On 11/30/22, review of the last 6 months grievance log, lacked documented evidence of Resident #36's concerns. On 11/30/22 at 10:54 AM, during an interview was held with the SSD, who revealed on 10/13/22 she was out sick and when she returned to work on 10/18/22, she was informed of Resident #36's concerns. The SSD voiced she was informed the concern was reported to the former DON, and the former DON did not initiate a grievance, report it or investigate the concern. When the SSD spoke to the current DON about the concern, the current DON revealed it was too late to do anything about the concern as it happened a month ago. The SSD confirmed there was no grievance written about the concern. The SSD voiced she would initiate a grievance today (11/30/22) and start an investigation. 4. Record review of Resident #30 documented and admission date of 08/04/20 with diagnoses that included Parkinson's, Diabetes, Heart Disease and Dementia. The resident Minimum Data Set assessment, dated 08/29/22, documented Resident #30 as severely cognitively impaired requiring extensive assistance to total care for all activities of daily living and documented the resident is not self-mobile requiring extensive assistance for transfer and locomotion in a wheelchair. On 11/28/22 at 11:32 AM, Resident #30's husband stated they keep losing her clothes and he filed a grievance verbally again last week. He said he does not understand why it is an ongoing battle. He placed a laundry basket in her room with signs posted not to take the laundry because he washes her clothes. He stated he filed a grievance a while ago, but nothing changed. On 11/28/22 at 11:36 AM, an observation of Resident #30's room revealed a laundry basket labelled with the resident's name and a sign posted stating the family with do the residents clothes laundry and the basket is for her clothes only. Photographic Evidence Obtained. On 12/01/2022 at 11:02 AM, Resident #30's husband stated he spoke to several people about the missing clothes over three weeks ago. Three pairs of pants and two tops were missing. One of the tops was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 6 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0585 a Red Sox top that is special to his wife. Level of Harm - Minimal harm or potential for actual harm On 11/30/22, the Grievance logs were reviewed for the months of June 2022 through November 2022 with no documentation of grievances for Resident #30's lost clothes. Residents Affected - Some 5. Record review of Resident #73 documented an admission date of 10/04/22 with diagnoses that included End Stage Renal Disease, Stroke, Heart Disease and Hepatitis. A Minimum Data Set resident assessment dated [DATE], documented Resident #73 as cognitively intact requiring limited assistance, to independent for all activities of daily living. On 11/28/22 at 11:46 AM, Resident #73 stated his over bed light did not work. He said he reported it several times in the last two months. He said maintenance came in and stated yes it was broken, and never came back to repair it. The surveyor noted there was no cord to turn the light on, and when the switch was activated by the door, the light did not turn on. On 11/30/22, the Grievance logs were reviewed for the months of June 2022 through November 2022 with no documentation of a grievance for Resident #73's broken light. 6. Record review of the Minimum Data Set (MDS) assessment done 08/17/2022 documented Resident #67 as cognitively intact and independent for activities of daily living and ambulating. On 11/29/22 at 9:02 AM, Resident #67 stated his toilet has been broken for 5 days. He said maintenance came to fix it, turned the water off and never came back. He stated he must go next door to use the restroom. The surveyor observed that the toilet did not flush, was half full of dark yellow fluid with what appeared to be crystals floating on top. The administrator was notified. On 11/30/22, the Grievance logs were reviewed for the months of June 2022 through November 2022 with no documentation of a grievance for Resident #67's broken toilet. 7. Record review for Resident #8 documented an admission date of 05/11/2022 and readmission on [DATE] with diagnoses that included Diabetes, Hepatitis, Lung Disease and Cancer. A Minimum Data Set resident assessment done 10/05/2022 documented Resident #8 as cognitively intact requiring limited assistance to supervision only for all activities of daily living. On 11/28/22 at 10:26 AM, Resident #8 stated her glasses broke a week ago and she can't see without them. She stated when she told the staff, they handed her a roll of tape to fix them. She showed the surveyor a three-inch roll of silk tape and stated she tried to repair them herself but the tape does not hold. She stated she complained a few times but nothing happened. On 11/30/22. the Grievance logs were reviewed for the months of June 2022 through November 2022 with no documentation of a grievance for Resident #8's broken glasses. 8. Record review for Resident #26 documented an admission date of 08/05/2020 with diagnoses that include Heart Disease, Deep Vein Thrombosis and Seizures. A Minimum Data Set resident assessment done 11/10/2022 documented Resident #26 as cognitively intact requiring extensive assistance for bed mobility and transfers. On 11/28/22 at 12:50 PM, Resident #26 stated they are not giving him his showers. He is supposed to get a shower three times a week, but has not had a shower in a month. He said he has his own shower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 7 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in his room but can't get help to use it. He has complained many times recently and in the past about it, but it did not help. On 11/30/22 at 9:10 AM, Residents #26 stated he still has not had a shower. On 11/30/22 at approximately 2:00 PM during an interview with Resident #26 and Staff E (LPN), the resident restated that no one had given him a shower for the last month. Staff E pointed to the sign posted on the resident wardrobe cabinet that stated showers MWF Evening and said he made the sign to remind everyone. Staff E said he will make sure the resident gets a shower tonight. On 11/30/22, the Grievance logs were reviewed for the months of June 2022 through November 2022 with documentation of a grievance on 08/09/2022 for Resident #26 regarding showers that stated resolved. No further documentation of shower grievances for Resident #26 were listed. 9. Record review of Resident #47 documented an admission date of 05/18/20 with diagnoses that included Hypertension, Diabetes, and Dementia. A Minimum Data Set (MDS) assessment completed 08/28/22 documented Resident #47 with moderate cognitive impairment requiring limited assistance for all activities of daily living and mobility. On 11/30/22 at 2:00 PM, Resident #47 approached the surveyor and stated that her toilet had been leaking for 2-3 days and that she uses towels to contain the water. She stated that she was afraid someone would fall and that she reported it a couple of times. She said she ran out of towels and today was using paper towels on the floor. The surveyor noted paper towels along the north side of the toilet with a dark stained and partially missing toilet seal along the floor. On 11/30/22, the Grievance logs were reviewed for the months of June 2022 through November 2022 with no documentation of a grievance for Resident #47's broken toilet. On 12/01/22 at 11:27 AM, Staff K (Registered Nurse / RN) stated if a resident has a complaint, she notifies the staff first then the social worker. On 12/01/22 at 11:54 AM, the Social Service Director stated that if there is a complaint, the staff tells her verbally and she will initiate a grievance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 8 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interview and record review, the facility failed to conduct a thorough investigation in a timely manner relating to use of derogatory words directed at a resident's sexual orientation in which the resident felt verbally abused for 1 of 1 sampled resident, Resident #36. The findings included: The Policy, titled, abuse, neglect, exploitation and misappropriation, revision date 11/16/22, indicated it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employees may at any time commit an act of physical, psychological, or emotional abuse, neglect. Mistreatment, and/or misappropriation of property against any resident. The policy indicated definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The procedure indicated acts of abuse directed against residents are absolutely prohibited. The policy indicated the facility would conduct an investigation whereas the abuse coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation, and exploitation. A social service representative may be offered in the investigations will be accomplished in the following manner. A preliminary investigation would be conducted immediately upon an allegation of abuse or neglect, the suspect (s) shall be segregated from residents pending investigation of the resident allegation. The abuse coordinator and/or director of nursing shall take statements from the victim, the suspect (s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. The policy also indicated any employee or contracted services provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials in accordance with state law. Once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with federal and state regulations, including notification of law enforcement if a reasonable suspicious of crime has occurred. Review of Resident #36's record revealed the resident was re-admitted to the facility on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 9 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with diagnoses included: High Blood Pressure, Respiratory Failure, Anxiety Disorder and Depression. The annual MDS assessment, reference date 10/30/22, recorded a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #36 was cognitively intact. This MDS documented no mood or behavior issue for Resident #36. On 11/28/22 at 10:35 AM, an interview was held with Resident #36, the resident council president, voiced a Certified Nursing Assistnat (CNA), Staff H, had used a derogatory word directed at his sexual orientation in which Resident #36 felt verbally abused, belittled, humiliated, and disregarded. Resident #36 explained that Resident #6 (his roommate) had been sitting in the chair for 2 and half hours and wanted to go to bed. Resident #6 had his call light on, when Staff H finally arrived in the room Resident #36 tried to advocate for Resident #6 and told Staff H, 'my roommate had the call light on for over 2 hours waiting to go to bed.' Subsequently, [Staff H], used a derogatory word towards his sexual orientation, and stated you need to mind your business, you don't pay my salary. Resident #36 voiced, 'he had written and provided a letter to the former Director of Nursing (DON) about the concern.' Resident #36 showed the letter to the surveyor. The letter read, 10/18/22 to (DON), 'on Monday evening my roommate [Resident #6] and I went out for dinner, we returned to Woodlake at 7:30 pm, the CNA I know as Q [Staff H] came in and asked [Resident #6] if he was ready for bed, he had already taken off his shirt and was looking for his body wash; she said I'll be back. She returned with a night gown and linens put them on the bed and again said I'll be back. By 8:30 PM she had not come back, Resident #6 put on the call light to remind her [Staff H] that he was still waiting. He fell asleep with no shirt about to fall out of his wheelchair. [Staff H] returned at 9:45 PM she said again are you ready for bed? I said he's had the call light on for over an hour. Staff H said why are you so concern about [Resident #6]? Are you, his girlfriend?! I said he is my vice president, my roommate, and my friend! [Staff H] said mind your own business, you don't pay my salary! I said as a matter of fact, I do! She jerked the curtain closed and I said excuse me, I will get out of your way. And I left the room and went to the front desk and asked who was in charge, there were a few CNAs standing around the front desk and they said no one was in charge, try your nurse. [Staff E] was my nurse, and he came to the front and told me to calm down as I was struggling to breath and obviously had high blood pressure. When I told [Staff E] that [Staff H] had asked if I was [Resident #6's] girlfriend, one of the female CNAs laughed out loud! I said do you think that's funny? She did not respond. [Staff M] was at the desk, and I asked him, [Staff M] you know I'm not a troublemaker, I don't overreact. He said that's true. [Staff E] said talk to the DON tomorrow. I went back to my room; [Staff H] was gone, and Resident #6 was in bed. This is unacceptable and a shame on Woodlake. Thank you! Signed by Resident president. On 11/30/22, review of the last 6 months of grievance logs lacked documented evidence of Resident #36's concerns. On 11/30/22 at 10:54 AM, during an interview process held with the Social Services Director (SSD), she revealed on 10/13/22, she was out sick and when she returned to work on 10/18/22, she was informed of Resident #36's concerns. The SSD voiced she was informed the concern was reported to the former DON, and the former DON did not initiate a grievance, report it or investigate the concern. When the SSD spoke to the current DON about the concern, the current DON revealed it was too late to do anything about the concern as it happened a month ago. The SSD confirmed there was no grievance or investigation written for this concern. The SSD voiced she would initiate a grievance today (11/30/22) and start an investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 10 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to provide scheduled showers for 2 of 2 sampled residents, Residents #6 and #75. Residents Affected - Few The findings included: 1. During Resident Council Interview, Resident #6, the [NAME] President of the Resident Council, stated, It has been months since I have had a shower. The Resident Council President confirmed Resident #6's statement as being true, and that he and Resident #6 have complained to staff about not getting his showers. Resident #6 has a Brief Interview for Mental Status (BIMS) of 15, indicating there was no cognitive impairment or memory deficit. Review of the Quarterly MDS (Minimum Data Set), dated 09/08/22, showed Resident #6 required total assistance with bathing. Review of Resident #6's shower task sheet for November 2022 documented that the resident was to receive his showers on Mondays, Wednesdays and Fridays by the 11:00 PM - 7:00 AM shift staff. The task sheet documented that Resident #6 had 10 showers in November 2022 (11/07/22 at 5:13 AM, 11/10/22 at 5:27 AM, 11/11/22 at 4:46 AM, 11/14/22 at 5:00 AM, 11/21/22 at 5:31 AM, 11/25/22 at 5:00 AM and 8:21 PM, 11/28/22 at 5:08 AM, and 12/01/22 at 3:55 AM). On 12/02/22 at 9:51 AM, Resident #6 confirmed, I still have had no showers. My roommate (Resident Council President) has complained about it. It makes him upset too, because I don't get them. I have only had bed baths, no showers. When the resident was asked about the documentation regarding his showers, the resident adamantly denied that any showers had been given. What is written down is not true! I did not have those showers. 2. Resident #75 was admitted on [DATE]. She was transferred to and from a hospital from [DATE] 11/16/22 and again from 11/18/22-11/23/22. On 11/28/22 at 12:41 PM, Resident #75 stated, I have not had a shower since being admitted . At this time, the resident's hair appeared unwashed. Review of the MDS, dated [DATE], showed Resident #75 required total assistance with bathing. Resident #75's care plan documented the resident has an ADL (Activities of Daily Living) performance deficit related to weakness / poor coordination, with potential for inevitable decline related to diagnoses of degenerative neurologic disease process . Resident requires maximal to total assistance times 1-2 staff with bathing / showering as necessary. Review of shower task sheet for the past 30 days (11/02/22 - 11/28/22) showed no documented times that Resident #75 had received a shower during these dates. The task sheet did show that the resident received a bed bath on 11/04/22, 11/07/22, 11/09/22, 11/14/22, and 11/28/22; and the resident received partial bath on 11/02/22, 11/11/22, and 11/25/22 (and 12/01/22 10:25 AM). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 11 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/01/22 at 10:25 AM, Resident #75 confirmed that she had still not received a shower. She stated, I really want to have a shower. During interview with Staff D, Certified Nursing Assistant (CNA), on 12/01/22 at 10:30 AM, she stated, [Resident #75] is supposed to get a shower on 11 AM -7 PM shift, so I don't know when she last had a shower, but I will get someone to help me and get her a shower this morning. On 12/01/22 at 10:34 AM, Staff D went into Resident #75's room to provide care and start shower preparations. On 12/02/22 at 10:15 AM, Resident #75 stated that she did have shower yesterday, and I feel so much better. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 12 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 facility policy, record review, and interview, the facility failed to have physician orders for monitoring residents' blood glucose levels and failed to notify the physician of elevated blood glucose results, for 1 of 1 sampled resident reviewed for diabetic management, Resident #8. Residents Affected - Few The findings included: A blood glucose test is a blood test that measures the level of glucose (sugar) in a person's blood. Normal blood sugar levels range between 70-100 milligram per deciliter (mg/dl). Review of the facility Policy, dated 11/30/2014, titled, Blood Glucose Monitoring & Disinfecting documented, Verify Physician order. On 11/28/22 at 10:12 AM, Resident #8 stated she did not think they were monitoring her blood sugar properly and was she getting her insulin as needed. Record review for Resident #8 documented an admission date of 05/11/22 and readmission on [DATE] with diagnoses that included Diabetes, Hepatitis, Lung Disease and Cancer. A Minimum Data Set (MDS) resident assessment done 10/05/2022 documented Resident #8 as cognitively intact and requiring limited assistance to supervision only for all activities of daily living. A physician's order on 05/11/22 documented: give Lantus Insulin 20 Units subcutaneously two times a day for Diabetes. There was no physician's order for monitoring blood sugars noted. A care plan, dated 03/15/22, titled, Diabetes Mellitus, documented, fasting blood sugar as ordered by doctor. The following blood sugar results were documented in Resident #8's chart: 11/30/22 at 10:51PM, blood sugar result 280 mg/dL 11/29/22 at 11:33 PM, blood sugar result 350 mg/dL 11/28/22 at 11:06 PM, blood sugar result 284 mg/dL 11/27/22 at 11:25 PM, blood sugar result 288 mg/dL 11/25/22 at 11:07 PM, blood sugar result 316 mg/dL 11/25/22 at 12:39 AM, blood sugar result 233 mg/dL 11/23/22 at 10:46 PM, blood sugar result 206 mg/dL 11/22/22 at 7:04 PM, blood sugar result 191 mg/dL 11/21/22 at 11:24 PM, blood sugar result 201 mg/dL. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 13 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 Resident #8's chart lacked documentation of physician notification of abnormal blood sugar results for the above blood sugar results. On 12/01/22 at 10:59 AM, Staff K, Registered Nurse / RN, stated a doctor's order is needed to check blood sugars. Residents Affected - Few On 12/01/22 at 1:03 PM, Staff C, Licensed Practical Nurse / LPN, stated she was unable to find documentation of a physician's order for blood sugar monitoring for Resident #8 or documentation that the physician was notified of abnormal blood sugar results. On 12/01/22 at 2:00 PM, the Regional Consultant nurse stated a physician's order is needed to check the resident's blood sugars. After reviewing Resident #8's chart, she stated there was no physician's order for blood sugar monitoring or documentation of the physician being notified of elevated blood sugar results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 14 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, record review and policy review, the facility failed to supervise and identify risk for residents who smoke and vulnerable residents who wander, for 3 of 3 sampled residents reviewed. Residents Affected - Few The finding included: The facility policy, titled, Smoking - Supervised, effective date 11/30/14 and revised 02/07/20, stated, in part: For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. The Center will retain and store matches, lighters, etc., for all residents. 1. Observation revealed that the smoking times are posted throughout the facility. The times were noted as: 10:30 AM - 10:35 AM, 1:30 PM - 1:45 PM, 3:30 PM - 3:45 PM and 6:00 - 6:15 PM. On 11/28/22 at 10:30 AM, Resident #59 stated he was going to the patio to smoke. The resident removed his cigarettes and lighter from a drawer in his room and proceeded via wheelchair to the door of the smoking area. Resident #59 put the code in the keypad to open the door, opened the door to the patio and proceeded to the smoking area. The resident was accompanied to the smoking patio where Resident #67 was already sitting on the patio in his wheelchair and was smoking a cigarette. Resident #59 and Resident #67 both stated someone from the facility is supposed to accompany us, however, they don't have enough staff to come to the smoking patio. They both expressed they had the code to the patio. They would not divulge who or how they obtained the code. On 11/30/22 at 8:46 AM, Resident #67 was interviewed in his room. He stated he was waiting for a breathing treatment. He was asked if he keeps his own cigarettes and lighter in his room. He stated sometimes because the facility employees don't want to hold them for him because it is a bother to give them to the resident when they need them. On 11/30/22 at 9:25 AM, Resident #67 exited his room with his cigarettes and lighter which he had stored in his room. He stated he was on his way to the smoking patio. On 11/30/22 at 11:41 AM, the Administrator was informed of the door code being used by the residents and of the residents storing their own lighters and cigarettes in their rooms. She was also informed the residents go to smoking area without any supervision. On 12/01/22 at 10:50 AM, an observation was made of the smoking patio. Resident #67 was waiting at the smoking patio door. The resident stated the facility is breaking their own rules by not having anyone to accompany us to the smoking patio. He stated the scheduled time to smoke is 10:30 AM. He stated, I cannot get out the door. They changed the code. 2. Record review of Resident #73 documented an admission date of 10/04/22 with diagnoses that included End Stage Renal Disease, Stroke, Heart Disease and Hepatitis. A Minimum Data Set (MDS) resident assessment, dated 10/11/22, documented Resident #73 as cognitively intact requiring limited assistance, to independent for all activities of daily living. A care plan, dated 10/05/22, documented the resident is a smoker and The resident will not smoke (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 15 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0689 without supervision through the review date of 02/14/2023. Level of Harm - Minimal harm or potential for actual harm On 11/28/2022 at 12:02 PM, Resident #73 stated he smokes occasionally about three times a day. He stated the facility has posted smoking times, but they do not have the staff to cover it. Residents Affected - Few On 11/30/22 at 9:27 AM, Resident #67 was observed going to the south exit door, putting in the access code for the keypad lock, the door opened, and he exited. On 11/30/22 at 9:30 AM, Resident # 73 was observed going to the south exit door, putting in the access code for the keypad lock, the door opened, and he exited. On 11/30/22 at 9:33 AM, both Resident #67 and Resident #73 were observed to have and light their own cigarettes. No staff was noted to be present in the smoking area. On 11/30/22 at 9:45 AM, the south exit door remained ajar, pushed open by two additional alert and oriented residents who exited to smoke. No activated audible or visual alarm was noted by the surveyor. On 11/30/22 at 11:39 AM, the surveyor exited the door to the smoking area and found an open gate leading to the parking lot with access to the road. Photographic Evidence Obtained. The facility's Administrator and the Regional Nurse Consultant were notified immediately. The Administrator ordered an immediate resident count while the Regional Nurse Consultant surveyed the parking lot for residents. The Maintenance Director arrived and found that the gate lock was not functioning and repaired it. All residents were accounted for. On 11/30/22 at 12:35 PM, the Regional Nurse Consultant and Administrator stated residents are supposed to be supervised while smoking. She said the exit door and gate are being repaired today. The keypad code to exit has been changed and a staff member is remaining at the exit until all repairs are complete. On 11/30/22 at 1:30 PM, Resident #73 stated the facility is supposed to keep their cigarettes and lighters, but they don't have enough staff to keep locking and unlocking all the smokers supplies or be with them when they smoke. He stated that is why they have the code to the door lock and keep their own supplies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 16 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on Facility Policy, observation, interview and record review, the facility failed to obtain a urology consult as ordered for 1 of 1 sampled resident reviewed for urinary catheters, Resident # 66. Residents Affected - Few The findings included: Review of the facility policy, dated 11/30/2014, titled, Medical Consultations, documented, in part, The member of the medical staff requesting a consultation will order the consultation and a Request for Consultation will be initiated by nursing to the consulting physician. The consultation will include the examination of the resident and the medical record. The consultant physician will complete the Report section of the Request for Consultation or it's equivalent. Upon completion of the consultation the charge nurse will notify the attending physician that the consult is complete and obtain any changes in plan of care or medications recommended by the consulting physician. Record review for Resident #66 documented an admission date of 08/08/22 with diagnoses that included Stroke, affecting speech and swallowing, and Diabetes. A Minimum Data Set assessment (MDS) completed on 08/15/22 for Resident #66 documented severe cognitive impairment and with extensive assistance to total dependence on staff for all activities of daily living except locomotion on and off the unit requiring limited assistance and a urinary catheter. There was no documentation of a completed Urology Consultation noted. On 11/28/22 at 2:50 PM, Resident #66 was observed to have an indwelling urinary catheter connected to a drainage bag. The resident stated that he did not know why he still had a catheter. He said he thought they were going to try to get rid of it or find out why he cannot urinate properly. On 09/19/22, a physician's order for Resident #66 documented, Urology Consult Dx. (Diagnosis) urinary retention, failed voiding trial x 2. On 09/21/22, a physician's order for Resident #66 documented, Please schedule urology consult prior to D/C (discharge). Dx. (diagnosis) urinary retention. Give patient/family appointment date prior to D/C. On 12/01/22 at 1:40 PM, Staff C, Licensed Practical Nurse, was asked for verification that the Urology Consult ordered on 09/19/22 was completed for Resident #66. After record review, she stated it appears the urology consult was not entered, signed off or completed. On 12/01/22 at 2:03 PM, the regional nurse consultant reviewed the chart for Resident #66 and confirmed the urology consult ordered on 09/19/22 and 09/21/22 had not been done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 17 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. On 11/28/22 at 10:24 AM, an interview was held with Resident #56, who stated, the facility doesn't have enough people to work, or I wouldn't have to wait an hour or two for drinks. Review of Resident #56's record revealed the quarterly minimum data set (MDS) assessment, reference date 09/14/22, recorded a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #56 was cognitively intact. This MDS documented no mood or behavior issue for Resident #56. On 11/28/22 at 10:35 AM, an interview was held with Resident #36, resident council president, who voiced concern related to staffing. Resident #36 explained, Resident #6 (his roommate) had been sitting in the chair for 2 and half hours, wanted to go to bed. On 10/18/22, on Monday evening at 7:30 PM, Staff H came and asked (Resident #6) if he was ready for bed, he had already taken off his shirt and was looking for his body wash, she said I'll be back. She returned with a night gown and linens, put them on the bed and again said, I'll be back. By 8:30 PM, she had not come back, Resident #6 put on the call light to remind her (Staff H) that he was still waiting. He fell asleep with no shirt, about to fall out of his wheelchair. Staff H returned at 9:45 PM and said again are you ready for bed? I said he's had the call light on for over an hour. Review of Resident #36's record revealed the annual MDS assessment, reference date 10/30/22, recorded a BIMS score of 15, indicating Resident #36 was cognitively intact. This MDS documented no mood or behavior issue for Resident #36. Based on interview, record review and observation, the facility failed to have sufficient staff to meet the needs of the residents. The findings included: The facility policy, titled, Smoking - Supervised, effective date 11/30/14 and revised 02/07/20, stated, in part: For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. On 11/28/22 at 10:30 AM, Resident #59 was accompanied to the smoking patio area. Resident #59 stated he had the code to the smoking patio door. He put the code in to the keypad and opened the door to the smoking patio. Resident #67 was already in the smoking patio area and was smoking a cigarette. Resident #59 and Resident #67 were interviewed and both residents stated someone from the facility is supposed to accompany us to the smoking area. Both residents stated they don't have enough staff to accompany us, so we have the code to the door. They stated we feel like prisoners in the facility, we need to get outside. Residents #59 and Resident #67 would not divulge who gave them the code to the door or how they obtained it. On 11/30/22 at 11:41 AM, the Administrator was informed of the door code being used by the residents and the residents were going to the smoking area without an employee accompanying them. On 12/01/22 at 10:50 AM, an observation was made at the door leading out to the smoking patio. Resident #67 was waiting at the smoking patio door. Resident #67 stated the facility is breaking their own rules by not having anyone to accompany us to the smoking patio. He stated the scheduled time to smoke is 10:30 AM and I cannot get out the door. They changed the code. He again expressed the facility does not have enough staff to accompany us to the smoking patio. On 11/29/22 at 8:37 AM, an interview was conducted with Staff A, Registered Nurse (RN). She was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 18 of 19 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 105611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Greenacres 6414 13th Rd S Green Acres, 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asked about staffing and how many residents she was responsible for on her shift. She stated she usually has 20-25 residents to care for however today she has 26 residents in her care. She stated they do not have enough staff so she can complete her work in a timely manner. On 11/29/22 at 8:55 AM, Resident #8 was interviewed. She stated they do not have enough staff to meet the meet her needs. She stated when she uses the call bell, sometimes someone will come and sometimes they will not come. She stated, I just give up. On 11/29/22 at 10:10 AM, Staff C, Licensed Practical Nurse (LPN), was interviewed who stated she is caring for 27 residents. She stated the facility does not have enough staff. She stated she cannot complete all her task by the end of her shift. On 11/29/22 at 10:17 AM, an interview was conducted with Staff D, Certified Nursing Assistant (CNA), who stated there is not enough staff to care for the needs of the residents in her care. She stated it is difficult to get everything completed by the end of the shift. On 11/30/22 at 9:30 AM, an interview was conducted with Staff E, LPN, who stated, 'I must be vigilant to care for the number of residents I am given. I can never finish in 8 hours so the documentation in the resident's records is always completed after my shift is done.' On 11/30/22 at 12:15 PM, Staff B, Certified Nursing Assistant (CNA), was interviewed. She stated the facility does not have enough staff and she cannot complete her task in her 8-hour shift. She stated the facility does not like the employees to stay overtime to complete their work. On 12/01/22 at 1:55 PM Staff F, CNA was interviewed who stated today she has 15 residents in her care but usually has 20 plus residents to care for on the days she is working. She stated the facility does not have enough staff. She stated she is not able to complete her work in the 8-hour shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 19 of 19