Inspection·February 26, 2026

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, interview and record review the facility failed to respond to call lights in a timely manner due to nonfunctioning call system in 5 out of 32 rooms on the South unit affecting rooms 216, 224, 259, 273, 279; failed to provide care and services to meet the needs for wound care and catheter care for 1 of 1 resident reviewed for wound care and catheter care (Resident #5); and failed to administer medications as ordered for 2 of 4 residents reviewed for medications (Residents #1 and #3). The findings included:Review of the facility's policy titled, Call Bell System -Inoperable with a revised date of 08/22/17 included in part the following: Residents must have at all times, a system to notify staff when assistance is needed. The call bell system is to be inspected on a regular scheduled basis by Maintenance. If the call bell system is inoperable, in one room, one hall, or the entire unit, the following procedure must be followed: Maintenance, the Executive Director of Clinical Services must be notified immediately. Hand bells or tap bells will be placed within reach of any resident affected by an inoperable call bell. Residents and staff will be educated on their usage. If a large number of resident are affected by inoperable call bells, a CNA or Licensed Nurse will be assigned to check on the residents affected every 15 minutes. They will sign a Round Sign Off form after each check as proof that residents were monitored closely. The Director o Maintenance and the Executive Director will focus on the repair of the inoperable call bell(s) which will be their priority until they are operable. Residents Affected - Few Review of the facility's policy titled, Clinical Guideline Skin and Wound with an effective date of 04/01/17 included in part the following: On admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Licensed Nurse to document presence of skin impairment/new skin impairment when observed and document weekly until resolved. Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record. Develop individualized goals and interventions. Review of the facility's policy titled, Dressing Change with a revised date of 12/06/17 included in part the following: A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Apply treatment as ordered and clean dressing. Review of the facility's policy titled, Catheter Care, Urinary with a revised date of 09/05/17 included in part the following: remove catheter securement device while maintaining connection with drainage tube. Reattach catheter securement device. Review of the facility's policy titled, Medication -Oral Administration of with a revised date of 08/15/19 included in part the following: Document the administration and acceptance or decline of all medications administered. When documenting in the EMR (Electronic Medical Record) the nurse will document immediately prior to administration and or immediately post administration based on preferred individual professional practice of the nurse. Should the resident decline or be unable to accept the medication this will need to be documented following standard protocol. Chart on nurse's notes. Pertinent observation after administration. 1. Record review for Resident #5 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE] with diagnoses that included in part the following: Metabolic Encephalopathy, Type 2 Diabetes Mellitus, and Cognitive Communication Deficit. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 2 of 9 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 02/26/2026 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 Review of the Physician's Orders for Resident #5 revealed in part the following: Level of Harm - Minimal harm or potential for actual harm An order dated 02/20/26 for catheter care every shift for catheter hygiene. Residents Affected - Few An order dated 02/25/26 for Right hip: paint with betadine and allow to dry. Cover with 6x6 bordered dressing. Change three times a week, Monday, Wednesday, and Friday and as needed. There was no order to secure the catheter device. Review of the Treatment Administration Record for Resident #5 revealed no documentation of right hip wound care having been performed from 02/19/26 to 02/24/26. Review of the Nurse Progress Notes for Resident #5 entered as a late entry on 02/24/26 with an effective date of 02/20/26 included in part the following: Wound noted to right hip area measures 7 x 6.6 x 0. Wound bed covered 100% eschar, peri wound skin within normal limits, no drainage or sign/symptom of infection. Orders added for betadine to right hip three times week on Monday, Wednesday, and Friday. On 02/25/26 at 11:26 AM observation of Resident #5 lying in bed disheveled, long uncombed hair, long untrimmed beard who was wearing a gown that was secured around his neck but off of his body, the covers of the bed were only covering his feet, his body was exposed and he was wearing an intact white brief with see through sides with the right side exposed revealing an approximate 5 inch diameter darkened spot on his right hip under the see through part of the brief. The resident also was noted to have an indwelling urinary catheter in place that did not appear to be secured in place as the tubing was coming out of the back of the brief near the upper leg. The call light was on the floor and not within the reach of the resident. The Assistant Director of Nursing (ADON) came into the room and acknowledged the resident needed to be covered, she acknowledged he had a wound on the right hip that was not dressed in the intact brief. The nurse also acknowledged the drainage tubing for the indwelling urinary catheter was not secured in place. The nurse was asked about the wound not being covered, she said the resident must have taken the dressing off but could not locate the dressing and did acknowledge the brief was still secured. During an interview conducted on 02/26/26 at 2:00 PM with the Wound Care Nurse who was asked about the wound care for Resident #5, she said she had done it on 02/20/26 and did not do it on 02/23/26 because she was out that day. She acknowledged the wound care was not completed on 02/23/26. During an interview conducted on 02/26/26 at 3:11 PM with the Director of Nursing (DON) who was asked about Resident #5 she acknowledged he came back to the facility on [DATE] and had a right hip wound on admission. Wound care for right hip was provided on 02/20/26 and again on 02/25/26. She acknowledged the wound care orders were not entered into the resident's chart until 02/24/26 and there was no documentation of wound care provided to the right hip on 02/23/26. 2. Record review for Resident #3 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Discitis Unspecified Multiple sites in Spine, Type 2 Diabetes Mellitus and Heart Failure. MDS dated [DATE] Documented in Section C a BIMS score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #3 revealed in part the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 3 of 9 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 02/26/2026 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 An order dated 01/31/26 for daily weight and record for Congestive Heart Failure one time a day. Level of Harm - Minimal harm or potential for actual harm An order dated 02/19/26 for Bumex 0.5mg give 4 tablets by mouth daily. Residents Affected - Few An order dated 02/03/26 for Micafungin Sodium Intravenous Solution use 100mg intravenously one time a day. An order dated 02/09/26 for Ozempic (0.25 or 0.5mg/dose) subcutaneous solution pen injector 2mg/3ml inject 1 pen needle subcutaneously ever Monday. An order dated 02/18/26 for Victoza subcutaneous solution pen injector 18mg/3ml inject 0.6mg subcutaneously daily. An order dated 01/26/26 to monitor vital signs every shift. An order dated 01/26/26 for PICC or MID line: Measure upper arm circumference and external catheter length on admission, with each dressing change and as needed every shift for maintenance until 02/11/26. An order dated 02/03/26 for Havrix Intramuscular Suspension prefilled Syringe 0.5ml (Hepatitis A Vaccine) inject 1 syringe intramuscularly one time only for prophylaxis for 30 days. An order dated 02/12/26 for Hepllsav-B intramuscular solution prefilled syringe 20mcg/0.5ml (Hepatitis B Vaccine) inject 1 syringe intramuscularly one time only for prophylaxis. Review of the Medication Administration Record for Resident #3 revealed in part the following: On 02/01/26 and 02/02/26 no weights or documentation of weights. On 02/23/26 no Bumex 0.5mg 4 tablets administered. On 02/07/26 no Micafungin Sodium Intravenous Solution 100mg administered. On 02/09/26 no Ozempic administered. On 02/22/26 no Victoza administrator. On 02/07/26 no monitoring of vital signs documented. On 02/07/26 no PICC or MID line: Measure upper arm circumference and external catheter length on admission, with each dressing change On 02/03/26, 02/04/36 and 02/05/26 Havrix Intramuscular Suspension prefilled Syringe 0.5ml Hepatitis A Vaccine was not administered. On 02/12/26 and 02/13/26 Hepatitis B Vaccine was not administered. During an interview conducted on 02/25/26 at 1:00 PM with Resident #3 who stated the Social Worker has been helping him to get transferred to two other facilities closer to his brother in [NAME] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 4 of 9 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 02/26/2026 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 Beach, one does not accept Medicaid pending and the other does not have any long term beds available. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 02/26/26 at 10:30 AM with Director of Nursing (DON) who was asked about the grievance for Resident #3 that she investigated regarding call light response and provided education to staff who worked on the day of the incident. In the grievance report she documented in part the following: Staff will respond to call lights promptly per facility policy. Improved monitoring during shift. Resident satisfied with response time. When asked for the facility call light policy, she said they have no policy, it is a protocol and she wrote policy when she should have put protocol. She was asked for a copy of the facility protocol on call lights. Residents Affected - Few On 02/26/26 at 11:46 AM the DON stated they do not have any written policy or written protocol for answering call lights timely. During an interview conducted on 02/26/26 at 3:11 PM with the Director of Nursing (DON who was asked about Resident #3 she acknowledged the resident had several medications that were not given in the month of February. She acknowledged all medications had to be locked at all times. 3.During a tour of the South unit on 02/25/26 from 10:45 AM to 1:00 PM the following five observations were made: At 10:58 AM call lights were not functioning in room [ROOM NUMBER]. At 11:12 AM call lights were not functioning in room [ROOM NUMBER]. At 11:35 AM call lights were not functioning in room [ROOM NUMBER]. At 12:07 PM call lights were not functioning in room [ROOM NUMBER]. At 12:12 PM call lights were not functioning in room [ROOM NUMBER]. On 02/26/26 at 9:00 AM an interview was conducted with the Director of Maintenance, who was asked about the call lights not functioning. He said he was just made aware of the nonfunctioning call lights yesterday and he started working on it immediately. They have a vendor in the facility today to assist with the repair of the call light system. The vendor was observed by the surveyor in the facility on 02/26/26. 4. Record review revealed Resident #1 was admitted to the facility on [DATE] post knee replacement surgery. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assistance with activities of daily living. Resident #1 was care planned for pain medication therapy related to pain, recent surgery. An intervention included was to administer analgesic (pain) medications as ordered by physician. A review of Resident #1's orders revealed an order dated 12/10/25 for Naproxen (an ant inflammatory) one tablet every 6 hours as needed for pain. An order dated 12/10/25 was for Oxycodone one tablet every 4 hours as needed for moderate to severe pain level 5-10. A review of Resident #1's Medication Administration Record (MAR) revealed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 5 of 9 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 02/26/2026 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 administered Naproxen on 12/10/25 at 2:00PM (pain level 6), on 12/11/25 at 10:00 AM (pain level 5), on 12/12/25 at 8:47 AM (pain level 5), and on 12/15/25 at 6:00 AM (pain level 6). Further review of Resident #1's record did not reveal why the ordered Oxycodone was not administered or offered for the resident's moderate to severe pain level, or if the administered medication was effective. Residents Affected - Few An interview was conducted with the Director of Nursing (DON) on 02/26/26 at 12:00 PM. The DON acknowledged the above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 6 of 9 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 02/26/2026 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure ordered home health was set up for a resident upon discharge for 1 of 7 sampled residents (Resident #1).The findings included: Record review revealed Resident #1 was admitted to the facility on [DATE] post knee replacement surgery. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assistance with activities of daily living. A phone interview was conducted with Resident #1 on 02/25/26 at 11:00 AM. Resident #1 stated she was still waiting to receive home health treatment since discharge from the facility on 01/31/26.A review of Resident #1's orders revealed an order dated 01/30/26 to discharge home on [DATE] with occupational therapy (OT), physical therapy (PT), home health. DME (durable medical equipment) to include standard walker. An interview was conducted with the facility's Social Services Director (SSD) on 02/25/26 at 11:30 AM. The SSD stated Resident #1 was originally supposed to be discharged home on [DATE], but the ordered walker had not been delivered. SSD confirmed Resident #1 was discharged home without home health services being confirmed. The SSD stated she faxed orders to a home health agency on 01/29/26. The SSD stated she did not have documentation of confirmation of home health services. A review of Resident #1's records did not reveal any documentation related to the discharge of Resident #1's status with attempt to set up home health services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105611 If continuation sheet Page 7 of 9 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 02/26/2026 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and record review the facility failed to secure medications at the bedside for 1 of 6 sampled (Resident #7), and failed to secure medications at 2 of 2 nursing stations (North and South). The findings included: Review of the facility's policy titled, Medication Storage with no date included in part the following: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel as defined by facility policy. Record review for Resident #7 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Acute Respiratory Failure with Hypoxia, Quadriplegia C5-C5 Incomplete, and Dysphagia Unspecified. Review of the Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment. 1.Record review for Resident #7 revealed no assessment or physician's order to self-administer medication. Review of the Physician's Orders for Resident #7 revealed in part the following:An order dated 01/5/26 for Allergy Cream 2-0.1 % (diphenhydramine-Zinc Acetate) apply to back/affected area topically every 12 hours as needed for Itching.An order dated 02/20/26 for Allergy Cream 2-0.1 % (diphenhydramine-Zinc Acetate) apply to neck, back and chest topically as needed for Itching.An order dated 02/2/26 Clobetasol Propionate E External Cream 0.05 % apply to bilateral upper arms topically two times a day for bullous pemphigoid apply to bilateral upper extremities topically every 12 hours for eczematous rash, bullous pemphigoid for 14 Days Clean bilateral upper extremities forearms with normal saline. Apply Clobetasol to wounds/blisters. Cover with abdominal pads and wrap with Kerlex twice daily and apply to affected areas topically every 12 hours as needed for Bullous pemphigoid, rash. On 02/25/26 at 11:07 AM an observation was made of Resident #7 of night stand top drawer open with hydrocortisone 2.5% cream and Clobetasol Propionate 0/05% cream. On 02/25/26 at 11:08 AM during an interview conducted with Staff C Registered Nurse (RN) who was asked if Resident #7 has any creams ordered, she stated he has an order dated 02/02/26 for Clobetasol Cream and Allergy Cream (diphenhydramine-Zinc Acetate). On 02/25/26 at 11:09 AM during a side-by-side observation with Staff C RN with Staff A CNA who both acknowledged the medications are kept at the bedside and they both said they are there so the CNA can put the creams on the patient when they provide care. 2.On 02/25/26 at 11:55 AM observation of 1 bottle of melatonin 3mg and 1 bottle of melatonin 5mg was on the nursing counter (200 unit) with no staff member in sight and 3 residents adjacent from the nursing station.During an interview conducted on 02/25/26 at 12:00 PM with the Assistant Director of Nursing (ADON), she acknowledged the medications were left at the nursing station but they were unopened. 3.On 02/26/26 at 11:09 AM an observation was made at the unsecured North Nursing station of an unsecured enema saline laxative with active ingredient Diabasic sodium phosphate 7gm and Monobasic sodium phosphate 19gm. There were no staff members at or near the nursing station, however there were 4 residents near the nursing station.During an interview conducted on 02/26/26 at 11:15 AM with Staff E Registered Nurse Unit Manager who was asked if medications should be secured at all times, she said yes. When asked about the enema saline solution, she said she had no idea who left it at the nursing station but removed it immediately. Event ID: Facility ID: 105611 If continuation sheet Page 8 of 9 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 02/26/2026 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 2 sampled residents with a mechanical soft ordered diet (Resident #4).The findings included: Record review revealed Resident #4 was admitted to the facility on [DATE] with a readmission date of 04/18/25. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required substantial/max assist with activities of daily living.Resident #4 was care planned for at risk of malnutrition related to need for therapeutic and mechanically altered diet. Interventions included explain and reinforce to the resident the importance of maintaining the diet ordered and monitor/document/report as needed and signs and symptoms of dysphagia (difficulty swallowing): pocketing, choking, coughing, drooling.A review of Resident #4's orders revealed an order dated 12/17/23 for a dysphagia mechanical soft diet.Resident #4 was observed sitting in the hallway next to the nursing station, coughing, on 02/25/26 at approximately 12:00 PM. Resident #4 was observed with something grasped in the hand and putting it to the mouth and coughing. Staff was observed passing by the resident not intervening. Surveyor inquired what was in the resident's hand. Resident #4 exposed what appeared to be a chewy granola bar. Surveyor asked Staff Z, a certified nurse assistant (CNA) where the resident got the granola bar and she said from his drawer, but it was the last one. An observation of Resident #4's room revealed no food in the resident's drawer but revealed a breakfast tray on the bedside table with another resident's name the ticket. The tray had remnants of scrambled hard eggs and hashbrowns with crispy/crunchy edges. Staff Z was assisting Resident #4's roommate. Staff Z shrugged her shoulders when questioned about the tray. An interview was conducted with the Speech Therapist (ST) and Registered Dietician (RD) on 02/25/26. They both agreed Resident #4 should not have had the chewy granola bar and the crispy hash browns. Event ID: Facility ID: 105611 If continuation sheet Page 9 of 9