Inspection·November 10, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few partially on her left side in her bed. Resident #38 was not able to respond to any greetings other than to stare at the speaker. She appeared thin and frail. Certified Nursing Assistant (CNA) J entered the room at this time. It was lunch time and she was asked if the residents would be eating in their room today. She said, Yes, but she (pointing to Resident #38) is a feeder. Resident #38's roommate, who was in the next bed, exclaimed, I'm not a feeder! CNA J responded by saying No, you are not a feeder. An interview was conducted with LPN K on 11/09/21 at 11:44 AM. When asked about Resident #38's nutritional needs, she replied, She is a feed. She is total (assist) for everything, Hoyer (a mechanical lift used for transferring a resident between surfaces) and a feed. A record review for Resident #38 found a quarterly MDS assessment with an ARD of 10/12/21. She was assessed with continuous inattention and disorganized thought. Resident #38 required extensive assistance with activities of daily living including feeding. Her diagnoses included CVA, non-Alzheimer's dementia and depression. A Nutritional Review, dated 4/14/21, also noted Resident #38 required total assistance with eating. A review of the CMS (Centers for Medicare and Medicaid Services) 672 (Resident Census and Condition) form found there were seven residents in the facility who were dependent on staff for dining at the time of the survey. In an interview with CNA M on 11/10/21 at 11:12 AM, she was asked how the facility staff referred to residents who needed to be fed by staff. She replied Feeders. When it was suggested the term was degrading, CNA M explained that was what everyone here called it. She stated she had received training in treating residents with dignity and respect and acknowledged using such a label was a dignity issue. In an interview with the DON on 11/10/21 at 2:10 PM, she was told of the observation. The DON said the term feeder should not be used for residents who were dependent diners. The DON agreed the use of labels for residents, especially in their presence, was a dignity issue, and said she did not realize the term was being used by staff. 3. Observations of Resident #44 throughout the survey (11/7/21 to 11/10/21) found she had a preference for independently walking up and down the long hallway repeatedly during the day. During an observation on 11/09/21 at 2:10 PM, CNA H and another unsampled employee were seen escorting Resident #44, who was able to walk without assistance, to her bedroom. Each employee had one arm hooked under each of the resident's underarms. When the trio reached Resident #44's room, the unidentified CNA walked away. CNA H let go of Resident #44's arm at the threshold of the bedroom in order for the resident to enter the room. Instead, Resident #44 started to back out of the room. CNA H, who was now directly behind the resident, placed her open right hand on the resident's upper middle back and pushed her towards and into the bedroom. The Activities Director, who was present at the time, explained that Resident #44 would walk and walk and refuse to stop to go to her room for personal care. She often needed assistance getting that care. CNA H emerged from Resident #44's room on 11/09/21 at 2:13 PM with a tied up plastic bag in her hand, contents unknown. She disposed of the bag in the soiled utility room. CNA H was interviewed at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 2 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this time. She explained that Resident #44 had been up wandering the hallways since the overnight shift last night. Resident #44 needed personal care and hopefully, a nap. This resident did not like to stop walking for personal care and when staff tried to direct her to her room, she plopped herself on the floor. It took two staff members to get Resident #44 back to her room. A record review for Resident #44 found she was [AGE] years old. The Significant Change MDS with an ARD of 10/19/21 noted inattention was continuously present. She required supervision with locomotion on and off the unit. Her walking was not steady, but she was able to stabilize without staff assistance. Resident #44 was assessed as requiring extensive assistance from one person with toilet use and was always incontinent of bowel and bladder. Resident #44 was care planned on 10/12/21 for her multiple behaviors which included wandering while holding several items, and removing her brief and voiding on the floor. There was no mention of her refusing to go to her room for personal or incontinence care in her behavioral plan of care. (Photographic evidence obtained) On 11/10/21 at 3:14 PM during an interview with LPN I, she said she was not aware staff were using a 2-person escort when Resident #44 refused to be changed. She explained it was a very rare occasion that this resident plopped down to the ground, but she usually responded well enough to one person accompanying her to her room. The DON, who was also present, also expressed unawareness of the 2-person transport and nudge into the room. She also stated a side-by-side one-person escort was usually sufficient. The DON acknowledged while it was not a forceful gesture, the method used to get Resident #44 to, and into, her room was not dignified. The DON said she had recognized that overall, facility staff needed retraining in dignity issues for this population. She said staff did receive some dignity training online, but face-to-face training was her goal. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 3 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to ensure dining throughout the facility was provided in a way to maximize independence, personalization, and a comfortable, homelike environment at mealtimes. This had the potential to affect all 54 residents in the facility. The facility also failed to ensure resident bed linens were clean and in good condition for one (Resident #2) of eight sampled residents reviewed for environmental concerns, from a total of 30 residents in the sample. The findings include: 1. Lunch service was observed on 11/7/21 at 12:28 p.m. Residents were served lunch in resident rooms and in the main dining room with all meals left on top of the plastic serving trays. The meals were not placed on tables or prepared for the residents in a homelike manner. Lunch service was observed on 11/9/21 at 12:32 p.m. Meal service was again served with the food kept on the plastic serving trays for all residents in the dining room and in resident rooms. Lunch service was observed on 11/10/21 at 12:18 p.m. Meal service was again served to all residents with the food items kept on the plastic serving trays. An interview was conducted with the Registered Dietitian (RD) on 11/10/21 at 12:00 p.m. She stated she tried to come to the facility once a week to review initial, quarterly, and annual nutritional assessments. She further stated it would not be a homelike environment to serve meals on top of plastic serving trays. It would limit the dining space the resident would have to use while eating, and it could minimize a resident's ability to eat sufficiently without feeling rushed. An interview was conducted with the Certified Dietary Manager (CDM) on 11/10/21 at 2:24 p.m. He stated once the resident meals were sent to the floor, the dietary department did not monitor how the food was prepared in front of the residents. He was not aware that keeping serving trays underneath resident meals was not considered a homelike environment during dining. 2. On 11/7/21 at 12:25 p.m., Resident #2 was observed watching television while lying in his bed. There were two pillows observed under Resident #2's head. The pillows were observed to be without pillowcases. One pillow, beige in color, was observed to have darker beige stains and was observed to have a rip along one seam with white filler coming out. The second pillow, blue in color, was observed to have it's first layer of cloth ripped away from it's second layer, and beige stains were observed. Permission was obtained from Resident #2 to take a photograph of his pillows. In an interview with Resident #2 at this time, he was asked how long his pillows had been in this condition. He shrugged and replied, I really don't know. These have been my pillows for a while. On 11/8/21 at 9:45 a.m., the same two previously mentioned pillows were observed on Resident #2's bed. They were not in pillow cases, and were in the same condition as described on 11/7/21. On 11/9/21 at 12:20 p.m., Resident #2 was observed lying in bed. Two pillows were observed under his head with pillowcases on them. Resident #2 was asked if he had received new pillows. He stated he wasn't sure if they were new pillows. He was asked if staff had placed pillowcases on the pillows (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 4 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 for him, and he stated yes. Level of Harm - Minimal harm or potential for actual harm On 11/9/21 at 4:40 p.m., Resident #2 was observed returning to his room. He was asked if his pillows could be checked before he got in bed. He stated yes. Under the pillow cases, the pillows were observed to be the same two pillows from the observations made on 11/7 and 11/8/21. One pillow remained stained and torn on the seam with white filler coming out. The second pillow remained with a ripped top blue covering, exposing the actual pillow, and was stained. Residents Affected - Some On 11/9/21 at 4:45 p.m., the Director of Nursing (DON) was asked to come to Resident #2's room to observe his pillows. The DON asked Resident #2's permission to inspect his pillows. He agreed. The DON pulled the cases back and observed one pillow with stains and a ripped seam with white filler coming out, and the second pillow with stains and a ripped blue top layer exposing the inside of the pillow. The DON was advised the pillows were observed in this condition on 11/7/21 ans 11/8/21 without pillowcases. Today both pillows had pillow cases on them, but the same soiled, ripped pillows were inside the cases. The DON was asked who was responsible for ensuring bed linens and pillows were in acceptable condition. She stated, Well, I would hope if a nurses' aide saw these pillows, they would remove them and get new pillows before just putting cases on them. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 5 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that one (Resident #23) of four residents reviewed for nutritional risk, out of 30 sampled residents, was properly monitored for acceptable parameters of nutritional status. Specifically, the facility failed to ensure Resident #23 was properly monitored for potential weight loss. Residents Affected - Few The findings include: A review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnosis was dementia with behavioral disturbance. Secondary diagnoses included diabetes, schizoaffective disorder, hypertension, hypothyroidism, mild protein-calorie malnutrition, vitamin B12 deficiency anemia, and vitamin D deficiency. The 9/16/21 minimum data set (MDS) assessment documented a brief interview for mental status (BIMS) score of 0 out of a possible 15 points, indicating severe cognitive impairment. Resident #23 was documented as requiring supervision with set-up only for eating. Her weight was documented as 142 lbs. (pounds), and she was noted to have had no recent weight loss. She was documented as not rejecting care. Further review if the record revealed the resident had two documented weights. She was noted to weigh 153 lbs. on 3/9/21 and 142 lbs. on 5/25/21. There were no additional weights documented. This weight decline was a 7.19% loss, indicating a downward trend. (A weight loss of 7.5% in a three-month period of time is considered a significant loss.) A 6/16/21 Nutrition Therapy Recommendation documented that the resident needed fortified foods with meals, due to a weight trending down. A Nutritional Review, dated 9/17/21, indicated the resident was on a consistent carbohydrate diet (CCD), regular texture. She was also on fortified foods, and no added salt (NAS), for weight loss. She was documented as dependent with eating and needs to be fed, as she was difficult to get to eat or drink at times. The nutritional assessment documented that she had no recent weights, with the last being recorded as 142 lbs. on 5/25/21. The assessment noted that there was no identified weight trend in the last 30, 90, 180 days due to no trend due to no recent weights. The resident was noted to need continued monitoring of weights and intake, as needed. The resident was documented to have an anticipated decline if unable to consume adequate intake. A physician's progress note, dated 10/7/21, indicated the resident was somewhat dependent for activities of daily living. She was noted to have mild protein-calorie malnutrition, and the facility should encourage completion of all meals and snacks. The physician's progress note also identified that the resident had hypothyroidism, and it was advised that the facility report any weight changes. The progress note also documented that the resident had hyperlipidemia, and was advised to be on a low-fat diet with daily exercise. This physician's progress note identified that the resident's weight was 142 lbs. (documented on 5/25/21). A care plan initiated 3/17/21, and last revised on 7/7/21, revealed that the resident had a nutritional problem or potential nutritional problem related to dementia, schizoaffective disorder, diabetes, hypertension, multiple behaviors, wandering, refusal to eat or drink at times, therapeutic diet, and above BMI (body mass index) range of 27.1. She had the potential for weight loss anticipated. She was noted to have fortified foods, refusal to be weighed at times, and combative with staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 6 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Identified interventions, in pertinent part, indicated to offer snacks during the day; provide and serve diet as ordered, with fortified foods with meals; RD (registered dietitian) to evaluate and make diet change recommendations PRN (as needed); and weigh as ordered. A care plan initiated on 3/9/21, and last revised on 5/14/21, revealed that the resident had an ADL (activities of daily living)/self-care performance deficit related to dementia. Interventions, in pertinent part, identified that the resident was able to eat with set-up to limited assistance with meals. The lunch meal was served to Resident #23 on 11/10/21 at 12:18 p.m. Resident #23 was observed sitting up in her room next to her lunch tray. Staff was heard in the hallway stating that someone would come and assist her with her meal. On 11/10/21 at 12:44 p.m., Resident #23 was observed resting in bed, and her food tray was gone. An interview was conducted with Certified Nursing Assistant (CNA) P on 11/10/21 at 12:45 p.m. He stated he had assisted Resident #23 with her lunch because she required assistance with meals. He stated the resident did not want to eat her lunch, he could not make her eat her meal, and he had not provided her an alternative meal. He stated he had not been trained to provide alternatives or offer interventions to encourage the resident to eat if she did not want what had been provided. He further stated he had three other residents on the unit to assist with meals during this shift, and he could not force Resident #23 to eat her provided meal. An interview was conducted with the registered dietitian (RD) on 11/10/21 at 12:00 p.m. She stated she tried to come to the facility once a week to review initial, quarterly, and annual nutritional assessments. She would review for wounds, weight loss, and significant changes in weights. In October, she noted that a lot of residents did not have documented weights. She stated she gave this list to the Director of Nursing (DON). She further stated some of these residents may not have been compliant or may have been on hospice. She said the facility had tried to get resident weights, because they were needed. An interview was conducted with the DON on 11/10/21 at 4:09 p.m. She stated when she started, she had spoken with the RD. She stated she had not known that they did not have all of the resident weights. The restorative aide would do the weights, but they had been hiring new restorative aides, and were still training them. She sent the information to the RD so the facility could assess for any resident weight loss. She stated she would then take the information to the physician, and they would establish physician's orders as needed for the residents. The facility policy for Weighing the Resident, last revised 10/4/2021, stated in pertinent part: Residents will be weighted unless ordered otherwise by the physician: -Admission/readmission x 3 days -Weekly x 4 weeks -Monthly thereafter -As needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 7 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0692 Weights will be completed as indicated and documented in the clinical record. Level of Harm - Minimal harm or potential for actual harm Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change; consult with the Director of Dietary Services and/or dietitian; Notify the Interdisciplinary Team in order to update the plan of care. (Photographic evidence obtained) Residents Affected - Few The facility policy on Dining and Food Preferences, last revised 9/2017, stated in pertinent part: The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. The alternate meal and/or beverage selection will be provided in a timely manner. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 8 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility records and interviews with staff, the facility failed to post daily staffing information that included the name of the facility and the actual number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs) on one of four days during the survey, and on an indeterminate number of days between 10/27/21 and 11/7/21. Residents Affected - Few The findings include: An observation of the posted nurse staffing hours was made on 11/07/21 at 11:15 AM. The form was encased in a plastic picture frame and prominently displayed on the countertop at the nurses' station. The document, however, reflected the staffing hours for RNs, LPNs and CNAs for the day of 10/27/21. There were no additional completed staffing forms for more recent dates behind the single sheet. (Photographic evidence obtained) An interview was conducted with the Staffing Coordinator (SC) on 11/10/21 at 3:01 PM. She stated the night nurse was responsible for posting the daily nurse staffing form, but if the night nurse did not post it, she would. The SC did not realize the staffing was still posted for 10/27/21 on the day survey commenced, 11/7/21. She had no explanation. By survey exit on 11/10/21 at 5:50 PM, no staffing hour sheets for the missing dates 10/28/21 to 11/6/21 had been provided for review. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 9 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, interviews with staff, and a review of facility policies and procedures, the facility failed to ensure PRN (as needed) orders for psychotropic medications were limited to 14 days, and were not renewed unless the prescribing practitioner evaluated the resident for one (Resident #5) of one residents with an open-ended PRN order, out of six residents reviewed for unnecessary medications, from a total of 30 residents in the sample. The findings include: A record review for Resident #5 revealed she was [AGE] years old. An admission Minimum Data Set (MDS) assessment with an assessment reference date of 8/9/21, noted inattention and disorganized thought were continuously present. Diagnoses included non-Alzheimer's dementia, anxiety, depression and schizophrenia. Resident #5 had a physician's order for Lorazepam (used to treat anxiety) 0.5 milligrams every two hours as needed for anxiety, which was started on 9/18/20. The end date was noted as indefinite. (Photographic evidence obtained) Further review of the clinical record found there was no documentation by Resident #5's physician(s) justifying or extending the use of the Lorazepam beyond the 14-day period as required. A review of Resident #5's medication administration records (MARs), found the Lorazepam was administered on the following dates in 2021: January 1st and 7th; February 5th, 7th, 10th, 20th, 22nd and 26th; March 10th; April 9th, 19th and 23rd; May 6th, 14th and 19th; June 10th and 19th; July 3rd, and August 9th, 16th, and 28th. (Photographic evidence obtained) A review of the Narcotic Count Sheet for Resident #5's Lorazepam, indicated additional doses were counted and signed out for administration on: May 9, 2021, May 22, 2021, October 4, 2021 and October 25, 2021. (Photographic evidence obtained) An interview was conducted with Licensed Practical Nurse (LPN) I on 11/10/21 at 1:08 p.m. She was asked who entered physician's orders into the electronic record. She stated the night nurse usually filed the orders and checked them for accuracy. LPN I was asked if she was aware of the duration PRN psychotropic medications was limited to. LPN I stated some medications might be prescribed indefinitely. She was unaware of the requirement for a 14-day limit on PRN psychotropic medications, unless that medication was reviewed with justification documented by the physician. An interview was conducted with the Director of Nursing (DON) on 11/10/21 at 2:10 p.m. She was asked to review the order for Resident #5's Lorazepam. When she recognized the order duration was indefinite, she said, No, that is supposed to have a 14-day stop date. The DON acknowledged there had been no stop date since the order was written on 9/18/20. A review of the facility's policy and procedure titled Medication Management, Psychotropic Medications (policy N-1255 revised 3/23/18), revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 10 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Policy: Residents who have not used Psychotropic medications are not given these medications unless it is necessary to treat a specific condition as diagnosed . Procedure: . 7. PRN physician orders for psychotropic medications are limited to 14 days, except, if the physician or prescribing practitioner believes that it is appropriate to extend beyond 14 days and documents the rationale in the medical record. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 11 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. This failure affected all 54 residents who received meals from the kitchen, as well as any residents who received food from the nourishment room, from a total of 55 residents in the facility. The findings include: On 11/7/21 at 12:39 p.m., two clinical staff were observed entering the kitchen without hairnets. On 11/9/21, the trayline was observed at 12:10 p.m. Observations were made of Dietary Aide S putting plastic bottoms on top of a resident's plate. The Certified Dietary Manager (CDM) was asked at this time whether bottoms were being used as tops and he stated no. Observations were made of a barbequed chicken sandwich being served on a plate that was being compromised by being pressed down on with the plastic bottom. The CDM stated they were bottoms, then proceeded to ask staff to use tops and bottoms plastic ware on each plate. At this time Dietary Aide S stated, We don't have enough tops. The CDM did not respond to her, so she proceeded with the use of the bottoms. Observations were made of the dietary staff running out of plastic tops and bottoms. Kitchen Staff Member R was asked how many plates they had left to serve and she stated about 20. The CDM then directed the dietary staff to go to the resident hallways and get the plastic tops so they could be cleaned and used again for the last 20 trays. During trayline, a clinical staff member entered the kitchen without a hairnet and took 5 to 7 steps across the kitchen before being told to exit. Kitchen Staff Member R changed gloves without washing her hands first. It was observed at this time the kitchen had run out of hamburger buns for the lunch meal service and had to use sandwich bread for the last 20 or so plates. Kitchen Staff Member R was again observed changing gloves without washing her hands between glove changes. The CDM told the kitchen staff to wash the tops before putting them on the remainder of the plates. Dietary Aide S was observed waving two tops through the air to get them dry before placing them on top of the plates. During an interview with Dietary Aide S, she was asked how long the kitchen had been low on plastic tops and bottoms. She replied, Around the same time as the pandemic started sometime last year. She reported the CDM was aware of the equipment shortage. An interview was conducted with the CDM on 11/09/21 at 1:48 p.m. He stated he was not aware of the shortage of plastic tops and bottoms, and he was not able to place an order for more himself. An interview was conducted with Manager in Training T on 11/10/21 at 9:30 a.m. He stated he had been employed with the facility for 2.5 weeks, and was not made aware of the shortage of plastic tops and bottoms, but he would order more of them. On 11/9/21 at 4:00 p.m., an observation was made of the facility's nourishment room refrigerator. A pitcher of cranberry juice was dated 11/1/21 to 11/4/21. (Photographic evidence obtained) On 11/10/21 at 2:45 p.m., a second observation was made of the facility's nourishment room refrigerator. A bag containing two cupcakes was labeled with a name but it was not dated. One Styrofoam container with food in it was labeled with a name and room number on it but no date. Applesauce to be used for medication pass was dated 11/5/21 to 11/8/21, and a bag of fruit was labeled with a name, a room number and was dated 8/24/21. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 12 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An interview was conducted the Manager in Training T on 11/10/21 at 2:45 p.m. When asked who was responsible for cleaning the nourishment room, he reported the Certified Nursing Assistants (CNAs) were responsible. On 11/10/21 at 3:48 p.m., Personal Care Assistant (PCA) D was asked about cleaning of the nourishment room and refrigerator. She reported that housekeeping was responsible for cleaning out the refrigerator. On 11/10/21 at 3:49 p.m., the Housekeeping Manager was asked who was responsible for cleaning the nourishment room. He reported that housekeeping cleaned the floors and wiped down the inside of the refrigerator on Fridays, but they did not dispose of anything in the refrigerator. On 11/10/21 at 4:15 p.m., the Director of Nursing (DON) was interviewed about the nourishment room cleanliness. She stated she believed the kitchen staff were responsible for cleaning it, and she had no duties assigned to nursing staff related to the nourishment room. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 13 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who required restorative services to assist with carrying out activities of daily living, received those services. Specifically, the facility failed to ensure one (Resident #50) of three residents reviewed for activities of daily living (ADLs), from a total of 30 sampled residents, received appropriate restorative assistance with dining. Residents Affected - Few The findings include: A review of Resident #50's medical record, revealed she was initially admitted to the facility on [DATE], and then readmitted on [DATE]. Her primary diagnosis was lack of coordination. Secondary diagnoses included chronic obstructive pulmonary disease, dementia with behavioral disturbance, anxiety, muscle weakness, mild protein-calorie malnutrition, anorexia, and a need for assistance with personal care. The 10/26/21 minimum data set (MDS) assessment documented a brief interview for mental status (BIMS) score of 0 out of a possible 15 points, indicating severe cognitive impairment. The resident was documented as requiring extensive assistance of one person for eating. A review of the resident's record revealed a Nutritional Review on 10/24/21 that indicated the resident was on a regular, dysphagia advanced diet with the addition of Med Pass (nutritional supplement). She was documented as requiring supervision with eating. She was noted to require restorative dining. Additional documentation indicated the resident was able to eat by herself with the assistance of a staff member. Her intake was between 76-100% of meals while in restorative dining. The facility would continue to encourage intake and snacks. A physician's progress note, dated 10/28/21, indicated the resident was somewhat dependent for ADLs. She was noted to have mild protein-calorie malnutrition, and the facility should encourage completion of all meals and snacks. A 3/3/21 physician's order documented that the resident should receive restorative dining, set up for meals, prefers three sugars with oatmeal, cut up/break up chunks of food; provide verbal, visual, tactile cues for patient to sustain attention toward meal assist with completion of intake to meet nutritional needs; tactile cue-put spoon in patient hand and provide assistance with putting food on utensil and then to patient mouth 1-2 times, patient will then facilitate the motion on her own. With meals. A care plan, initiated 8/30/19 with last revision on 10/14/21, documented that the resident had an ADL/Self-Care Performance Deficit related to dementia, fatigue, and generalized weakness. Interventions included, in pertinent part, that the resident was on restorative-dining, to provide the resident with set-up, reduce as much as you can from being visually overwhelming. Have resident sit upright in chair to improve her alertness and engagement with meals. Provide verbal and visual cues for resident to re-attend (may put food on spoon and hand to resident to help reorient towards meal). Turn plate so foods are close to resident . All meals seven days a week. Continuous observation on 11/9/21 from 10:01 a.m. until 1:44 p.m. revealed: -11:01 a.m. Resident #50 was observed in bed with her eyes shut. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 14 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -11:17 a.m. Resident #50 came out of her room, and sat in a chair across from her room in the facility hallway. -11:26 a.m. A snack and drink cart came down the hallway, and a staff member handed the resident an opened package of cheese crackers. She was offered no drink. The resident sat in her chair, and held the crackers in her hand. There was no staff around to cue or assist the resident to eat the crackers. She continued to hold them in her hand. -11:29 a.m. The resident stood up, still holding the crackers in her hand. A staff member observed the resident standing up, and asked her if she wanted to lie down in bed. The staff member assisted the resident into her room, turned off the resident's overhead light, and exited the room at 11:30 a.m. The resident was now observed in bed, with the lights out, and the crackers were gone. -12:50 p.m. Resident #50 was observed with her eyes open, still in bed with the lights off. Meals were now being brought to the resident rooms. -12:54 p.m. The resident's meal was brought to her room. She was assisted to sit up on the side of her bed, her meal placed in front of her on her table, and the staff member left. -1:01 p.m. The resident was observed holding a piece of bread in her hands, and holding a bowl of food up to her mouth and licking the contents. No staff was observed cueing or assisting the resident during the meal. -1:07 p.m. Certified Nursing Assistant (CNA) L was observed entering the resident's room and repositioning her in bed. She sat her up in bed, stirred up some of her mashed potatoes, and offered the resident a bite. The resident turned her head away, so CNA L left the room. -1:20 p.m. The resident was observed still sitting up in bed, staring at her plate, left untouched. CNA L entered the resident's room again and asked the resident, You don't want it? She picked up the resident's roommate's tray and left the room. -1:32 p.m. CNA L entered the resident's room and said, You didn't like this, did you? She then took Resident #50's lunch tray and left the room. CNA L was observed at 1:36 p.m. pushing the lunch meal cart back down the facility hallway, without offering the resident any additional food items. -1:43 p.m. CNA L entered the resident's room and cleaned the resident with a washcloth. She did not offer the resident any additional food or drink. An interview was conducted with CNA L on 11/9/21 at 1:44 p.m. She said Resident #50 was on a mechanical soft diet and could eat by herself. Sometimes the resident would need a little help with her drinks. If the resident liked her meal, she would have eaten it all up, but she did not like the one that came today. CNA L stated the resident ate better with a pureed diet, but that was not what she was normally eating. The resident really enjoyed eating sweets. The following meal observations were made on 11/10/21: Breakfast An observation on 11/10/21 at 8:27 a.m., revealed the resident sitting up in her bed with her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 15 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few overbed table in front of her. She was observed eating unsupervised. She had a divided plate, and had eaten 75% of her meal. She had a full cup of orange juice and an uneaten bowl of cereal out of reach on the bedside table. She had no other drink on her tray. Her meal ticket documented that the resident required a divided plate, a foam built-up spoon, and a two handled cup. Only the divided plate was observed in use. An interview was conducted with the registered dietitian (RD) on 11/10/21 at 12:00 p.m. She stated she tried to come to the facility once a week to review initial, quarterly, and annual nutritional assessments. She said she would review for wounds, weight loss, and significant changes in weights. Resident #50 required staff participation with dining, which would include one-on-one assistance at meals. The RD said this would be a part of the resident's restorative program to improve meal intake. Lunch On 11/10/21 at 12:19 p.m., Resident #50's lunch tray was brought to her room. She did not have the two-handled cup or the built-up spoon on her tray, as was identified on her meal ticket. She was assisted to the side of her bed, the overbed table was placed in front of her, and the staff member left the room. The resident did not touch her food, but drank only from her water cup. She did not have her dessert or milk. The Director of Rehab (DOR) was interviewed on 11/10/21 at 12:24 p.m., as she entered Resident #50's room. She stated the resident should not be sitting on the edge of her bed eating, she should be on the restorative dining program, and should be eating in the dining room so she could receive cueing or assistance as needed. The DOR stated the resident did not have the adaptive equipment identified on the meal ticket and did not have her dessert. The Occupational Therapist (OT) was interviewed on 11/10/21 at 12:28 p.m. She stated the resident needed assistance with dining. The resident's dining needs fluctuated, but she had required assistance with dining for awhile. CNA L was interviewed on 11/10/21 at 12:38 p.m. She stated the resident should be eating her meals in a chair. She said she had not looked at the meal tickets before to see whether adaptive equipment was being served with the resident's meal. It was understood that the dietary department would be responsible for ensuring meals were served properly. Resident #50 should be in the dining room to get assistance with meals, because she needed restorative dining. The resident needed help with meals. An interview was conducted Restorative CNA O on 11/10/21 at 12:47 p.m. She stated there were two restorative aides. For restorative dining, the residents should be receiving assistance with all of their meals in the dining room. Resident #50, due to her dementia, would want to go to sleep if she was always eating in her bed. The resident should be eating with assistance in the dining room. An interview was conducted with the Certified Dietary Manager (CDM) on 11/10/21 at 2:24 p.m. He stated once the resident meals were sent to the floor, the dietary department did not monitor how the food was prepared in front of the residents. The dietary department and the staff on the floor should all be looking at the resident meal tickets to ensure the meal tickets matched the items that were served to the residents. Both the staff on the meal service line and the CNAs on the floor should all be making sure the residents received the right food and any adaptive equipment. He stated he was not aware that Resident #50 required adaptive equipment with dining, but would review her record. At 2:44 p.m., the CDM said he had reviewed the resident's meal ticket and noted that it indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 16 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0825 adaptive equipment, but he could not find any current physician's orders for them. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Director of Nursing (DON) on 11/10/21 at 4:09 p.m. She stated they had new restorative aides that they were training. Resident #50 required restorative dining. She said she thought that meant staff would sit with the resident and help the resident stay at her current best level for dining. She stated that would include adaptive equipment. Residents Affected - Few The facility policy on Restorative Nursing Services, last revised 8/24/17, stated in pertinent part: Restorative nursing will be provided to residents as indicated upon evaluation to assist in achieving the highest practicable level of physical functioning as possible. (Photographic evidence obtained) The facility policy on Dining and Food Preferences, last revised 9/17, stated in pertinent part: The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. The alternate meal and/or beverage selection will be provided in a timely manner. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 17 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records and interviews with staff, the facility failed to ensure accurate documentation of psychotropic medication administration for one (Resident #5) of six residents reviewed for unnecessary and psychotropic medications, from a total of 30 residents in the sample. The findings include: A record review for Resident #5 revealed she was [AGE] years old. She had diagnoses including non-Alzheimer's dementia, anxiety, depression and schizophrenia. Resident #5 had a physician's order, dated 9/18/20, for Lorazepam (used to treat anxiety) 0.5 milligrams (mg) every two hours as needed for anxiety. (Photographic evidence obtained) A review of the Medication Administration Records (MAR) and corresponding Narcotic Count Sheets for Resident #5 identified discrepancies on the following dates: On May 6, 2021, May 14, 2021, and May 19, 2021, the MAR was signed by a nurse indicating one dose of Lorazepam was administered to Resident #5 on each of those days, however, the corresponding Narcotic Count Sheet indicated additional doses were dispensed on May 9, 2021 (1 dose) and May 22, 2021 (1 dose). Those dispensed doses were not noted on the MAR. (Photographic evidence obtained) In October 2021, the MAR was not signed all month, indicating zero (0) doses of Lorazepam were administered to the resident, however, the Narcotic Count Sheet indicated Lorazepam 0.5 mg was dispensed on October 4, 2021 (1 dose) and October 25, 2021 (1 dose). (Photographic evidence obtained) An interview was conducted with the Director of Nursing (DON) on 11/10/21 at 2:10 p.m. She was asked to review the Narcotic Count Sheets and the MARs for Resident #5's Lorazepam. After doing so, she acknowledged the discrepancies and that the MAR and Narcotic Count Sheets did not match. The DON could not explain the discrepancies. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 18 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on staff interviews, a review of resident records, and a review of facility policies and procedures, the facility failed to maintain a current hospice plan of care in the resident records for one (Resident #5) of two residents reviewed for hospice services, out of four residents receiving hospice, from a total of 30 residents in the sample. The findings include: An interview was conducted with Resident #5's hospice certified nursing assistant (CNA) on 11/09/21 at 11:35 a.m. after she emerged from Resident #5's room. She stated she came in to see Resident #5 twice a week to provide patient care, showers, bed baths and range of motion exercises. Some mornings she assisted with breakfast if Resident #5 was still in bed, as she needed help if eating in bed. After the hospice CNA provided care, she said she documented that and gave the notes to the hospice provider. Licensed Practical Nurse (LPN) K was interviewed on 11/09/21 at 11:29 a.m. She confirmed Resident #5 was on hospice and that the hospice nurse was just in yesterday. The CNA also came in 2 times a week and as needed. She was asked how she knew what the hospice plan of care, as opposed to the facility's care plan was. LPN K said she knew it would likely address keeping Resident #5 comfortable and pain-free, notifying hospice of any changes, and incorporating her advance directives. A record review for Resident #5 found an annual minimum data set (MDS) assessment with an assessment reference date of 8/9/21. Resident #5 was noted with continuous inattention and disorganized thought. She required extensive to total assistance with activities of daily living. Her diagnoses included non-Alzheimer's dementia, malnutrition, anxiety, depression, schizophrenia, sick sinus syndrome, and adult failure to thrive. Resident #5 was coded with a terminal prognosis that would result in a life expectancy of less than six months and was under hospice care. Resident #5 was care planned on 10/26/21 for her multiple diagnoses and needs. All care plans noted she was under hospice care with a decline anticipated. She had a specific plan of care for her terminal prognosis related to dementia. Interventions included having hospice care in the facility and working cooperatively with hospice to ensure the resident's needs were met. A Hospice Benefit Election form was signed by Resident #5's representative on 5/26/20. Further review of Resident #5's hospice records found there was no hospice plan of care or update to the plan of care since 9/18/20. An interview was conducted with the Director of Nursing (DON) on 11/10/21 at 10:54 a.m. She stated hospice staff verbally communicated with her when they came in to see the residents. The DON was not aware that the facility had no updates to Resident #5's hospice plan of care since 2020. A review of the facility's Hospice Services Agreement with Resident #5's hospice provider, dated 1/12/18, stated in Section 2: Responsibilities and Services to be Furnished by Hospice: .2.1 Hospice Plan of Care and Facility Services: Hospice will develop and/or maintain a Hospice Plan of Care for Hospice Patient in accordance with the COP (conditions of participation) for hospice . Hospice will furnish facility a copy of the applicable Hospice Plan of Care after admission to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 19 of 20 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 105665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119 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 0849 Level of Harm - Minimal harm or potential for actual harm hospice program. Hospice will update the plan of care in accordance with provisions of the COP. Any such updates to the Hospice Plan of Care by Hospice must be reviewed with facility's Minimum Data Set department and maintained in the facility's care plan binder. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 20 of 20