Inspection·August 29, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the resident's nursing progress notes revealed that on 8/3/23, a certified nursing assistant (CNA) called a nurse to the dining room. The CNA stated she saw Resident #47 punch a female resident in the face, and the CNA sustained a bump on the left side of her lip. The nurse and CNA tried to move Resident #47 away from the woman, when he became combative, hitting staff in the face. They were unable to redirect Resident #47. He was described as confused, combative, and unable to answer questions about the incident. A physician's order was obtained to send Resident #47 to the emergency room (ER) for a change in cognition and combative behavior toward staff. 911 was called, police and emergency medical services (EMS) arrived, and Resident #47 was transported to the emergency room. A progress note dated 8/4/23 indicated the psychiatric nurse practitioner (NP) and physician were both notified of the altercation. The NP evaluated Resident #47 and completed the [NAME] Act paperwork. The sheriff and responsible party were notified. Resident #47's record contained a Certificate of Professional Initiating Involuntary Examination (a form required to initiate a [NAME] Act) dated 8/4/23, initiated by the psychiatric NP. It noted diagnoses including major depressive disorder, general anxiety disorder and dementia with agitation. The NP noted Resident #47 had a mental illness and because of the mental illness, was unable to determine for himself whether an examination was necessary. There was substantial likelihood that without care or treatment, the resident would cause serious bodily harm to others in the near future as evidenced by his recent behavior. The supporting evidence noted the incident, and assessed Resident #47 as unpredictable and dangerous to residents and staff. He could not be managed on psychotropic medications and would benefit from psychiatric hospitalization to adjust medication in a safe environment. (copy obtained) Further review of the record found there was no written notification provided to Resident #47 or his representative stating the reason for or effective date of the transfer; the location to which the resident was being transferred; a statement of the resident's appeal rights, including the the name, address (mailing and email), and telephone number of the entity that received such requests; or information about how to obtain an appeal form, assistance in completing the form, and submitting the appeal hearing request; including the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. An interview was conducted with the facility's Regional Nurse Consultant (RNC) on 8/28/23 at 3:28 p.m. She confirmed that she had reviewed Resident #47's record and was unable to locate the required written notification of the transfer. The RNC stated it was her expectation that the form be completed for an emergency transfer. Review of the facility's policy for Transfer/Discharge Notification and Right to Appeal (policy OP-102) effective 9/23/17 and revised on 10/24/22 revealed: Policy: Transfer and discharges of resident, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. Procedure: The center must permit each resident to remain in the center and not transfer or discharge the resident unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the center . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 2 of 11 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 08/29/2023 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 0623 Notice Before Transfer: Before a center transfers a resident, the center must: Level of Harm - Minimal harm or potential for actual harm -Notify the resident and resident representative(s) of the transfer and reason for the move in writing . Residents Affected - Few -The center must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman . -Notice must be made as soon as practicable before transfer . Contents of the Notice: The written notice must include the following: -The reason for the transfer . -The effective date of the transfer . -The location to which the resident is transferred . -A statement of the resident's appeal rights including the name, address, telephone number of the entity which receives such request . (copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 3 of 11 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 08/29/2023 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, facility policies and procedures, and interviews with staff, the facility failed to provide written information prior to hospital transfer that notified the resident/representative of the facility's bed hold policy for one (Resident #47) of one resident (Resident 47) reviewed for a hospital transfer/Baker Act, from a total of 22 residents in the sample. The findings include: A review of Resident #47's medical record found he was admitted to the facility on [DATE]. He had diagnoses including, but not limited to, dementia with behavioral disturbance, history of transient-ischemic attack (a brief stroke-like attack), mild cognitive impairment, insomnia, anxiety, and major depressive disorder, single episode, moderate. Resident #47's medical record revealed that he had a family member designated as his primary emergency contact and responsible party. A quarterly minimum data set (MDS) assessment with a reference date of 8/22/23, noted that Resident #47 presented with continuous inattention and disorganized thoughts. He was assessed with a short temper and was easily annoyed on 7 to 11 out of a total of 14 days over the assessment look-back period. Physical behavior towards others such as hitting, kicking, pushing, and scratching, and verbal symptoms toward others (threatening, cursing, screaming) occurred on 1 to 3 days of the 7-day look-back period. Resident #47 was ambulatory without assistance. Resident #47 was care planned on 2/28/23, and was last reviewed 8/9/23 for multiple behaviors including, but not limited to, kicking, slapping, or punching others, awake throughout the night, wandering, pacing, exit seeking, combativeness, hallucinations, delusions, screaming, cursing and rejection of care. The care plan description reported a resident-to-resident altercation on 8/3/23 and a hospital transfer for a [NAME] Act on 8/4/23. The goal was to have fewer episodes of behavior by the review date. Interventions included medications as ordered, anticipating and meeting needs, explaining procedures, and intervening as necessary to protect the rights and safety of others. Remove resident from situation and take to alternate location. Send out for psychiatric evaluation (8/4/23). A review of the resident's nursing progress notes revealed that on 8/3/23, a certified nursing assistant (CNA) called a nurse to the dining room. The CNA stated she saw Resident #47 punch a female resident in the face, and the CNA sustained a bump on the left side of her lip. The nurse and CNA tried to move Resident #47 away from the woman, when he became combative, hitting staff in the face. They were unable to redirect Resident #47. He was described as confused, combative, and unable to answer questions about the incident. A physician's order was obtained to send Resident #47 to the emergency room (ER) for a change in cognition and combative behavior toward staff. 911 was called, police and emergency medical services (EMS) arrived, and Resident #47 was transported to the emergency room. A progress note dated 8/4/23 indicated the psychiatric nurse practitioner (NP) and physician were both notified of the altercation. The NP evaluated Resident #47 and completed the [NAME] Act paperwork. The sheriff and responsible party were notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 4 of 11 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 08/29/2023 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A Certificate of Professional Initiating Involuntary Examination was completed by the psychiatric nurse practitioner (NP) on 8/4/23 and noted that the resident could not be managed on psychotropic medications and would benefit from psychiatric hospitalization to adjust medication in a safe environment. (copy obtained) Per the record, Resident #47 remained hospitalized until 8/9/23, however, there was no bed hold notice provided to the resident or representative notifying them of the facility's bed hold policy, the duration the bed would be held in his absence, or any daily room rate should the resident/representative choose to hold a bed while hospitalized . An interview was conducted with the facility's Regional Nurse Consultant on 8/28/23 at 3:28 p.m. She confirmed she had reviewed Resident #47's record and was unable to locate written notification of the bed hold. She stated it was her expectation that the form be completed for an emergency transfer. A review of the facility's policy for Bed Hold (policy SS-136), effective 3/1/15 and revised 11/1/17, revealed: Policy: Resident or Resident Representative will be notified on admission and at the time of transfer (to the hospital or therapeutic leave) of the bed hold policies, according to Federal/State requirements. Procedure: .2. At the time of transfer to the hospital. the center will provide a copy of notification of bed hold. -Requirement at time of transfer is met if the resident's copy of the notice is sent with other papers accompanying resident to the hospital. 3. The resident and/or representative to sign the Bed Hold Authorization, if possible, or if not available, telephone authorization may be used and documented in the clinical record or on a bed hold authorization form. (copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 5 of 11 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 08/29/2023 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 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, interview, and record review, the facility failed to ensure that one (Resident #1) of two residents who were unable to carry out activities of daily living (ADL) independently, from a sample of 22 residents, received the care and services necessary to maintain good grooming and personal hygiene. Resident #1 was not provided adequate nail care. Residents Affected - Few The findings include: On 8/27/23 at 3:00 p.m., Resident #1 was observed in bed watching television. Her fingernails were long on both hands. In an interview on 8/27/23 at 3:02 p.m., Resident #1 confirmed that she preferred her fingernails short and polished. She looked at her thumbnails and said, These are too long and dirty; they need to be trimmed. A review of the resident's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (dementia), osteoarthritis, unspecified cognitive/communication disorder, major depression, and unspecified dementia and without behavioral disturbance. A review of the care plan revealed that Resident #1 had a focus area for activities of daily living (ADL) self-care deficit related to dementia, impaired balance, limited mobility, and musculoskeletal impairment. Interventions included, but were not limited to: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. (copy obtained) A review of the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/13/23, revealed that the resident had a brief interview for mental status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. She also required limited one-person physical assistance with bed mobility and transfers, extensive one-person physical assistance with toilet use and personal hygiene, and total one-person physical assistance with bathing. She was documented as always incontinent of bowel and bladder. Rejection of care behaviors was not exhibited. (copy obtained) On 8/29/23 at 2:15 p.m., Resident #1 was observed in bed, alert, pleasant, and responding appropriately to questions about her fingernails. Both of her thumb nails were approximately two inches long and covered with brown matter. The resident stated she previously told a man that she wanted nail care. She was asked if she desired nail care today and she said, yes. On 8/29/23 at 2:19 p.m. in an interview with Certified Nursing assistant (CNA) C, she was asked who was responsible for providing nail care to the residents. She stated, CNAs provide nail care as we give care on shower days and as needed. She confirmed that she was assigned to Resident #1. She stated the resident required extensive to total care assistance for all ADLs. CNA C was accompanied to the resident's room and confirmed that the resident's nails were long and soiled. She stated the resident's brother did her nails at times when he visited. The resident stated again that she would like her nails clipped and filed. CNA C left to collect supplies to perform nail care. On 8/29/23 at 2:29 p.m. in an interview with Licensed Practical Nurse (LPN) D, she was asked who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 6 of 11 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 08/29/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm was responsible for providing nail care to residents. She replied, CNAs do nail care on shower days and anytime that it is needed. When asked how she ensured that that care/tasks assigned to CNAs had been completed, she stated that at times she went into the residents' rooms with the CNAs to assist in the provision of care. Additionally, the CNAs completed shower sheets and documentation for the care they provided during their shift. Residents Affected - Few A review of the facility's policy and procedure for Bathing/Showering (revision date 9/1/17), revealed: Assistance with showering and bathing will be provided at least twice a week and PRN (as needed) to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. This schedule will take precedence over the twice a week and PRN cleansing. The resident's frequency and preferences for bathing will be reviewed at least quarterly during care conference. A review of the facility's policy and procedure for Care of Nails (revision date 9/1/17), revealed that the procedure for nail care included the following: 1. Perform hand hygiene 2. Explain procedure to resident and bring the following equipment to resident's bedside. a. Basin, optional b. Towel c. Emery board d. Orange sticks e. Nail clippers 3. Place towel beneath the area to be treated. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 7 of 11 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 08/29/2023 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 0677 May soak hand in basin half- full with warm water if needed. Level of Harm - Minimal harm or potential for actual harm 5. Trim fingernails. Residents Affected - Few 6. Clean nails. 7. Apply lotion to nail area if indicated. 8. Clean and return equipment to designated area. 9. Discard disposable equipment. 10. Perform hand hygiene. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 8 of 11 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 08/29/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5%. There were five errors with 38 opportunities for error, resulting in an error rate of 13.15789% and involving four (Residents #24, #29, #44, and #9) of six residents observed during medication administration, from a total of 22 residents in the sample. Residents Affected - Some The findings include: During medication administration on 8/28/23 at 3:45 p.m., Licensed Practical Nurse (LPN) A was observed preparing medication for Resident #24. She obtained Eliquis (anticoagulant) 5 milligrams (mg), Coreg 6.25 mg for blood pressure, another Eliquis 5 mg and Vitamin C 500 mg. She stated medication should be crushed and administered via gastrostomy tube (G-tube - feeding tube). She picked up a pill crusher pouch ready to pour the medication in. She was asked to verify the medications with the orders and she confirmed that she had pulled two tablets of Eliquis 5mg instead of one as was ordered. She removed one Eliquis pill from the medication cup and discarded it. On 8/28/23 at 3:53 p.m., LPN A was preparing medication for Resident #29. She obtained Aspirin (blood thinner) 81 mg chewable, Senna S 8.6-50 mg for constipation, Midodrine 10 mg for hypotension (low blood pressure), and clonazepam 0.5 mg for anxiety disorder. She crushed the medication, mixed it in apple sauce then administered the medication to the resident by mouth. She was asked to review the physician's orders. After reviewing the physician's orders, she stated the medication should have been administered via G-tube. She further stated the resident was able to eat by mouth and was only getting bolus feedings via the G-tube. She said she did not pay attention because she thought since the resident was eating a mechanically textured diet, he could have the medication crushed. (Copies of the physician's orders were obtained.) On 8/29/23 at 10:08 a.m., LPN B was observed preparing medications for Resident #44. After reviewing the physician's orders, she stated she was missing Glimepiride 1 mg and Folic acid 1 mg for type II diabetes. She obtained over-the-counter folic acid 800 micrograms (mcg) and stated she would administer one and a quarter tablets of the folic acid. As she was pulling the medication from the packaging, she was asked to review the physician's order again. She stated the order was for Folic Acid 1mg, give 2 tablets by mouth one time a day. It was explained to her that 2 mg (two tablets) was the equivalent of 2000 mcg and again stated she would administer 1.25 tablets from the 800 mcg. She said, I don't know what I'm doing wrong. She then walked to the medication storage area at the nurses' station to see whether there was medication available of that strength. The Assistant Director of Nursing (ADON), who was at the nursing station, asked what she was looking for. She said folic acid 1mg. She was told that the resident would have their own medication for that strength; central supply did not order that strength. When asked if she had taken care of the resident previously, she replied,I had him on Wednesday and Thursday last week. She was asked what medication she administered then and she replied that she could not remember. A review of the reorder history revealed that the order for glimepiride was reordered on 8/22/23 and the medication administration record was signed off indicating the medication was not available. She was asked what the facility's protocol was for reordering medication. She replied, I'm not sure about the process in this facility, I work as needed. LPN B was observed again on 8/29/23 at 10:08 a.m. preparing medication for Resident #9. She obtained Vitamin D 1250 mg. A review of the physician's orders revealed an order for Calcium - Vitamin D 600- 400 mg. As LPN B was about to administer the medication to the resident, she was asked to clarify the mediations in the cup. She confirmed that she had the wrong medication (Vitamin D 1250 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 9 of 11 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 08/29/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some instead of Calcium - Vitamin D 600- 400 mg). She discarded the medication and obtained the correct medication. During an interview with the ADON on 8/29/23 at 10:45 a.m., she stated the nursing staff should reorder medications when they have at least three days' worth of medication left. When asked about the medications for Resident #44, she confirmed that the medication had not been available since 8/22/23. She added that she contacted the pharmacy and there was an issue with the insurance. The nurse assigned to the resident should have followed up. During an interview on 8/29/23 at 11:46 a.m., the Director of Nursing (DON) and ADON were notified of the concerns observed during medication administration. They both acknowledged the errors and the DON stated she would initiate training and competency checks for all nurses. A review of the facility's policy and procedure for Administering Medications (revised April 2019), revealed: 4. Medications are administered in accordance with prescriber orders, including any required time frames. 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dose, right time and right method (route) of medication before giving the medication. (copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 10 of 11 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 08/29/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations throughout the facility and interviews with staff, the facility failed to provide a sanitary, homelike environment for residents, staff and visitors by neglecting to maintain walls that housed resident personal air conditioner units in five of five rooms observed on the east wing (rooms 2, 3, 4, 6 and 12) out of 10 rooms on the unit and a total of 22 resident rooms in the facility. The facility also failed to provide needed maintenance and cleaning to the baseboards and the carpeted walls under the handrails on both the east and west wings. The findings include: Observations of the east wing were conducted on 8/27/23 at 12:56 p.m. In room [ROOM NUMBER], approximately 16 inches of the vertical surface wall to the right of the window air conditioner was observed with a significant amount of what appeared to be water damage. The wall was warped, bubbled, and cracking/peeling. The area extended approximately 16 inches up the right side of the unit. A ¼ inch gap between the unit and the wall exposed sunlight and the outdoors. Several feet of the horizontal wall surface above the baseboard had similar damage (warping and peeling paint and drywall). The windowsill housing the air conditioner was coated with dark dust and dirt-like matter. The floors and door jambs were scuffed and stained. (Photographic evidence obtained) Four more rooms on the east wing were inspected on 8/29/23 at 2:01 p.m. The window air conditioner in room [ROOM NUMBER] was observed with a similar ¼ inch gap to the outdoors along the right side of the unit. The sill to the right of the unit was coated with dark substance resembling dirt and dust. The sill and wall to the left of the unit in room [ROOM NUMBER] was observed with the same dark substance on the sill and wall. room [ROOM NUMBER] presented with the same condition on the right side of the air conditioner. In room [ROOM NUMBER], the grates and interior of the air conditioner were observed with black spots, resembling biological growth. The wall to the right of the unit was chipped and warped. There was also a 1/4-inch gap between the unit and the wall at the top of the unit on the right. Sunlight could be seen through the gap. (Photographic evidence obtained) The wall carpeting beneath the handrails on both the east and west wings was soiled with dark stains at the bottom where the carpet met the baseboard. Horizontal surfaces of the baseboard throughout both units were coated with dark substances resembling dirt and dust that wiped off with a finger swipe. The baseboards and doors were scuffed, dirty and in need of repairs or paint, as were the floors at the corners of door jambs throughout. (Photographic evidence obtained) A tour of the unit and halls was conducted with the Interim Administrator on 8/29/23 at 2:22 p.m. She confirmed the condition of the air conditioning units and walls and stated she had already spoken to the new owners about the situation. She acknowledged this was only a sampling of rooms and confirmed the condition of the walls, doors, floors and baseboards throughout the facility. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105665 If continuation sheet Page 11 of 11