Inspection·December 12, 2024

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some from his pocket. Resident #8 removed a lighter from her purse and began to smoke. Staff Member S was asked to point out the safety aprons. Staff Member S indicated that he did not know where the smoking aprons were. The staff member was asked to see the area where smoking supplies are kept for the residents. Staff Member S stated that several of the residents normally keep their cigarettes and lighters with them. He explained that Resident #9 was not allowed to keep his lighter with him but many of the other residents keep their smoking supplies with them. He explained that he did not know where the box of smoking supplies or the aprons were kept. He indicated that he was a temporary staff member who came up after the hurricane. He indicated that he worked for a sister facility and has received training regarding safety in resident smoking areas. After the interview, Staff Member S stepped inside and left the residents smoking in the smoking area without supervision for approximately 1 minute. At approximately 9:34 AM, Staff Member B came out to assist. On 12/10/24 at approximately 9:40 AM, the Assistant Director of Nursing (ADON) came out to the smoking area. She was asked if the residents should have their lighters in their possession at all times. The ADON explained that residents should not have lighters with them. She explained that the facility has a smoking box that is supposed to come out with the aprons at smoking time. Resident #10 had a lighter in her hand at the time. The ADON collected the lighters from Resident #5, #6, #7, #8 and #10. At approximately 9:50 AM, a staff member brought Resident #4 outside to the smoking area. Resident #4 said, I can't see. Where is my cigarette? The staff member told her they are getting her an apron to wear for smoking. Resident #4 shifted impatiently raised her voice slightly as she said, I don't wear no apron. Where is my cigarette? Resident #4 was asked if she normally wears an apron when she smokes. She replied: No, No, No Ma'am. I don't know what they are giving an apron for. I have never worn an apron. As the staff member applied the apron, the resident said, What is this apron for? I have never used an apron. This is the first time they ever done this. On 12/10/24 at approximately 10:00 AM, a review of the record of Resident #4 revealed that she was admitted on [DATE]. Resident #4's care plan indicted that she had impaired vision and loss of vision in both eyes. The surveyor was unable to locate a smoking evaluation in the electronic record for Resident #4. Additionally, there was no mention that the resident smokes in the care plan. There was no indication she ever received any smoking related injuries or mishaps. On 12/10/24 at approximately 11:00 AM the ADON provided copies of two smoking evaluations for Resident #4, one dated 11/27/24 at 5:33 PM and the other dated 12/10/24 at 10:12 AM and the facility smoking policy. A review of the smoking evaluation dated 11/27/24 was conducted. The evaluation indicated that Resident #4 does not smoke. A smoking evaluation was not completed on that date. A review of the evaluation completed on 12/10/24 at 10:12 AM indicated that Resident #4 smoked. The assessment indicated that her vision was inadequate. She was determined to be a safe smoker. The assessment indicated that Resident #4 requires constant supervision while smoking. There was no mention of use of the smoking apron in the evaluation. Page 7 of the updated care plan indicated that Resident #4 was a smoker. Date initiated 12/10/24. Goals: The resident will not smoke without supervision through the review date. Date initiated 12/10/24. Interventions included the resident was instructed about the facility smoking policy on 12/10/24. The resident requires a smoking apron while smoking. Date initiated 12/10/24. The resident requires SUPERVISION while smoking. Date initiated 12/10/24. The resident's smoking supplies are to be stored at the nursing station. Date initiated 12/10/24. On 12/10/24 at approximately 12:00 PM, a review of the facility smoking policy dated 11/30/2014 was conducted. The policy stated, Residents that wish to smoke will be evaluated on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105764 If continuation sheet Page 2 of 3 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 105764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Gardens - Tallahassee 1650 Phillips Rd Tallahassee, FL 32308 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete admission/readmission, quarterly, and with change of condition to determine if assistance or supervision is required for smoking. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking the center will include the appropriate information on the care plan. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. The policy also stated that the center will retain and store matches, lighters etc . for all residents, which was not the case for Residents #5, #6, #7, #8 and #10. Event ID: Facility ID: 105764 If continuation sheet Page 3 of 3