Health inspection·June 11, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interviews and record review the facility did not ensure the recommendations from a Level II Preadmission Screening and Resident Review (PASRR) were initiated for one resident (#7) out of 15 residents sampled. Findings included: Review of the admission Record revealed Resident #7 had an initial admission date of 9/02/2016 with a readmission date of 4/20/2023. Resident #7 had a primary diagnosis of hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting the left non-dominant side. Resident #7 had secondary diagnoses to include unspecified psychosis not due to a substance or known physiological condition, schizoaffective disorder unspecified, impulse disorder unspecified, major depressive disorder recurrent moderate, need for assistance in personal care, bipolar disorder current episode depressed moderate, other specified anxiety disorders, and oppositional defiant disorder. A review of Resident #7's physician orders for June 2024 revealed an order for Fluoxetine HCL oral capsule 40 mg (milligrams) to give two capsules by mouth one time a day for depression, dated 8/31/2023; and Seroquel XR oral tablet extended release 24 hour 400 mg to give one tablet by mouth at bedtime for schizo-affective disorder dated 9/04/2023; with a new order for Seroquel XR oral tablet extended release 24 hour 300 mg to give one tablet by mouth at bedtime, dated 6/11/2024. A review of Resident 7's care plan revealed a Focus of Mood related to moderate depression initiated on 9/01/2023, with the following statement, PHQ 9 (Patient Health Questionnaire) score 10-14 (moderate to moderately severe depression), states feeling down, depressed, or hopeless, states/observed with insomnia-trouble falling asleep or staying asleep or sleeping too much, states/observed feeling tired or having little energy, states/observe with poor appetite or overeating, looks sad , pained or worried. The Goal for this focus area is to improve mood state or anxiety level by next review, minimize decline in ADLs (activities of daily living), participate in activities of choice and take medication as prescribed. Interventions for this goal included to administer psychotropic medications as ordered, observe for changes in mood /depression, notify physician and psychological services and observe/record/report to MD (medical doctor) prn (as needed) acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills. A Focus area, initiated on 9/01/2023, [Resident #7] has a use of psychotropic medications related to antidepressant to manage depression and insomnia and antipsychotic to manage schizoaffective disorder. The Goal for this focus area is to have minimal side effects and for resident to be at the lowest dose required to reduce symptoms while minimizing adverse effects to ensure maximum functional ability both mentally and physically through the next review. Interventions included psychological services per order and as needed, psychiatry services per order, as needed, per protocol, consult with pharmacy, MD to consider dosage reduction when clinically appropriate, and use of psychotropic medications will be reviewed at least quarterly with the IDT (interdisciplinary team)/ MD to review continued need for the medication and ensure lowest dose. A Focus area of psychosocial, initiated on 9/01/2023, with the following statement, [Resident #7] has a history of psychosocial well-being problem related to (actual); Resident does not get along well with roommates at times. Resident unwilling at times to share or compromise with roommate at times. The Goal for this focus area will have resident adjust to roommate by next review and to share room space on a fair basis with roommate as evidenced by willingness to utilize only half of the floor space, not overcrowd room with personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 2 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 0644 belongings etc through the next review. Interventions included psychiatric services as needed. Level of Harm - Minimal harm or potential for actual harm A review of Resident #7's Level II PASRR letter of determination, dated 5/23/2024, showed specialized services are deemed not necessary given the client does not appear to be in need of acute inpatient psychiatric care at this time. It is recommended that the following rehabilitative services, of a lesser intensity than specialized services, are added to the patient's Comprehensive Person-Centered Nursing Care Plan: Psychiatric medication management and supportive counseling. Residents Affected - Few A review of Resident #7's progress notes in the electronic medical record, as well as the hard chart, did not show psychological or psychiatric entries regarding supportive counseling. On 6/10/24 at 3:43 p.m. an interview was conducted with the Social Services Director (SSD). The SSD stated she was unable to locate any psychiatry notes on Resident #7 in the electronic chart. The SSD confirmed Medical Records was unable to locate psychiatric notes for Resident #7 and deferred to the Director of Nursing (DON) for assistance. On 6/11/24 at 3:30 p.m. an interview was conducted with the DON, who confirmed there was no follow up with psychology/psychiatry based on the recommendations from the Level II PASRR for Resident #7. The DON stated, We have contacted psych ARNP [advanced registered nurse practitioner] today to establish visits. A review of the facility's policy and procedure titled, PASRR Requirements Level I and Level II -Florida, effective February 2021, showed the policy as: Preadmission screening for mental illness and intellectual disability is required to be completed prior to admission to a nursing home. The screening is reviewed by admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. PASRR screening applies to all new admissions into a Medicaid certified nursing facility regardless of payor source . The procedure showed: PASRR Level I .2. Social services or RN (registered nurse) will review to determine if a serious mental illness (SMI) and intellectual disability (ID) or both exist while reviewing the PASRR form. The existence of either, or both, condition triggers the requirement for Level II review and will be provided to the appropriate state agency by the Social Services Director upon admission. The Social Services Director/Nursing Administration will review for completion and accuracy during the clinical meeting process. Recommendations will be implemented into the resident's plan of care then the document will be filed in the resident record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 3 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the admission Record showed Resident #86 was admitted to the facility on [DATE], with diagnoses that included other insomnia. Residents Affected - Some During and observation and interview on 6/10/24 at 1:09 p.m. Resident #86 was in bed and stated he was in bed and he doesn't attend activities by choice. He stated he just doesn't feel good. Review of the Order Summary Report as of 6/11/24 showed a physician order for the following: Lexapro Oral Tablet 10 MG (milligram) Give 1 tablet by mouth at bedtime for depression, start date of 4/16/24. Review of the Medication Administration Record (MAR) for June 2024 showed administration of: -Lexapro Oral Tablet 10 MG (milligrams) 1 tablet by mouth one time a day for Depression as ordered. Review of the care plan for Resident #86 showed: -[Resident #86] uses psychotropic medications r/t antidepressant to manage depression, date initiated: 4/18/24. Review of a new PASRR Level I for Resident #86, dated 5/27/24, showed: Section IA - no diagnoses checked Section III - not a provisional admission was checked no. During an interview on 6/11/24 at 3:16 p.m. the DON confirmed the PASRR Level I completed for Resident #86 on 5/27/24 was not revised correctly to include the new diagnosis of depression. She explained there was a full house sweep of PASRRs for current residents to determine if they were correct or needed revision. Resident #86's revised PASRR Level I was not correct. 4. Review of the admission Record showed Resident #200 was admitted to the facility on [DATE], with diagnoses to include unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the Order Summary Report as of 6/11/24 showed a physician order for the following: Psych evaluation due to increase anxiety and confusion, start date 5//18/24; Memantine HCI Oral Tablet 5 MG give 1 tablet by mouth one time a day for dementia, start date 5/19/24; Mirtazapine Oral Tablet 7.5 MG give 1 tablet by mouth one time a day for depression with poor appetite, start date 5/22/24. Review of the Medication Administration Record (MAR) for June 2024 showed Memantine HCI Oral Tablet 5 MG and Mirtazapine Oral Tablet 7.5 MG were administered as ordered. Review of the care plan for Resident #200 showed: -[Resident #200] uses psychotropic medications for treatment of depression with antidepressant, initiated on 5/20/24 and revised on 5/28/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 4 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 0645 Review of a PASRR Level I for Resident #200, dated 5/8/24 showed: Level of Harm - Minimal harm or potential for actual harm Section IA - no diagnoses checked Section IB - no conditions checked Residents Affected - Some Section II - all boxes checked no 5. Dementia checked no and related neurocognitive disorder checked no 6. Secondary diagnoses checked 'no' Section III - not a provisional admission was checked no. During an interview with the DON on 6/11/24 at 3:20 p.m., she confirmed the diagnoses of dementia should have been checked as a secondary diagnosis and the Level I PASRR should have been revised with the new diagnosis of depression. 5. Review of the admission Record showed Resident #201 was admitted to the facility on [DATE] and had an original admission date of 11/3/21 with diagnoses to include major depressive disorder (11/3/21). Review of a PASRR Level I for Resident #201, dated 5/23/24 showed: Section IA - no diagnoses checked Section IB - no conditions checked Section II - all boxes checked no Section III - not a provisional admission was checked no. During an interview with the DON on 6/11/24 at 3:22 p.m., she confirmed Resident #201 had a diagnosis of major depressive disorder. She confirmed this diagnosis was not included on the Level I PASRR for Resident #201. She stated if diagnosis is their documentation then, yes, it should have been on the PASRR. A review of the facility's policy and procedure titled, PASRR Requirements Level I and Level II -Florida, effective February 2021, showed the following policy: Preadmission screening for mental illness and intellectual disability is required to be completed prior to admission to a nursing home. The screening is reviewed by admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. PASRR screening applies to all new admissions into a Medicaid certified nursing facility regardless of payor source. Level 1 screening is typically done by discharge planners and hospital staff as a step in the discharge process. Procedure PASRR Level I showed: 1. During the admission process, Admissions or Business Development will communicate with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 5 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 0645 facility regarding prospective admissions and confirm a Level I PASRR has been completed. Level of Harm - Minimal harm or potential for actual harm 2. Social services or RN (registered nurse) will review to determine if a Serious Mental Illness (SMI) and Intellectual Disability (ID) or both exist while reviewing the PASRR form. The existence of either, or both, condition trigger(s) the requirement for Level II review and will be provided to the appropriate state agency by the Social Services Director upon admission. The Social Services Director/Nursing Administration will review for completion and accuracy during the clinical meeting process. Recommendations will be implemented into the resident's plan of care then the document will be filed in the resident record. RN will follow the Florida 3008 form for completion of all sections prior to submission of the PASRR Level II for the review period. Residents Affected - Some Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review form (PASRR) was completed to include accurate admission diagnoses, and updated when new diagnoses were added for five residents (#83, #86, #200, #201 and #74) of 15 residents sampled. Findings included: 1. Review of the admission Record showed Resident #83 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder and anxiety. Review of the care plan for Resident #83 showed: -[Resident #83] uses psychotropic medications r/t [related to] anxiety, date initiated: 02/05/2024. Review of the Medication Administration Record (MAR) for June 2024 showed: -Lexapro Oral Tablet 5 MG (milligrams) 1 tablet by mouth one time a day for Depression, date started: 05/07/2024, and -Clonazepam Oral Tablet 1 MG 1 tablet by mouth every 8 hours for Anxiety, date started: 02/15/2024. Review of a PASRR Level I for Resident #83, dated 02/02/2024 and located in the resident's hard chart and the resident's electronic medical record showed: Section IA - no diagnoses checked Section IB - no conditions checked Section II - all boxes checked no 5. Dementia checked no and related neurocognitive disorder checked no 6. Secondary diagnoses checked 'no' Section III - not a provisional admission was checked no. During an interview with the Director of Nursing (DON) on 6/11/24 at 1:34 p.m., she confirmed the diagnoses were not listed correctly on the PASRR for Resident #83, and confirmed he did have admission diagnoses that included anxiety and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 6 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A review of Resident #74's admission Record showed an admission date of 7/23/23 with diagnoses to includes other specified anxiety disorder and personal history of traumatic brain injury. A review of Resident #74's care plan Focus for Activities, initiated 7/30/23, showed [Resident #74] requires staff assistance with involvement of activities related to cognition: impaired cognitive function impaired thought processes related to traumatic brain injury, has problem with communication: rarely or never understood, unable to express ideas or want. Requires physical assistance to and from activities unable to complete interview for daily and activity preference in room activities. The goal for this focus is to provide in-room activities. The interventions included the resident needs assistance escort, to and from activity functions. A review of Resident 74's physician orders for June 2024 showed an order for side effects monitoring initiated on 7/20/2023. A review of resident 74's PASRR Level 1 with review date of 5/11/2024 showed in Section 1: PASRR Screen Decision- Making, Section A. Mental illness or Suspected Mental Illness had Resident 74's diagnosis of anxiety disorder checked as a mental illness and in Section B. Intellectual Disability or Suspected ID, Resident 74's traumatic brain injury was not checked. An interview was conducted on 6/11/24 at 3:30 p.m. with the DON. The DON confirmed upon review of Resident 74's Level 1 PASRR that the diagnosis of traumatic brain injury was not checked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 7 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 respiratory care and services were provided in accordance with professional standards for two residents (#44 and #206) of ten residents sampled for oxygen therapy. Residents Affected - Few Findings included: 1. A review of Resident #44's admission Record revealed she was readmitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (5/22/24), COVID-19 (5/22/24), and pneumonia (3/25/24). An observation on 6/8/24 at 1:39 p.m. of Resident #44 revealed the resident was receiving oxygen via a nasal cannula and the oxygen concentrator was set to 2.5 liters per minute (LPM). A review of Resident #44's physician orders, active as of 6/11/24, revealed an order, dated 5/23/24, for oxygen at 3 LPM via N.C. (nasal cannula) continuously for pneumonia every shift. An observation of Resident #44 on 6/9/24 at 4:13 p.m. revealed the resident was in bed and receiving oxygen via a nasal cannula. The oxygen concentrator was set at 2.5 LPM. Review of Resident #44's care plan, revised 5/23/24, revealed a Focus of Oxygen: [Resident #44] has Oxygen Therapy. Interventions included special equipment: Oxygen, initiated 6/6/24, administer oxygen as ordered, initiated 2/28/24. Review of Resident #44's Treatment Administration Record (TAR) for May 2024 revealed a check mark for the day, evening and night administration of oxygen at 3 LPM for 5/1/24 - 5/7/24 and 5/9/24 - 5/10/24. On 5/8/24 there was no documentation on the TAR for the day shift and a check mark for the evening and night shift. In an interview with Resident #44 on 6/10/24 at 3:50 p.m. it was observed that she was receiving oxygen via a nasal cannula at 2.5 LPM. She was observed with no signs or symptoms of distress. She stated the oxygen felt a little bit low. In an interview on 6/10/24 at 4:24 p.m. Staff B, Registered Nurse (RN) stated that it was the nurse's duty to monitor the oxygen for a resident and that it should be checked during med pass. She confirmed Resident #44 was to receive 3 LPM of continuous oxygen. At this time Staff B, RN and this surveyor entered Resident #44's room and Staff B confirmed Resident #44's oxygen concentrator was set at 2.5 LPM. 2. A review of Resident #206's admission Record revealed he was admitted to the facility on [DATE] with diagnoses to include pneumonia. An observation on 6/8/24 at 3:29 p.m. of Resident #206 revealed the resident was in bed receiving oxygen via a nasal cannula and it was set to 2.5 liters per minute (LPM). A review of Resident #206's physician orders, active as of 6/11/24, revealed an order, dated 5/8/24, for oxygen at 2 LPM via nasal cannula PRN (as needed) for pneumonia as needed for shortness of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 8 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 0695 breath. Level of Harm - Minimal harm or potential for actual harm Review of Resident #206's care plan, initiated 5/7/24, revealed a Focus of Oxygen: [Resident #206] has Oxygen Therapy. Interventions included special equipment: Oxygen, and administer oxygen as ordered. Residents Affected - Few In an interview on 6/11/24 at 10:22 a.m. the Director of Nursing stated the nurses should be checking the oxygen settings every shift. She confirmed if nurses are placing a check in the TAR that would indicate they checked the oxygen levels. Review of a policy titled, Oxygen Therapy, effective November 2023, revealed the policy as, Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 9 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner related to not ensuring the dishwashing machine reached the required wash temperature, not sanitizing beverage carts prior to beverage service, not ensuring cookware was in good condition, and not ensuring expired food was removed from the walk in refrigerator that could potentially affect 87 residents of a census of 95. Findings included: An observation on 6/8/24 of the two dietary aides (Staff A and Staff E) at 9:58 a.m. revealed they were washing the dishes from the breakfast service. Observation of them processing a couple of dish racks of dirty dishes revealed the dishwashing machine showed the wash temperature varied between 130 and 140 degrees and the rinse was at 180 degrees each time. Staff A and Staff E did not rewash the dishes. Staff E was not able to confirm if the dishwashing machine was a high temperature or low temperature machine. She stated she looks at the dishes and if food is still on them that is when they know to do it again. Staff A and Staff E stated the wash temperature should be at 150 degrees. Observation of the machine showed it was an es2000 HT (high temperature) machine. Staff A, Dietary Aide confirmed they do receive training when they first start. An additional observation on 6/8/24 at 10:13 a.m. revealed Staff A and E washing dishes from the breakfast meal. Staff E stated they keep an eye on it (temperatures). Staff E was observed to push a dish rack of dirty dishes into the dishwasher and started the washing cycle. The washing temperature reached 140 degrees and the rinse temperature reached 180 degrees. Staff E glanced at the temperatures during the cycle. Staff A proceeded to remove the dish rack from the machine following the completion of the rinse cycle. The dishes were not redone. A continued observation on 6/8/24 revealed, in the same area as the dishwashing machine, a personal cell phone, and a bottle of [brand name] disinfectant cleaner on a shelf below a shelf containing five trays of approximately 20 clean bowls. In addition, a florescent green speaker was observed on the same tray of clean coffee mugs. (Photographic Evidence Obtained) Further observation of the kitchen revealed a beverage cart with containers of creams with drips of a light brown substance on the outside of the packaging. (Photographic Evidence Obtained) Later, during this tour of the kitchen, the Dietary Manager stated this was from the breakfast service and they would be discarded. An observation of the walk in refrigerator revealed an open bag of celery with some of the tips colored brown and the bag approximately ¼ full of water and dated 5/9/24. The Dietary Manager removed the bag at this time. A muffin pan was observed on the top shelf of a storage shelf near the three compartment sink and was noted to have a blackened staining on the outside of the individual muffin sections and within the exposed muffin sections there was brown staining. (Photographic Evidence Obtained) During the continued observation on 6/8/24 the Dietary Manager confirmed the wash temperature for the dishwashing machine should be at 150 degrees or above and the rinse should be 180. She explained if the machine isn't reaching the temperatures the staff should stop and let her know and she would contact [vendor name]. An observation on 6/8/24 at 10:40 a.m. revealed Staff A, Dietary Aide and Staff E, Dietary Aide washing dishes and the wash temperature did not hit 150 degrees. The Dietary Manager then instructed Staff A and Staff E to do the dishes again. The Dietary Manager stated sometimes it takes three times (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 10 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 - Some for the machine to hit the correct temperature. The Dietary Manager was informed at this time of the previous two observations of the temperatures not getting to the 150 degrees and Staff A and Staff E continued to process the next load of dishes each time. The Dietary Manager stated they should have redone the dishes. A continued tour of the kitchen revealed an observation of the toaster on 6/8/24 at 10:50 a.m., with a heavy coat of crumbs on the rungs of the toaster. The Dietary Manager stated they had toast for breakfast and she attempted to remove the coating with her finger and the crumbs did not come off. An observation on 6/8/24 at 12:09 p.m. of the lunch service in the main dining room revealed sixteen residents receiving beverage service. The beverage cart was observed to have creamers with drips of a light brown substance on the outside of the packaging on the cart. In addition, a top to one of the pitchers was placed on top of the creamers. On 6/8/24 at 4:05 p.m. the Dietary Manager stated [vendor name] serviced the dishwashing machine today and stated the representative from [vendor name] said the rinse and wash temperatures will fluctuate up and down and when it is in the 140s it is acceptable. Review of the [vendor name] ES 2000 HT sell sheet revealed the operating temperature for wash (minimum) is 150 F and for rinse (minimum) is 180 F. Review of the Culinary Department Daily/Weekly Cleaning Schedule for the week of 6/2/24 revealed the item Clean Toaster was done by the AM [NAME] on 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8. The schedule also revealed the item of Coffee Carts Wipe Dwon/Clean Binders/Restock was completed by A3 on 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8. On 6/10/24 at 9:42 a.m. and observation of Staff C, [NAME] and Staff A, Dietary Aide revealed they were washing dishes from the breakfast meal. The dishwashing machine reached a wash temperature of 140 degrees. Staff C, [NAME] stated the wash temperature has to hit 150 degrees and sometimes she has to do it three times in a row for it to hit the number. On 6/10/24 at 11:35 a.m. an additional tour of the kitchen revealed six beverage carts with three pitchers on each and containers filled with creamers and sugar as well as a pitcher of lemonade, apple juice and tea. Staff C was wiping down each cart with a white rag dipped in soapy water in a clear pitcher. Staff C stated she got the soap from the dishwashing machine and filled the pitcher with hot water. Staff A, Dietary Aide was placing pitchers on the carts and then Staff C, [NAME] was observed removing the pitchers and placing them on the counter next to the beverage machine and the pitcher of soapy water. The tip of a white pitcher touched the clear pitcher and as she was rotating the pitchers from cart to counter a base of a black pitcher touched the clear pitcher of soapy water. As this cleaning continued, Staff C would ring out the white rag after dipping it into the clear pitcher of soapy water and carry the rag over the pitchers filled with beverages to be served to residents. At this time, the Dietary Manager was asked to confirm if the white pitcher of soapy water was sanitizer. The Dietary Manager asked Staff C if she used the sanitizer bucket and she stated she did not, that she filled the pitcher with the soap used for the dishwasher and then filled it with hot water. The Dietary Manager stated she needed to use the sanitizer bucket. Staff C, [NAME] proceeded to reclean two of the six carts with the sanitizer solution and Staff A, Dietary Aide pushed the carts out of kitchen. The other four carts were not recleaned with the sanitizer solution and were taken out of the kitchen by Staff A for beverage service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 11 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 - Some During an interview on 6/10/24 at 11:55 a.m. the Dietary Manager stated that she provides training to her staff monthly and annually. Review of the policy and procedure titled, Dish Machine, effective June 2024, revealed the policy as: o monitor dish machine temperatures and chemical saturation (parts per million [PPM]) for both high and low temperature machines each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes. Review of the policy and procedure titled, Cleaning and Sanitizing, effective June 2024, revealed the policy as: The facility promotes a safe, clean and sanitary environment for its employees, residents and visitors. The Food and Nutrition Services team maintains clean and sanitary kitchen facilities. Walls, floors, ceiling, equipment, dishware and utensils are clean and/or sanitized and in good, working order. Procedure: 8. Dishes washed in dish machines will comply with one of the following guidelines: a. High temperature dish machine per manufacturer guideline plate or at 150-165 degrees F (Fahrenheit) wash and 180 degrees F final rinse (or in accordance with State regulations). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 12 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 - Few 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 observation, interview and record review the facility failed to maintain a safe and homelike environment related to an unsecured toilet in one bathroom (Rm 405) shared by two independent residents of a sample of 10 resident bathrooms. Findings included: An observation on 6/8/24 at 1:05 p.m. of the resident bathroom in room [ROOM NUMBER] revealed a toilet that was crooked and slightly facing towards the wall. (Photographic Evidence Obtained) During an interview on 6/9/24 at 11:08 a.m. with a resident who resided in room [ROOM NUMBER] revealed she was in her room in her wheelchair with uncontrolled bodily movements as she spoke during the interview. She stated, It moves. She confirmed she uses the restroom independently. She stated she has told facility staff and it was never fixed. She stated, It is a safety issue being disabled in a wheelchair. Review of the Maintenance Work Orders North Wing Log Book on 6/10/24 at 1:14 p.m. revealed one work order logged for a broken handle on a toilet on 4/6/24. The log book was silent of any work order requests to fix the toilet in room [ROOM NUMBER]. In an interview on 6/11/24 at 10:05 a.m. with Staff D, Certified Nursing Assistant (CNA) she stated she would go right to maintenance or housekeeping and tell them if there was a concern in a resident's room or a maintenance issue. She confirmed the resident in Bed A/Rm #405 uses the bathroom independently. She confirmed she was aware the toilet was not straight. She stated, She (resident) twists it. She pushes it. It is easier for her to do on a slant. She stated, I usually go in and push it back. Staff D also confirmed the resident in Bed B/Rm #405 was independent and uses the toilet herself as well. In an interview on 6/11/24 at 10:41 a.m. the Nursing Home Administrator (NHA) stated the facility has [electronic work order system] and everybody should use it. If they don't have access; a nurse can put it (concern in resident room) into the system. In an interview on 6/11/24 at 11:53 p.m. the Social Services Director stated if something needs to be fixed or repaired it should be put into [electronic work order system]. In an interview on 6/11/24 at 11:58 both residents in Bed A and Bed B were in room [ROOM NUMBER]. The resident in Bed B confirmed she used the toilet independently. She confirmed the toilet moves. She stated, I noticed that. The resident in Bed A stated, It affects me. An additional observation on 6/11/24 at 1:33 p.m. revealed the toilet was crooked and able to be moved when pushed. A review of the work orders provided by the NHA and generated from the electronic work order system showed no work orders for the months of April, May or June 2024 to secure the toilet in room [ROOM NUMBER]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 13 of 14 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 105780 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Avon 1010 US 27 N Avon Park, FL 33825 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 During an interview with the NHA on 6/11/24 at 2:27 p.m. and the Director of Risk Management, they confirmed a review of the work orders generated from the electronic work order system included the months of April, May and June of 2024. They confirmed the work orders revealed one work order was generated for room [ROOM NUMBER] and it was for the toilet not flushing on 5/16/24 and that was fixed/completed on 5/17/24. Residents Affected - Few In an additional interview with the NHA on 6/11/24 at 3:44 p.m. the photographic evidence was shared and the NHA stated this should have been placed into [electronic work order system]. Review of the policy titled, Physical Environment, effective 1/1/20, revealed the Policy as: A safe, clean, comfortable, and home-life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation, and program areas are provided to enable staff to provide resident/patients with needed services. All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105780 If continuation sheet Page 14 of 14