Health inspection·August 18, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented the resident was cognitively intact and required extensive to total one to two-person assist with activities of daily living. A record review revealed a physician order to transfer Resident #52 to the hospital on [DATE]. Further review of the records revealed no corresponding progress note or assessment of the resident's condition. The last documentation of the resident was a progress note dated 08/08/22 at 3:00 PM. An interview was conducted with the ADON on 08/18/22 at 10:00 AM. The ADON acknowledged the above. 3. Resident #89 was admitted to the facility on [DATE]. A progress note dated 04/29/22 at 9:53 PM documented the resident was transferred to the hospital around 5:30 PM. Family was notified. Further review of Resident #89's record did not reveal any documentation of the resident's condition or reason for transfer. An interview was conducted with the ADON on 08/18/22 at 10:00 AM. The ADON acknowledged the above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the facility in a clean, comfortable and home like environment on 1 of 2 units (200 unit). The findings included: An environmental tour was conducted on 08/17/22 at 11:30 AM with the Plant Operations Director and House Keeping Manager. The following was observed: 1. room [ROOM NUMBER] had missing slates on window blinds, bathroom light fixture with debris and insect carcasses, and air conditioner unit with dust and debris. 2. room [ROOM NUMBER] air conditioner unit with dust and debris, bathroom floor border separating. 3. room [ROOM NUMBER] air conditioner unit with dust and debris, paint on wall peeling, bathroom floor border separating, and bathroom paint peeling. 4. room [ROOM NUMBER] air conditioner unit with dust and debris, bathroom floor tiles loose. room [ROOM NUMBER] air conditioner unit with dust and debris, walls with nails and stains. The Plant Operations Director and House Keeping Manager acknowledged the above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 provide ADL (Activities of Daily Living) Care in the form of shower per resident's preference and according to determined schedule for 1 of 4 residents reviewed for ADLs, (Resident #42). Residents Affected - Few The findings included: Resident #42 was admitted to the facility for current stay on 10/19/20. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #42 had a Brief Interview for Mental Status (BIMS) score of 8, indicating 'moderately impaired'. The MDS documented that Resident #42 required Extensive to limited assistance and 'one person physical assist' for Activities of Daily Living (ADLs) with the exception of eating and locomotion on unit. The assessment documented that Resident #42 required 'Physical help in part of bathing activity' with 'One person physical assist' and that the resident was ambulatory with the use of a walker and/or a wheelchair. The assessment documented that Resident #42 was 'always incontinent' of urine and bowel. Resident #42's diagnoses at the time of the assessment included: Anemia, Hypertension, Diabetes Dementia, Chronic Lung disease, Obesity, personal history of UTI, History of falling, Cataract. Resident #42's care plan, initiated on 04/11/22, documented, [Resident #42] has an ADL self-care performance deficit r/t Activity Intolerance, Limited self Mobility, dementia, decreased motivation. s/p Covid. The goals of the care plan were documented as: o Staff will keep resident appropriately groomed & dressed daily w/ pt participation w/ simple tasks, thru next review. 04/11/22 with a target date of 09/12/22 o Maintain balance and current level of strength, (75 feet) through next review date 07/01/22 with a target date of 09/12/22. Interventions to the care plan included: o Ambulatory to bathroom with assist and RW to maintain strength and balance (atleast 3 x week). o Maintain safety & dignity w/ cares. o Side Rails:: 1/4 bilateral upper side rails to promote independence in bed. o BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. o BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. o BATHING/SHOWERING: The resident requires (Extensive assistance) by (1) staff with (bathing/showering) (Schedule/Request) and as necessary. o BATHING/SHOWERING:Per resident requested schedule and routine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm o BED MOBILITY: The resident requires (Extensive assistance) by (1) staff to turn and reposition in bed (daily) and as necessary. o TRANSFER: The resident requires (Extensive assistance) by (1) staff to move between surfaces (daily) and as necessary. Residents Affected - Few During an interview with Resident #42, on 08/15/22 at 12:33 PM, when asked about being provided a bath or shower, Resident #42 replied, They said that I had COVID 2 months ago and they put me in another room with another woman that had COVID 19 and I haven't been showered since then. It's been three months at least. They clean me in the bed every morning. I would rather have a tub bath. Resident #42's Shower schedule documented resident's shower days as being every Monday, Wednesday and Friday on the 7-3 shift. On 08/18/22 at 9:27 AM, an observation was made of the shower room on the first floor, located behind the nurse's station with full sized sit in tub. It was noted that, upon turning on the water to tub/shower, the tub basin did not hold and the water only came out of the hand-held shower attachment. During an interview, on 08/18/22 at 9:31 AM, with Staff J, RN/UM and the Director of Nursing (DON) when asked about the concern with the tub, Staff J stated that it is used for showers. The DON stated that they can accommodate tub bath if resident requests. During an interview, on 08/18/22 at 9:37 AM, with the Plant Operations Director, when asked about the tub basin not holding water and water only coming out of the hand-held shower, the Plant Operations Director replied, I was told that they don't use the tub. Since I have been here, it has never been used. The Plant Operations Director stated that he had been working at the facility for 4 years. If they request it, they ask me to plug it to fill it up with water. No resident requested that or they (the nurses and CNAs) would let me know. During an interview, on 08/18/22 at 10:41 AM, with Staff B, CNA, when asked about when Resident #42 was most recently given a bath or shower, Staff B replied, this morning, she was supposed to have one, but she has a doctor's appointment and I will give her a shower when she gets back. Staff B further stated, (she) never asked for tub bath. Tuesday she said the she didn't want a shower. She is one person transfer I have never tried to get her in the tub. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative services to 4 of 4 residents reviewed for Restorative care (Residents #59, #20, #79, and #21). The findings included: A review of the facility's policy Restorative Nursing Services, revised 08/24/17, documented: Restorative Nursing will be provided to residents as indicated upon evaluation to assist in achieving the highest practicable level of physical functioning as possible. Therapy may refer a resident to restorative upon discharge from therapy services as deemed appropriate. Restorative programs provided by Restorative Nursing Assistants will be documented each time the program is provided on the Restorative Tracking Form. A weekly restorative nursing assistant note will also be completed weekly on the progress of the program on the restorative Tracking Form. Restorative programming will be included in the resident written plan of care. 1.) Resident #59 was admitted to the facility on [DATE] with multiple readmissions. A comprehensive assessment dated [DATE] documented the resident as severely cognitive impaired, and required total two-person assist with activities of daily living (ADL). The assessment further documented Resident #59 had no restorative services and required no braces/splints. Record review revealed Resident #59 was care planned for ADL self-care performance deficit and limited range of motion. An intervention included bilateral knee braces during the day, hip brace at night, and right elbow splint 6 hours a day. Resident #59 was observed on 08/15/22 at 9:30 AM in bed. Right upper extremity was observed contracted. There was no brace/splint in place. Pillows were tucked under the resident's knees. There was no splint or brace in place. Resident #59 was observed on 08/15/22 at 12:30 PM in bed being fed. Right upper extremity was observed contracted. There was no brace/splint in place. Pillows were tucked under the resident's knees. There was no splint or brace in place. Resident #59 was observed on 08/15/22 at 3:00 PM in bed. Right upper extremity was observed contracted. There was no brace/splint in place. Pillows were tucked under the resident's knees. There was no splint or brace in place. Resident #59 was observed on 08/16/22 at 10:00 AM anf 2:00 PM in bed. Right upper extremity was observed contracted. There was no brace/splint in place. Pillows were tucked under the resident's knees. There was no splint or brace in place. Resident #59 was observed on 08/17/22 at 9:30 AM in bed. Right upper extremity was observed contracted. There was no brace/splint in place. Pillows were tucked under the resident's knees. There was no splint or brace in place. An interview was conducted with Staff H, a Certified Nurse Assistant (CNA), on 08/17/22 at 12:00 PM. Staff H stated she used to be restorative CNA, but since the pandemic (03/20) has been pulled to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the floor for duties. Staff H stated there was no restorative aid, and as she knew it, it was delegated to the resident's primary care CNA. Staff H stated she does not have an assigned floor or rooms, she floats as needed. Surveyor inquired of any splints/braces required for Resident #59. Staff H stated she remembered the resident had splints at one time, and the resident was able to get up into a wheel chair, but the resident was too contracted to sit up in a wheel chair at this time. Staff H located a splint/brace in the back of a bottom drawer of the resident's room. Staff H stated it was an elbow splint, and stated she would apply. An interview was conducted with the Director of Rehabilitation on 08/17/22 at 4:30 PM. The Director stated it was the resident's primary CNA's responsibility to apply splints/braces. The Director stated Resident #59 was last discharged from physical therapy (PT) services on 09/14/21, and occupational therapy on 09/21/21. The Director further stated Resident #59 was discharged to restorative services for range of motion and splinting. A review of a Therapy Communication to Restorative Nursing Program dated 09/15/21 documented: Current Functional Status- dependent bed mobility and transfers, dependent activities of daily living, dependent feeding, and hoyer lift transfer. Problems/Needs- maintain joint mobility and reduce risks for contractures. Recommendations- apply knee braces throughout daytime and hip brace for night time every day, passive range of motion bilateral upper extremities, passive range of motion bilateral lower extremities, passive range of motion right wrist/hand/elbow, don right resting hand splint for 6 hours a day, don right elbow splint for 6 hours a day. The Director presented an attendance log for training on brace schedule on 09/10/21. The summary stated: Resident #59 was to wear both knee braces throughout the day time and the hip brace throughout night time to avoid increased contractions. Monitor skin throughout day and night and notify nursing if swelling, pain, or skin redness. The attendance log had 4 CNAs and 1 RN's signature (Staff H was in attendance). No documentation of training for Resident #59's right elbow brace. The Director stated she would do an evaluation on the resident for services. Further review of Resident #59's record did not reveal any documentation of any passive range of motion or splints applied since discharge from therapy services to restorative. An interview was conducted with the Director of Rehabilitation on 08/18/22 at 10:00 AM. The Director stated Resident #59 had a significant increase in contractors, and would resume PT and OT services. On 08/17/22 at 10:33 AM Staff D Licensed Practical Nurse (LPN) was asked who does Restorative Therapy, replied they used to have someone, but they left. On 08/17/22 at 11:44 AM Staff E LPN stated that they do not have Restorative Therapy. On 08/17/22 at 11:47 AM Staff F CNA stated that Staff H used to do the Restorative Therapy and splints. She stated that sometimes it is too busy to see who is doing the Restorative Therapy and she does not know who does it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 On 08/17/22 at 11:50 AM Staff G CNA stated that she does not do Restorative Therapy, Staff H used to. Level of Harm - Minimal harm or potential for actual harm On 08/18/22 at 10:09 AM the Director of Staffing stated that there has not been anyone designated as a Restorative Personnel since January of this year. Residents Affected - Few On 08/18/22 at 11:45 AM Staff B CNA stated that she does not do Restorative Therapy or splints, she believes that Staff H CNA does it. On 08/18/22 at approximately 12:05 PM the Administrator stated that the Restorative Employee left in January of this year and they have not been able to fill the position. 2) On 08/15/22 at 12:51 PM Resident #79 stated he wanted more therapy, but they stopped it. On 08/17/22 at 12:05 PM Resident #79 said he had asked Staff H CNA (certified nursing assistant) for restorative therapy, and she could not do it because there is no more restorative therapy, she is working as a CNA now. On 08/17/22 at 12:10 PM Resident #79 stated he had recently asked Physical Therapy for Restorative Therapy, but nothing ever happened. They told him the insurance was finished and he could not have any more therapy. He said he was worried because he feels he is getting weaker. Record Review for Resident #79 documented an admission date of 11/11/18 with diagnoses that include stroke with left sided paralysis, heart disease and depression. A Minimum Data Set assessment on 07/25/22 documented Resident #79 with moderate cognitive impairment requiring extensive assistance for all activities except locomotion (resident self-propels in wheelchair) and eating (requires set up help). An Occupational Therapy (OT) Evaluation on 04/20/22 documented, Patient demonstrates exacerbation of pain, impaired balance and impaired postural alignment indicating the need for OT to decrease painful condition of UE (upper extremity), minimize safety hazards/barriers, assess and modify environmental hazards and facilitate sitting tolerance and postural control. An Occupational Therapy Discharge summary dated [DATE] documented, Patient required skilled OT services to assess safety and independence with self-care and functional tasks of choice in order to enhance patient's quality of life by improving ability to be able to return to prior level of living. Discharge Recommendations: Home Exercise Program. 3) On 08/15/22 at10:25 AM Resident #20 stated he would like Restorative Therapy and said they do not come any more. He said he asked for therapy, but there isn't anyone that does Restorative Therapy. He stated because he is blind, he used to go for walks with Restorative Therapy. Record review of Resident #20 documented an admission date of 07/16/18 with diagnoses that include Blindness, Diabetes, Heart Disease and Peripheral Vascular Disease of the lower extremities. A Minimum Data Set assessment on 05/23/22 documented Resident #20 as cognitively intact requiring extensive assistance for locomotion in and off the unit. No documentation of Restorative Services was noted on the assessment. A Physical Therapy note dated 07/28/21 documented Resident #20 will be referred to Restorative for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 ambulation and for maintenance program. Level of Harm - Minimal harm or potential for actual harm On 10/15/2021 Restorative Nursing Progress Note documented, Mr [NAME] remains on restorative for ambulation. Continues to tolerate 200 feet with rolling walker and min assist. Left crow boot in place. Requires verbal and tactile cues during ambulation due to visual deficit. No further documentation entries for Restorative Therapy are noted. Residents Affected - Few 4) On 08/15/22 at 11:00 AM, 1:16 PM and 3:06 PM, no splint was observed on Resident #21's right hand. On 08/16/22 at 10:08 AM, 11:30 AM and 12 Noon, no splint was observed on Resident #21's right hand. On 08/17/22 at 10:32 AM, no splint was observed on Resident #21's right hand. Record review for Resident #21 document a readmission date of 03/25/22 with diagnoses that include Stroke with Right Sided Paralysis, Diabetes, and Pressure Ulcer. A Minimum Data Set Resident assessment dated [DATE] documented Resident #21 with severe cognitive impairment and a functional ability of total dependence on staff for all activities of daily living. A physicians order dated 06/01/22 states resident to wear right resting hand splint for up to 6 hours and or as tolerated for contracture management during the daytime. On 08/17/22 at 10:33 AM the surveyor asked Staff D LPN when does Resident #21 wear her splint. Staff D LPN stated the splint had been missing for more than a month and she had notified Physical Therapy. She said the resident transferred up from the first floor but the splint did not come with her belongings. Occupational Therapy Discharge Summary Notes dated 06/02/22 documented Restorative Splint and Brace Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 observation, interview, record review and policy review, the facility failed to provide services to accurately monitor weight, feed resident and prevent weight loss for 1 of 3 residents reviewed for nutrition, (Resident #65). Residents Affected - Few The findings included: On 08/15/22 at 12:43 PM, Resident #65 was observed resting in bed with eyes closed. A family member at the bedside said he feeds the resident when he is there. On the same day, preliminary record review showed Resident #65 was admitted to the facility on [DATE] after a stroke. Additional diagnoses included Dementia, Diabetes, Anemia, and Protein-Calorie Malnutrition. The resident's height and weight were documented as 66 tall and 117 pounds on 07/06/22, the day prior to admission. The admission progress note identified +2 (moderate) pitting edema to her arms and +3 (severe) pitting edema to both legs caused by fluid retention. Review of the comprehensive assessments completed on 07/18/22 and 08/11/22 showed BIMS (Brief Interview for Mental Status) exam scores of 13 out of 15 which indicated mild cognitive decline. The functional status section noted the resident needed extensive assistance from one person to eat. The weight loss section to identify a loss of 5% or more in the last month or loss of 10% or more in last 6 months was documented as no or unknown on both assessments. Review of the Initial Nutrition Evaluation dated 07/08/22 documented a different height of 69 tall, and a Usual Body Weight (UBW) of 117 pounds. The Ideal Body Weight (IBW) was calculated as 125 pounds with a range between 113-137 pounds. The evaluation showed the plan and recommendations to include obtain current body weight; and monitor as per facility protocol. Eleven days later, on 07/18/22 the resident's next recorded weight was 103 pounds which indicated a severe weight loss of 13 pounds or 11.8% of her body weight in 12 days. The evaluation also noted assistance with eating was required and possible weight fluctuations due to the fluid retention/edema in the arms and legs. Review of all facility orders did not reveal any use of diuretic medications to reduce fluid buildup nor was she a dialysis patient therefore weight changes did not occur due to fluid loss. On 07/25/22, eight days after the weight loss was documented, the Registered Dietitian (RD) documented the weight loss and wrote Will continue to monitor weight weekly and intervene PRN (as needed) along with other interventions. On 08/17/22 at 4:17 PM, the Registered Dietitian (RD) was interviewed. She stated, The first weight (07/06/22) is from the hospital so we don't know what it really was. She added the policy on admission weights was to weigh weekly for four weeks. To clarify, she was asked again if new residents are supposed to be weighed every week for four weeks. She stated, Yes once the patient got here and with a diagnosis of Malnutrition, that resident should be seen within three days by the RD. She further stated, Once they get here automatically, we need to get the weight and then we add the patient to the weekly or monthly list. She makes the list and gives it to the staff or puts it in the binder at the nurses' station. If there is a weekly list for weights, she tells the unit manager where it is. She wasn't certain who was weighing the residents and deferred that question to the DON or NHA because they assign someone to do them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled Weighing the Resident (N-1525) last revised on 09/05/2017 showed the policy: Residents of the facility shall be weighed upon admission and monthly and as needed unless ordered otherwise by the physician. A policy and procedure for unintended weight loss was requested however the NHA and the RDCO confirmed there was no separate policy or procedure for that. On 08/17/22 at 4:33 PM, the dietitian's list of weekly and monthly weights for July and August were requested from the DON at the nursing station near this resident's room. The July list had a date of 07/14/22 written on the top with the weight of 103.2 written next to Resident #65's name without a date. The August list was reviewed, and Resident #65's name showed a weight of 104 pounds on 08/03 with the word week written next to it. The DON and the UM were unable to locate or provide any other weights for this resident. The DON said weights are not done on any particular day of the week. She added, the Restorative Aide usually obtains weights but they haven't had a restorative aide since April. The DON deferred questions about the restorative program to the NHA. On 08/17/22 at 5:15 PM, the resident was weighed by Hoyer lift with the bed pad, draw sheet, padded boots and lift sling at 102.2 pounds by Staff M and Staff N, both Certified Nursing Assistants (CNA) in the presence of the surveyor. On 08/18/22 at 10:30 AM during an interview with the resident's Power of Attorney (POA) who was also a family member, he said her UBW was about 120 pounds. Resident #65 also said she weighed about 120 pounds before the stroke. On 08/18/22 at 2:43 PM during an interview with Staff L, an LPN, she reported the weight she entered for 07/06/22 was information she received when taking the telephone report from the hospital prior to the actual admission. She added that she enters that weight and then when the resident arrives another weight should be taken and documented. Review of Resident #65's [NAME], which tells the CNAs the specific and personalized care needed for each resident showed under the Eating/Nutrition category: Eating: The resident is able to feed self after set up which conflicts with the MDS assessments and nutrition/dietary assessments. The care plan also showed conflicting interventions under the ADL/Self-Care Deficit Focus under Eating: The resident is able to feed self after set up. Review of the Point of Care responses by CNAs from the previous 30 days showed the resident received less than the Extensive Assistance required to eat for 18 meals. Fourteen meals required more than Extensive Assistance and 13 other meals during the same period were not documented at all. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) On 08/16/22 at 9:45 AM, Resident #77 was observed leaving the facility in a wheel chair for dialysis with paper bag [NAME]. Inside the paper bag was an egg salad sandwich, diet gingerale, and graham crackers. There was no cooling pack/component. An interview was conducted with the Registered Dietician (RD) on 08/17/22 at 3:00 PM. The RD acknowledged the above. Based on observation, interview and record review, the facility failed to provide meals that were prepared and served in a sanitary manner and in a manner to prevent the formation of pathogens that cause foodborne illness. The findings included: 1). During the initial kitchen tour, accompanied by Staff A, Cook, Staff A stated that the Dietary Manager was on vacation and would not be at the facility during the survey and stated that she was the designated person in charge of the kitchen in the absence of the Dietary Manager. The following were noted: a. There was an accumulation of residue on the blade of the can opener. b. The unit that mounted the can opener was noted to be encrusted with food residue. c. There was an accumulation of residue inside of the kettle used for making batches of tea. d. There was an accumulation of debris underneath the tea machine. e. The portion scale was noted to have what appeared to be rust on the platform of the scale as well as the body of the scale. f. Numerous cutting boards were noted to be scored and stained to the point that they were no longer cleanable. g. Inside of the ice machine, there was a strip of plastic that was becoming detached from the inside of the door. h. In the Dry Storage area, the facility was using particle board that had shown signs of wear and were no longer cleanable. Staff A acknowledged understanding of the concerns. 2). During a follow up tour of the kitchen, on 08/17/22 at 10:54 AM, accompanied by Staff A, Staff K, Cook, was observed handling portioned drinks with her bare hands in direct contact with the lip contact surface of the cups that were to be served to the residents. Staff A and Staff K acknowledged understanding of the concern. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3). During an observation of lunch being served on the 100 unit, on 08/17/22 at 11:41 AM, Staff B, CNA, and Staff C, CNA, were observed serving trays to the residents in their rooms. During the observation, none of the residents that were served hamburgers and hot dogs were given an opportunity to perform hand hygiene before eating with their hands. During an interview with Staff B and Staff C, at the time of the observation, Staff B and Staff C acknowledged that they had not given residents an opportunity to perform hand hygiene prior to eating with their hands. It was noted that there was a container mounted to the wall that contained hand sanitizing wipes, however the container was empty. 4). The facility's policy for 'Re-heating Resident Food and Beverages', dated 11/30/14, documented: Policy: To reduce the risk of Resident burns related to hot beverages, liquids and food, and to provide guidance on re-heating resident food and/or liquids. Staff members only are to re-heat resident food and or liquids in the microwave to temperatures that are safe and palatable for residents. Procedure: Locate the dial thermometer available in the re-heating area and wash with soap and running watr to ensure the thermometer is clean. After washing, wipe thermometer with sanitizing wipe or alcohol wipe. When item re-heating is completed, staff member is to use a clean utensil to stir the item or liquid to ensure even heating throughout. The staff member is to use the dial thermometer to ensure the item or liquid reaches 165 degrees F to prevent food borne illnesses. Dietary services will provide thermometers for reheating. During an observation of the 100 unit nutrition pantry, on 08/18/22 at 1:24 PM, accompanied by the Regional Dietary Manager, two residents' lunches, including Resident #42's lunch, were in the reach in cooler. When asked about the trays Staff I, CNA, stated, They are out at a doctor's appointment. When they get back I put it in the microwave when asked how long it would be re-heated, the CNA replied, for a minute or so. Staff J further stated that she did not have a thermometer to ensure that the meal would be properly re-heated to a temperature that would maintain the meal safe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 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 105795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Coral Bay 2939 S Haverhill Rd West Palm Beach, FL 33415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, interview, policy review and record review, the facility failed to maintain accurate documentation of regular maintenance, compatibility, and areas of entrapment for 3 of 3 residents observed for use of bed rails (Residents #12, #30 and #244). The findings included: On 08/15/22 at 9:24 AM, Resident #12 was noted to have bilateral side rails in the raised position for use on the bed. The side rails were tall, rectangular metal half-rails with multiple gaps between the bars, large enough for a limb to be trapped. On 08/15/22 at 10:37 AM, Resident #244 was observed in bed, with the same half-rails as described above in the raised position for use on the bed. While demonstrating continuous full body movements, the resident was also tightly gripping the right siderail with both hands pulling it toward him. Resident #244 has advanced Parkinsons with Dementia, as well as vision and hearing deficits. On 08/15/22 at 12:06 PM, Resident #30 was noted to have side rails on the bed in the raised position for use, however the rails were one-quarter to one-third the length of the bed with a much lower profile, with fewer and smaller gaps to prevent limb entrapment. On 08/15/22 at 4:05 PM, during an interview with the Director of Nursing (DON) and the Unit Manager (UM), the specific siderails in use on the bed for Resident #244 were discussed due to his increased risk of injury because of his cognitive and sensory deficits with advanced illness. On the morning of 08/16/22 at 11:03 AM, the resident's bed was noted to have much smaller, modern, plastic siderails with fewer and smaller openings, reducing the risk of injury. The DON said the entire bed was changed-out on Monday evening. On 08/18/22 at 12:15 PM, during an interview with the Nursing Home Administrator (NHA) and the Regional Director of Clinical Operations (RDCO), maintenance records for all side-rails in use were requested. Review of the facility policy titled Side Rail/Bed Rail (Name N1282) dated 04/19/18 revealed, Follow the manufacturers' recommendations and specifications for installing and maintaining side rails/bed rails. On 08/18/22 at 3:15 PM, during an interview with the Plant Operations Director (POD), the NHA and the RDCO, documented monthly maintenance checks from the TELS system were provided with a list of tasks to be completed during the maintenance checks. The documentation read: Beds & Mattresses: Inspect Bed Rails with the monthly completion date. The POD said he checks the rails for looseness, makes repairs when needed and measures gaps. There was no documentation available for bed model compatibility with attached siderails since at least three different types of side rails were observed, maintenance performed to either beds or siderails, whether maintenance was performed per manufactures' instructions or verification of the measurements taken. The POD also verified facility use of side rails with specialty air mattresses, which increases the risk of entrapment or injury due to compressibility. The POD, NHA and RDCO all acknowledged the discrepancy between required documentation and what was available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 14 of 14