Inspection·December 14, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her eyes. When asked if she would like a shower, Resident #23 stated, If I could, further explaining that she had a stroke and couldn't walk. When asked how often she would like a shower, Resident #23 stated once a week would be ok. Review of the record revealed Resident #23 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented the resident had a BIMS score of 13, on a 0 to 15 scale, indicating she had minimal cognitive impairment. Review of the current care plan initiated on 02/10/22 documented as of 04/29/22 the resident needed total assistance from staff for her Activities of Daily Living (ADLs). This care plan included the provision of baths and showers, and lacked any documented refusal of ADL care. Review of the ADL documentation from 09/01/23 through 12/12/23 lacked any documented provision of showers. During an interview on 12/13/23 at 3:50 PM, when asked the process for the provision of resident showers, Staff F, Certified Nursing Assistant (CNA) stated they had a shower list that had scheduled showers three times weekly. Staff F confirmed a resident could also request a shower on a different day and she would provide one. When asked what she would do if a resident refused a shower, the CNA stated she would tell the nurse. When asked where she documented the provision of a resident shower, the CNA stated in the computer and on a shower sheet. During a side-by-side review of the shower schedule, Staff F stated Resident #23 was scheduled for a shower every Tuesday, Thursday, and Saturday, on her shift, the 3 PM to 11 PM shift. When asked if she had provided a shower for Resident #23, Staff F stated the resident had always refused a shower for her. The CNA volunteered that yesterday, 12/12/23, Resident #23 refused a shower because of her cough, and that she had told the nurse. Review of the Shower Book that contained the shower sheets lacked any documented showers for Resident #23 since September of 2023. During an interview on 12/13/23 at 4:17 PM, when asked if she was offered a shower yesterday, Resident #23 stated, No ma'am. When asked if she refused a shower yesterday because of her cough, Resident #23 stated, I've had a cough, but did not refuse a shower. I'm also on antibiotics. Is that a reason to not get a shower. Resident #23 denied being offered a shower the previous day. During an interview on 12/14/23 at 11:55 AM, Staff B, Licensed Practical Nurse (LPN), confirmed she had worked on Tuesday, 12/12/23, and did not receive notice that Resident #23 had refused a shower. The LPN stated if she had, she would have found out why and documented it in the computer. Review of the progress notes from 09/01/23 through 12/12/23 lacked any documented refusal of a showers by Resident #23. 3) During an interview on 12/11/23 at 2:59 PM, Resident #24 stated she was not getting her weekly shower. The resident stated she only wanted one every Thursday. Review of the record revealed Resident #24 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented the resident had a BIMS score of 11, on a 0 to 15 scale, indicating she had some cognitive impairment. The annual MDS dated [DATE] documented the resident's BIMS score was 15 at that time, indicating she was cognitively intact, and that it was somewhat important for her to choose between a bath and a shower. Review of the current care plan initiated on 12/27/18 and revised on 12/14/23 documented the resident had a self-care deficit for performance of ADLs, and that she required extensive assist with bathing and showering. This care plan did document the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 2 of 24 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 12/14/2023 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 0561 resident refused showers at times. Level of Harm - Minimal harm or potential for actual harm During the continued side-by-side record review and interview on 12/13/23 at 3:50 PM, Staff F, CNA, stated Resident #24 was scheduled a shower on Tuesday, Thursday, and Saturday on the 7 AM to 3 PM shift. The CNA denied any knowledge about the resident's showers, either the provision of or refusal. The CNA could only find two recent shower sheets that documented the provision of showers for Resident #24, one dated 10/14/23 and one dated 10/12/23. Residents Affected - Few Review of the ADL documentation in the computer revealed Resident #24's shower preference as only on Thursdays. Further review of the ADL documentation lacked any documented showers in October, November, or December of 2023. Review of the progress notes from 10/01/23 through 12/12/23 lacked any documented refusal of showers. During an interview on 12/14/23 at 11:58 AM, when asked about the provision of showers for Resident #24, Staff B, LPN stated she only wants a shower on Thursday. The LPN further stated the resident would refuse at times, but that she would put a note in the computer if the resident refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 3 of 24 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 12/14/2023 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, record review, interview, and policy review, the facility failed to ensure a safe and comfortable environment for 2 of 2 sampled residents. Staff were aware of missing dentures for Resident #18 and their policy was not followed related to loss or theft. Resident #22 requested that his dripping bathroom faucet be fixed, and it was not completed timely. The findings included: 1) Review of the policy Personal Property - loss or theft revised 07/24/17 documented, Process: . 5. An employee receiving a concern regarding lost or missing item(s) from a resident or resident representative will initiate a Complaint/Grievance form or electronic equivalent. During an observation and interview on 12/11/23 at 3:10 PM, Resident #18 was noted with just her upper dentures, as her lower lip was obviously sunken into her mouth. When asked if she had her lower dentures, Resident #18 stated she did not and that she did not recall when she lost them. Review of a written complaint to the State Agency dated 09/14/23, revealed the resident representative documented the resident's dentures were missing again and that she has had to replace them more than once. Review of the grievance log for the past six months lacked any entry for missing items for Resident #18. Review of the record revealed Resident #18 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented Resident #18 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident had some cognitive impairment. During an interview on 12/13/23 at 2:41 PM, the Social Services Director (SSD) stated she was unaware of the lost dentures. During a subsequent interview on 12/13/23 at 3:04 PM, the SSD confirmed the missing bottom dentures, stated the resident was not sure when or where she lost them, and stated staff said they were unaware of the missing dentures. During an interview on 12/13/23 at 4:49 PM, Staff H, Certified Nursing Assistant (CNA) for Resident #18, stated the resident had both of her dentures, upper and lower. When told she was missing her lower dentures, the CNA denied any knowledge of the missing dentures, stating the resident takes care of her own dentures. During an interview on 12/14/23 at 1:46 PM, Staff G, Licensed Practical Nurse (LPN), stated Resident #18 originally lost the bottom dentures within a week of getting them, the family replaced them, the resident lost another bottom denture, and believed the daughter replaced them a second time. The LPN was unsure when she lost the most current bottom denture. During a subsequent interview on 12/14/23 at 2:45 PM, the SSD denied any knowledge of the previously missing dentures, and stated there were no grievance regarding any missing dentures. The SSD stated the facility was responsible for the missing dentures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 4 of 24 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 12/14/2023 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 During in interview on 12/14/23 at approximately 4:00 PM the Administrator confirmed they were responsible for replacing the missing dentures. 2) During an interview on 12/13/23 at 4:59 PM, Resident #22 stated he reported to maintenance at least 4 or 5 weeks ago, that his bathroom faucet was leaking. Upon observation of the bathroom faucet, a small stream of water was coming out of the faucet. Upon attempting to turn off the water, the leak did not stop. When asked who he spoke to about the leak, Resident #22 mentioned the name of the now part-time maintenance person, and further stated, And he was not the first person I told. Resident #22 explained that if he doesn't remind the staff to close the bathroom door in the evening, the leaking faucet will keep him awake. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Resident #22 was legally blind. During an interview on 12/14/23 at 9:31 AM, the Maintenance Director explained maintenance requests were logged in the maintenance books at the nurses' stations, and he checks them daily. When asked if he was aware of the dripping faucet for Resident #22, the Maintenance Director stated he was and that he had ordered a new faucet, but with the change in ownership, orders have been delayed. The Maintenance Director stated he had just received the faucet in the last shipment, he believed, but was unsure when he found out about the leaking faucet. The Maintenance Director was asked to locate and provide any documentation of the maintenance request and evidence of the order and receipt of the faucet. On 12/14/23 at 10:24 AM, the Administrator stated the Maintenance Director actually went down to a local store and paid for the faucet, so they don't have an invoice from their distributor, and he did not have the receipt. During a subsequent interview on 12/14/23 at 10:48 AM, the Administrator provided the maintenance log that revealed the leaking faucet was identified on 09/26/23, and was fixed, as evidenced by the initial of maintenance personnel. During this interview the Maintenance Director stated in September they were able to make some adjustments to the faucet to stop the dripping. During a subsequent interview on 12/14/23 at 1:15 PM, when asked if the faucet had been fixed at any point by some type of adjustment, Resident #22 stated it was never fixed. The resident further stated they would tighten up the faucet, but it would subsequently leak worse, probably because that was messing up the washer in the faucet. Resident #22 again stated they never fixed the leaking faucet, until earlier today. Observation revealed a new faucet in the resident's bathroom. Resident #22 stated, Why did it take them weeks, if not months, to fix it? FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 5 of 24 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 12/14/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessments related to medications for 2 of 5 sampled residents (Resident #18 and #23), and for 1 of 3 sampled resident discharges (Resident #81). Residents Affected - Few The findings included: 1) Review of the record revealed Resident #18 was admitted to the facility 12/18/20. Review of the current MDS assessment dated [DATE] documented Resident #18 received an insulin injection on 7 of 7 days during the look-back period of 10/17/23 through 10/23/23. Review of the corresponding Medication Administration Record (MAR) revealed Resident #18 was ordered Levemir insulin every night at bedtime. Further review revealed the resident did not receive any insulin on 10/20/23. During an interview on 12/14/23 at approximately 4:30 PM, the Regional Nurse Consultant agreed with the findings. 2) Review of the record revealed Resident #23 was admitted to the facility 04/20/18. Review of the current MDS dated [DATE] documented the resident received an insulin injection 3 of 7 days during the look-back period of 09/22/23 through 09/28/23. Review of the corresponding MAR revealed Resident #23 was receiving Regular insulin via a physician ordered sliding scale. Further review of this MAR revealed the resident received insulin on 09/23/23, 09/24/23, 09/25/23, and 09/28/23, indicating the MDS should have been coded as a 4. During an interview on 12/14/23 at 3:16 PM, the MDS Coordinator agreed with the findings. 3) Resident #81 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had a BIMS of 15. A review of Resident #81's Nurses progress notes dated 9/12/23 documented by Staff K' that Resident #81 left the facility AMA (Against Medical Advice) after she told the nurse on 09/12/23 that she wanted to go home. The nurse advised her that it is not safe to leave without a doctors order. Resident #81 called her family and left the facility AMA. A review of Resident #81's discharge assessment dated [DATE] documented that the resident was tranfered to the hospital. On 09/14/23 at 9:10 AM, during an interview with the MDS Coordinator, she acknowledged the discepancy regarding Resident #81's discharge location from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 6 of 24 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 12/14/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Observations on 12/11/23 at 10:29 AM, 12/11/23 at 2:38 PM, and on 12/12/23 at 2:13 PM, revealed Resident #14 had an oxygen concentrator and/or was using oxygen. Review of the record revealed Resident #14 was admitted to the facility on [DATE]. Although the record lacked an oxygen order, documentation under the vital sign section revealed Resident #14 began using oxygen on 11/22/23. Further review of the record lacked any care plan related to oxygen use. During an interview on 12/14/23 at 12:45 PM, the MDS Coordinator agreed with the findings. 4) Observations on 12/11/23 at 10:03 AM and 12/12/23 at 2:02 PM revealed a nebulizer machine and oxygen concentrator in the room of Resident #31. Neither machine was in use at the time of the observations, but appeared to have been used as both tubings were stretched out as having been used. Review of the record revealed Resident #31 was admitted to the facility on [DATE]. Review of the current orders revealed oxygen was ordered for Resident #31 as of 07/21/23, for use at 2 to 3 liters/minute to maintain an oxygen saturation of greater than 90%. Review of a progress note by the nurse practitioner dated 07/21/23 documented Resident #31 was oxygen dependent and was utilizing supplemental oxygen at 3 to 5 liters/minute. Review of the current vital signs section documented oxygen use in July and August of 2023 on various dates, and recent use specifically on 11/23/23, 11/24/23, 11/30/23, and 12/06/23. The record lacked any care plan for the use of oxygen. During an interview on 12/14/23 at 12:59 PM the MDS Coordinator agreed with the findings. 5) Review of the record revealed Resident #75 was admitted to the facility on [DATE]. Review of the orders revealed the resident had an indwelling urinary catheter as of 10/31/23. The record lacked any care plan for the use of Enhanced Barrier Precautions for indwelling devices, as per their policy. Based on observation, record review and interview, the facility failed to develop a care plan for 4 of 23 sampled residents: a resident with an indwelling catheter (Resident #75), residents with oxygen (Resident #14 and #31), and a resident with a Peg tube (Resident #62); and implement a care plan for a resident with a Peg tube (Resident #62). The findings included: 1) Resident #62 was initially admitted to the facility on [DATE] with diagnoses that included post Cerebral Infarction, Dysphagia, and Aphasia. The admission assessment dated [DATE] revealed the resident was admitted with a Peg tube (Percutaneous Endoscopic Gastrostomy which is a tube that brings nutrition directly into the stomach). His admission weight dated 08/23/22 was 172 pounds and his feeding was Jevity 1.5 CAL @ 65ml (milliliters (ml) per hour (hr) x 20 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 7 of 24 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 12/14/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A Brief Interview of Mental Status (BIMS) was not able to be performed per the resident's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/23. This MDS also revealed the resident had no impairment in range of motion of upper extremities. Resident #62 has continued to be fed through a PEG tube. An observation of the door to Resident #62's room revealed a sign that said Enhanced Barrier Precautions. The sign revealed everyone must clean their hands, including before entering and when leaving the room and Providers and Staff Must Also Wear gloves and a gown for the following High Contact Resident Care Activities. Among those activities is feeding tube device care. Review of policy for enhanced barrier precautions revealed the resident should have an updated care plan. The resident did not have a care plan for enhanced barrier precautions. An interview was conducted with the MDS oordinator on 12/14/23 at 3:54 PM who stated she will look through all of the care plans. She returned and stated that she did not find it on the care plan. 2) On 10/11/23 Resident #62 was transferred to the hospital after pulling out his PEG tube and returned to the facility on [DATE] with orders for an abdominal binder q (every) shift for prevention of Peg dislodgement. On 12/11/23 at 3:00 PM, an observation was made of Staff A, a Registered Nurse (RN) preparing the tube feeding and hanging a 1000 milliliter bottle of Jevity 1.5 CAL. Resident #62 did not have an abdominal binder on at this time. On 12/12/23 at 9:54 AM, an observation was made of Staff B, a Licensed Practical Nurse (LPN) taking down the tube feeding. The resident did not have an abdominal binder on. An interview was conducted with Staff B at that time asking if the resident should be wearing an abdominal binder. She replied that he should be wearing one and it is likely in the wash but he should have another one. Staff B looked for one and could not find another one. A review of Resident # 62's care plan revealed a focus of: Resident has a behavior of pulling at his Peg tube (dated 10/10/23) and interventions included abdominal binder (dated 10/10/23). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 8 of 24 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 12/14/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to coordinate hospice services for 1 of 1 sampled resident, after having been treated at the hospital (Resident #14). Residents Affected - Few The findings included: Review of the record revealed Resident #14 was admitted to the facility on [DATE] with hospice services in place. As per the electronic medical record census report, Resident #14 was last readmitted to the facility on [DATE], after a short hospitalization, with the payor source documented as the hospice provider. Review of the current Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 was terminal and was receiving hospice services. The MDS overview then documented a discharge assessment was completed on 11/18/23 and an entry assessment was completed on 11/21/23. No other MDS was pending or in progress after 11/21/23. Review of the current orders, both in the electronic and paper records, lacked a current order for hospice services. Review of the progress notes since the readmission date of 11/21/23 revealed only one note related to hospice. This note written by the Social Services Director and dated 11/23/23 documented the resident was readmitted to the facility and remains under hospice care. Current care plans initiated on 10/24/22 and still in effect at the time of readmission, documented Resident #14 was on hospice services with a terminal prognosis. During an interview on 12/14/23 at 10:35 AM, when asked if Resident #14 was receiving hospice services, Staff G, Licensed Practical Nurse (LPN), stated that the resident's daughter told her she was no longer on hospice services because they wanted aggressive treatment at the hospital. The LPN picked up her cell phone and called the resident's previous hospice nurse, who on speaker phone reported Resident #14 was no longer on hospice services as the family revoked services when admitted to the hospital. The hospice nurse stated she left paperwork for the business office manager, with the receptionist just today, related to the lack of hospice services. During an interview on 12/14/23 at 10:46 AM, when asked if a Significant Change MDS assessment should be completed if a resident revokes hospice services, the MDS Coordinator stated yes. When asked if Resident #14 was currently on hospice services, the MDS Coordinator explained the hospice provider did not report the revocation until about 11/30/23, and further stated I thought I opened up a Significant Change MDS assessment at that time. During a side-by-side review of the MDS assessments, the MDS Coordinator agreed to the lack of the Significant Change MDS in progress. During an interview on 12/14/23 at 12:45 PM, the Regional MDS Coordinator stated she asked the Social Services Director (SSD) to call the daughter of Resident #14 for clarification and to determine the family's wishes. The Regional MDS Coordinator explained that during the conversation, the daughter agreed to ongoing hospice services. The SSD called the hospice provider to continue services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 9 of 24 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 12/14/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure proper care and services for 1 of 1 sampled resident who had an indwelling urinary catheter (Resident #75). The findings included: Review of the policy Urinary Catheter Care revised 09/05/17 documented, Procedure: . Remove catheter securement device while maintaining connection with drainage tube. Clean catheter tubing with soap and water, starting close to urinary meatus (opening), cleaning in circular motion along its length for about 4 inches, moving away from the body. Rinse well using the same motion. Reattach catheter securement device. Observations on 12/11/23 at 9:36 AM, 12/12/23 at 11:06 AM, and 12/13/23 at 4:14 PM revealed Resident #75 had a urinary drainage device, as the urine collection bag was noted hanging from an open drawer in the resident's nightstand. Observation of the urine in the tubing revealed it was cloudy (Photographic Evidence Obtained). Resident #75 lacked any type of anchoring device during these three observations. Resident #75 stated staff do clean her private area along with the catheter, and she denied any pain or discomfort, although did state that the tubing does pull at times. Review of the record revealed Resident #75 was admitted to the facility on [DATE]. Review of the current orders revealed the use of an indwelling urinary catheter as of 10/31/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #75 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the use of an indwelling urinary catheter. During an observation on 12/13/23 at 4:31 PM, Staff F, Certified Nursing Assistant (CNA), provided personal care to the resident's front side, then cleaned the tubing from a point about 9 to 12 inches from the insertion area, wiping the catheter tubing toward the resident's body and meatus. The CNA proceeded to rinse the tubing in the same manner. During an interview on 12/13/23 at 4:43 PM, when asked how she cleaned the urinary catheter tubing, Staff F, CNA, demonstrated in the air in front of herself, moving her hand from away from her body toward her body, and stated toward the body. When told the proper technique would be away from the resident's body, the CNA stated, Oh. When asked if there was anything missing from the urinary catheter tubing, the CNA did not respond. When asked if the facility used any type of anchoring or securing device, the CNA stated, You mean the strap to hold it? The CNA then volunteered, She (the resident) is in bed so maybe she doesn't need it. During an interview on 12/13/23 at 4:54 PM, when asked if the facility utilizes any type of urinary catheter anchoring device, Staff B, Licensed Practical Nurse (LPN) stated they have leg straps. When told Resident #75 had not had one this week, the nurse stated, Ok let me see if they have any in supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 10 of 24 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 12/14/2023 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to ensure care and services for tube feeding for 2 of 2 sampled residents for tube feeding resulting in significant weight loss (Resident #62), and failure to provide tube feeding as ordered (Resident # 287). The findings included: The facility's policy titled Enteral Feeding-Enteral Nutrition Pump effective 11/30/14, and revised 11/12/18, revealed Nurses administer enteral feeding when volume control is indicated and as ordered by physician. The facility's policy titled Weighing the Resident effective 11/30/14, and revised 10/04/21, revealed Residents will be weighed unless ordered otherwise by the physician: . Admission/re-admission x 3 days . Weekly x 4 weeks . Monthly thereafter . As needed Weights will be completed as indicated and documented in the clinical record .When there is a significant variance from the previously recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change, consult with the Director of Dietary Services and/or dietician, notify the Interdisciplinary Team in order to update the care plan. 1) Record review revealed Resident #62 was initially admitted to the facility on [DATE] with diagnoses that included post Cerebral Infarction, Dysphagia, and Aphasia. The admission assessment dated [DATE] revealed the resident was admitted with a PEG tube (Percutaneous Endoscopic Gastrostomy which is a tube that brings nutrition directly into the stomach). His admission weight dated 08/23/22 was 172 pounds, height was 5 foot 5 inches, and the order for his feeding was Jevity 1.5 CAL @ 65ml (milliliters (ml) per hour (hr) x 20 hours. Jevity is a therapeutic nutritional formula for tube feedings. On 05/11/23 a nutritional evaluation was done post hospitalization which revealed the resident was taking Jevity 1.5 @ 60ml/hr x 20 hours. His weight was 170 pounds. On 06/13/23 the resident was sent to the hospital for PEG tube reinsertion and returned the same day. On 06/15/23, post hospitalization, a nutritional evaluation was done. He was on Jevity 1.5 @75ml/hr x 20hrs; Start time: 2:00 PM and End time:10:00 AM or until total volume is administered (total volume 1500 ml/daily). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 11 of 24 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 12/14/2023 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 0693 Weight recorded on 06/09/23 was 171.1 pounds. Level of Harm - Actual harm Weight on 07/10/23 was 172 pounds. Residents Affected - Few Weight on 08/04/23 was 172.3 pounds. Weight on 09/07/23 was 172.5 pounds. On 10/11/23 the resident was transferred to the hospital after pulling out his PEG tube and returned to the facility on [DATE] with orders for an abdominal binder every shift for prevention of PEG dislodgement. Nutritional evaluation dated 10/17/23 revealed the resident was recently re-admitted after being discharged to hospital on [DATE] for pulling his PEG tube out, remains NPO (nothing by mouth) with PEG, is tolerating tube feedings, resident is confused, weight dated 09/07/23 is 172.5 pounds. Plan/recommendation-Weigh x4 weeks, Obtain weight per facility protocol. Next weight dated 10/23/23 was 152.4 pounds. On 11/03/23 the electronic health record (EHR) revealed a dietary note written by the Registered Dietitian (RD). Resident has experienced wt (weight) loss, is currently 152.4# (pounds) as of 10/23/23, BMI (Body Mass Index) is 25.4, re-weigh has been requested, continues to tolerate TF Rx (tube feed prescription), Jevity 1.5 @ 75 ml/hr x20 hours w/ 250 ml water flush Q shift (750ml) ~provides 2250 kcal (kilocalories), 96g PRO (protein), and 1840 ml H2O (water) which meets estimated nutritional needs outlined in the Nutrition Evaluation assessment dated [DATE], nutritional needs were estimated according to previous body weight of 171#, weight loss was not anticipated will increase TF rate to 80 ml/hr x20hrs and will decrease flush order to 200 ml every shift (600 ml). Next weight dated 11/07/23 was 146.6 pounds. RD note dated 11/10/23 revealed resident has experienced sig wt (significant weight) loss of 13.8 % in 180 days, is currently 146.6# as of 11/07/23 after being re-weighed to confirm accuracy of weight on 10/23/23 .will continue to have resident re-weighed. Review of the nutritional review dated 11/27/23 revealed Resident #62's UBW (usual body weight) was 170 pounds. Most recent weight dated 11/07/23 was 146.6 pounds. Will continue to have resident re-weighed. Weight for Resident #62 on 12/13/23 per surveyor request was 152.8 pounds. Resident #62 was unable to do the Brief Interview for Mental Status (BIMS) according to the quarterly Minimum Data Set with an assessment reference date of 11/25/23. Observation of Resident #62 on 12/11/23 at 8:32 AM revealed the resident to be sleeping in bed. The tube feeding bag was not set up in the room. The orders for the tube feeding were for the tube feeding to start at 2:00 PM and off at 10:00 AM or until total volume is administered which was 1600ml/daily. Observation of Resident #62 on 12/11/23 at 2:00 PM. Resident in bed with no tube feeding present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 12 of 24 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 12/14/2023 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 0693 Level of Harm - Actual harm Residents Affected - Few On 12/11/23 at 3:00 PM an observation was made of Staff A, a Registered Nurse (RN) preparing the tube feeding and hanging a 1000 milliliter bottle of Jevity 1.5 CAL. The bottle was dated 12/11/23 with no start time. Rate 80 ml/hr for 20 hours. Total volume to be infused 1600 ml/daily. Interview with Staff A at this time who stated she stopped the feeding around 8:00-8:30 AM this morning and there was about 200 ml of Jevity left in the bottle. An observation was conducted on 12/12/23 at 7:29 AM of Resident #62 lying in bed with eyes closed, upon closer observation the resident had a bottle of Jevity 1.5 tube feeding hanging labeled with a start date of 12/11/23 and no start time. The tube feeding was at the 400 mark out of a 1,000-milliliter capacity bottle. This indicated the resident only received 600 milliliters when the resident should have received 1,400 milliliters (photographic evidence obtained). A review of a nursing progress note dated 12/12/23 at 6:00 AM revealed the feeding was held secondary to elevated residual 140ml. MD notified no new order given. On 12/12/23 at 9:54 AM, an observation was made of Staff B, a Licensed Practical Nurse (LPN) taking down the tube feeding. The bottle was at the 250ml mark. In an interview at this time with Staff B she stated the night nurse held the feeding, but she does not know how long the feeding was held. She stated normally the bottle is almost finished and she usually has an empty bottle. The bottle is hung at 2:00 PM and it runs all night and when it is 10:00 AM she takes the bottle down whether or not it is finished. An interview was conducted via telephone on 12/12/23 at 3:44 PM with Staff C, RN, who worked the prior night shift with Resident #62. She stated the residual was high, so she stopped the feeding for 2 hours. She stated she usually hangs a new bottle during the night, but she did not last night. Observation of Jevity feeding for Resident #62 on 12/13/23 at 8:30 AM revealed the bottle had approximately 800 ml of Jevity left in the bottle and was hung on 12/13/23 at 4:30 AM. An Interview was conducted with RD on 12/13/23 at 4:00 PM. The RD stated that he is in the facility 2 days a week usually Monday and Fridays. He has worked in this facility since November, 2022. He enters the weights into the electronic health record (EHR) and if there is significant weight loss he has the restorative aide reweigh the resident. Significant weight loss is 3 % in one week, 7.5% in 90 days and 10% in 180 days. The restorative aide has the previous weights and would know if there was a weight loss so she should be able to re-weigh them. He notifies the Director of Nurses (DON) or the Administrator if he does not get a re-weight on a resident. The RD was asked where the re-weights and weekly weights on Resident #62 were. The RD stated that he requested reweights. He said on 10/23/23 he emailed the DON, ADON (Assistant Director of Nurses) and the Administrator asking for weekly weights for this resident. He stated the restorative aide was new and had challenges on getting the weights on the residents he was requesting. Stated it is his responsibility to know what the residents weigh. For the weight loss, he suspected the restorative aide did not correctly weigh the person. He did not watch this resident being weighed. The RD was asked if he observed the tube feedings when they were hung for accuracy, and he replied that he did not. The RD stated he asked for weekly weights x 4 on Resident #62. He sent an email to the ADON, the DON and the Administrator on 11/10/23 about no re-weights being done. The ADON assured him that it would be done. Neither the Administrator or RD produced any emails. He informed the nurse practitioner (NP), and the NP informed the doctor about the resident's weight loss. The RD stated he does not get together with the DON, ADON and Administrator to discuss weights as a group. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 13 of 24 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 12/14/2023 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 0693 Level of Harm - Actual harm Residents Affected - Few On 12/13/23 at 4:42 PM, an interview was conducted with the DON, ADON and Administrator altogether. The Administrator stated in October she was told that if there is a discrepancy in a resident's weight a reweight should be done. The Administrator further stated that whenever the RD needs a reweight, they should be able to get it. She stated her, the DON and the ADON had a meeting about getting reweights in November and had the scales calibrated in November. An Interview was conducted with Staff D, restorative Certified Nursing Assistant (CNA) on 12/14/23 at 11:28 AM, regarding the weight process. She stated the new residents are weighed every week x 4 weeks and long-term residents are weighed every month. If there is a change in weight, the dietitian gives her a list of residents who need to be weighed. She stated not every week is she given a list for weekly weights. When she gets the list for re- weighs, she has no idea of what the person weighed the previous month, she only gets a list of names. She stated she does the weights and gives the weights to the dietitian when she sees him the next time he comes. She has no weights currently that have not been given to the dietitian. Staff D stated she has been with the facility for 10 months and the last 2 months she has been the restorative CNA. An additional interview was conducted with the RD on 12/14/23 at 12:57 PM. He stated he put an intervention in for Resident #62 on 11/03/23 because he was waiting for a re-weight but did not get it. He asked the ADON, DON and Administrator when the last time the scales were calibrated, and they said they would have a technician come out to do that. He stated what he should have done is put interventions in when he saw the weight loss of 10/23/23 instead of waiting for a re-weight. He did not expect the weight to be correct at that point since it was a huge drop. 2) Record review for Resident #287 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included: Parkinson's Disease, Type 2 Diabetes Mellitus, Dependence on Renal Dialysis, Gastrostomy Status, Dementia, and Mild Protein-Calorie Malnutrition. Review of the Minimum Data Set for Resident #287 dated 08/01/23 revealed a Brief Interview of Mental Status score of 4, indicating severe cognitive impairment. Review of Physician's orders for Resident #287 revealed an order dated 12/08/23 as follows: Nepro at 75ml/hr. x 18 hours, start time 2:00 PM, end time 8:00 AM or until total volume is administrated (total volume 1,350 ml daily). Review of Physician's orders for Resident #287 revealed an order dated 12/08/23 as follows: as needed may stop enteral feed to provide ADL care to the resident and resume care to the resident and resume enteral feeding after providing care. On 12/12/23 at 2:30 PM, an observation was made of Resident #287 lying in bed with eyes closed and a bottle of tube feeding Nepro 1.8 (Formulary Type) infusing at 75 milliliters per hour via pump. The tube feeding bottle was labeled as started on 12/12/23 at 2:00 PM. The tube feeding was just below the 1,000 mark out of a 1,000-milliliter capacity bottle. On 12/13/23 at 7:50 AM, an observation was made of Resident #287 lying in bed receiving care by Staff E Certified Nursing Assistant (CNA). There was no tube feeding present. There was an empty bottle of tube feeding with tubing in the garbage. The empty tube feeding bottle in the garbage was labeled as started on 12/12/23 at 2:00 PM. There were no other empty bottles of tube feeding. This would indicate that the resident only received 1,000 milliliter of tube feeding, not the 1,350 milliliter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 14 of 24 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 12/14/2023 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 0693 that was ordered. Level of Harm - Actual harm On 12/13/23 at 2:30PM, an observation was made of Resident #287 of resident lying in bed with a bottle of tube feeding Nepro 1.8 infusing at 75 milliliters per hour via pump. The tube feeding bottle was labeled as started on 12/13/23 at 2:00 PM. The tube feeding was just below the 1,000 mark out of a 1,000-milliliter capacity bottle. Residents Affected - Few On 12/14/23 at 7:50 AM, an observation was made of Resident #287 in the dialysis room with a bottle of tube feeding Nepro 1.8 infusing at 75 milliliters per hour via pump. The tube feeding bottle was labeled as started on 12/14/23 at 7:00 AM. The tube feeding was just below the 1,000 mark out of a 1,000-milliliter capacity bottle. This indicated that the resident had received just over 1,000 milliliters of tube feeding in 18 hours, rather than the 1350 ml ordered An interview conducted on 12/13/23 at 7:50 AM with Staff E, CNA who stated she has worked at the facility for 18 years. When asked how long she has been giving care to Resident #287 this morning, she said maybe about 15 minutes. When asked if the tube feeding was already disconnected before she started providing care to Resident #287, she stated there was no tube feeding hanging. During an interview conducted on 12/13/23 at 7:55 AM with Staff A, Registered Nurse (RN) who stated she has been a nurse for about 7 months. When asked what time her shift started today, she said she was here at 7:00 AM. When asked if the tube feeding was running for Resident #287 when she came on duty, she said no the resident gets bolus tube feeding. When asked if there were any tube feeding issues reported by the previous nurse for Resident #287, she said no. Staff A later approached the surveyor to clarify that the resident does not get bolus tube feeding, the resident receives continuous tube feeding from 2:00 PM to 8:00 AM. When asked was the tube feeding running this morning when she came on duty, she said no, the night shift nurse must have taken it down before she came on duty. During an interview conducted on 12/14/23 at 1:00 PM with the Registered Dietitian (RD) who stated he has been working with long term care residents as a RD for about 3 years. When asked when he would be expected to see a resident who was newly admitted or readmitted , he stated within 7 days. When asked if he observes a resident who is receiving tube feeding, he said yes. When asked how often he said when they are admitted /readmitted , have a significant weight loss, and quarterly. When asked if he checks on the tube feeding for the residents, he said he checks to make sure the rate is correct, and it is the right formula. When asked if he verifies the volume infuse, he said he does not. When asked if he checks with the nurse about the total volume of the feeding infused, he said no, he just assumes the total volume ordered is infused. The RD stated he does periodically ask the nurses if the residents are tolerating the tube feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 15 of 24 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 12/14/2023 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 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, record review, and policy review, the facility failed to ensure proper care and services for 3 of 3 sampled residents utilizing oxygen (Residents #14, #23, and #31). Residents Affected - Few The findings included: Upon request of the policy related to oxygen maintenance and use, the Regional Clinical Director provided their Administration of Medication - Oral policy, revised 08/15/19, and stated oxygen is a medication, so should be administered as per physician order and this policy. When asked specifically about oxygen tubing changes, the Regional Clinical Director stated there should be a physician order to follow. 1) During an observation on 12/11/23 at 10:29 AM, Resident #14 was noted in bed. Next to her bed was a running oxygen concentrator, set at about 2 liters/minute, with the tubing running over to the nightstand, and the nasal canula lying directly on top of the nightstand (Photographic Evidence Obtained). The oxygen tubing lacked any date and there was no bag to properly store and document the initial date of usage of the tubing (Photographic Evidence Obtained). During a subsequent observation on 12/11/23 at 2:38 PM, the oxygen was being administered to Resident #14, with the same non-dated tubing. Review of the record revealed Resident #14 was admitted to the facility on [DATE]. Review of the current orders lacked any related to oxygen use. Review of the vital sign section of the electronic medical record revealed Resident #14 had been receiving oxygen since 11/22/23. The photographic evidence of the non-dated oxygen tubing and improper storage of the oxygen was shown to the Assistant Director of Nursing (ADON) on 12/14/23, along with the lack of oxygen order. The ADON agreed with the findings. 2) During an observation on 12/11/23 at 9:03 AM, Resident #23 was in bed, receiving oxygen at about 2 liters per minute via a nasal canula. A sticker on the oxygen tubing attached to the concentrator was dated 11/27/23. A nebulizer machine was noted on the resident's bedside nightstand. A piece of tape attached to the tubing was dated 11/12/23. The nebulizer tubing was running from the machine, into an open drawer in the nightstand, and attached to a mask that was placed directly into the drawer (not in a protective plastic bag). A date written on the tubing near the mask documented 11/06/23 (Photographic Evidence Obtained). When asked if the machine is used currently to get nebulizer treatments, Resident #23 stated she still gets the treatments. Review of the record revealed Resident #23 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented Resident #23 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating she had minimal cognitive impairment. This same MDS documented Resident #23 used oxygen. Review of the current orders revealed Resident #23 had an order for oxygen use as of 09/28/22. Further review revealed an order for an Albuterol nebulizer to be given every 4 hours as needed dated 01/03/23. A current care plan Initiated 02/10/22 documented the resident was at risk for falls with an intervention of oxygen use. A second care plan initiated 02/10/22 documented the resident was at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 16 of 24 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 12/14/2023 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 0695 risk for altered respiratory patterns and used oxygen. Level of Harm - Minimal harm or potential for actual harm 3) During an observation on 12/11/23 at 10:03 AM, Resident #31 was in bed. An oxygen concentrator was noted next to the bed with the nasal canula lying over the machine, not properly stored in the plastic bag. There was a well-worn piece of tape on the tubing with an unreadable date. The date on the plastic Set-Up Bag was dated 11/06/23. A nebulizer machine on top of the bedside nightstand, had undated tubing that ran down on the floor, was stuck underneath the bed frame, ran back up and into the nightstand, with a mask hooked up to the tubing and lying directly in the drawer. Residents Affected - Few Review of the record revealed Resident #31 was admitted to the facility on [DATE]. Review of the current orders revealed the resident had oxygen for use as needed since 07/21/23. Review of the December 2023 Medication Administration Record (MAR) documented the oxygen tubing was changed on 12/08/23. (Note the oxygen Set-Up Bag was dated 11/06/23). Further review of the MAR lacked any current order for a nebulizer treatment and lacked any use of the nebulizer for at least the past three months. Review of the documented oxygen saturation level revealed Resident #31 was utilizing oxygen as needed in July and August of 2023, and recently on 11/24/23, 11/30/23, and 12/06/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 17 of 24 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 12/14/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to identify and clarify a physician's order for a drug with no dosage strength during monthly drug regimen review for 1 out of 7 residents observed for medication pass observation (Resident #70). The findings included: Review of the facility's policy titled, Medication Regimen Review (MRR) with a revision date of 08/17/23 included the following: The Consultant Pharmacist will conduct MMRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the resident's health record. The facility and Consultant Pharmacist will follow guidance outlined in the CMS State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care. Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Other Sequelae Following Unspecified Cerebrovascular Disease. Review of the Minimum Data Set for Resident #70 dated 09/07/23 Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. Physician's Orders for Resident #70 revealed an order dated 09/06/23 for Vitamin C Oral Tablet (Ascorbic Acid) Give 2 tablet by mouth one time a day for supplement (no dosage strength indicated). Review of the Medication Administration Record for Resident #70 the months of September, October, November, and December revealed the nurses had documented that the resident had been receiving Vitamin C 2 tabs with no dosage strength. Review of the Consultation Report for Resident #70 from 09/01/23 through 09/30/23 signed by the Consultant Pharmacist and dated 09/18/23 documented no recommendation. Review of the Consultation Report for Resident #70 from 10/01/23 through 10/31/23 signed by the Consultant Pharmacist and dated 10/17/23 documented no recommendation. Review of the Consultation Report for Resident #70 from 11/01/23 through 11/30/23 signed by the Consultant Pharmacist and dated 11/15/23 documented the recommendation as Please remind staff of the importance of administering/holding medication within the parameters ordered. On 12/12/23 at 9:20 AM, a medication pass observation was conducted with Staff I Licensed Practical Nurse (LPN) who was working at med cart 2 on the first floor. The LPN was passing medications for Resident #70 as follows: 1) Docusate sodium 100mg 2) Lamotrigine 200mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 18 of 24 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 12/14/2023 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 0756 3) Levetiracetam 500mg Level of Harm - Minimal harm or potential for actual harm 4) Lisinopril 10mg 5) Vitamin C 250mg (2 tabs) =500mg Residents Affected - Few During an interview conducted on 12/13/23 at 3:35 PM with the Director of Nursing (DON), she stated she has been working at the facility for 3 months. When asked in general what would be the components of a pharmacy order, she stated resident's name, drug name, dosage, route, frequency, and indication. When asked if a drug/vitamin does not have the dosage listed, she said it needs to be clarified by physician and the correct order needs to be put in as per MD order, and family notified. The DON stated if a medication without a strength of dosage was given to a resident it would be considered a medication error. When asked how the facility reconciles medication orders, she stated that for any new medication order it would be audited the next day by the nurse during the Interdisciplinary Team Morning Meeting team as well as monthly by the Pharmacist. When the DON was shown the order for Vitamin C with no dosage just give 2 pills orally, she acknowledged the order is incomplete and would need to be clarified. When it was pointed out the order was started on 09/06/23 she said that should have been caught by the nurse the next day during the meeting or should have been caught by the Pharmacist doing monthly drug regimen review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 19 of 24 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 12/14/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure appropriate behavior monitoring for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #18). The findings included: Observations on 12/11/23 and 12/12/23 throughout the day revealed Resident #18 sporadically yelling out. The resident would have intervals of loudly yelling out, sometimes heard through a closed door. At other times the resident would be quiet and appeared content. Review of the record revealed Resident #18 was originally admitted to the facility on [DATE], with a current readmission on [DATE]. Review of the current orders revealed Resident #18 was on Xanax for anxiety, and Olanzapine for a bipolar disorder. Review of the current orders and record lacked any monitoring for behaviors. Further review of the record revealed in October 2023, Resident #18 exhibited behaviors of agitation, calling out, or screaming on 5 of 93 shifts. Interventions for behaviors, to include one-to-one attention, position changes, provision of fluids, and administration of medications, were completed on 41 of the 93 shifts. During a side-by-side review of the record and interview on 12/14/23 at 1:46 PM, Staff G, Licensed Practical Nurse (LPN), agreed with the current lack of behavior monitoring. The LPN explained it may have been missed with the current readmission. Staff G explained Resident #18 had continued behaviors of yelling or screaming out, but they are usually managed with staff interventions. When told the October 2023 behaviors and interventions did not correspond, the LPN agreed for each behavior the nurse should document the intervention, and that the two should match up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 20 of 24 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 12/14/2023 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to serve food in a sanitary manner. Residents Affected - Few The findings included: On 12/11/23 at 7:37AM, an initial tour was conducted of the main kitchen with the Certified Dietary Manager. The following was observed: (1) A test of the red bucket revealed that the solution was 150 ppm instead of 200-400 ppm. (2) A fire extinguisher was hanging from the ceiling over a stainless-steel table, the bottom of the extinguisher is rusted. (3) The ceiling tiles in the kitchen are broken and there is black dust all over it. (4) The stove and the oven are dirty with grease and burnt on food. (5) The plate lowerator that clean plates are placed, is dirty with stains of food. On 12/11/23 at 12:20 PM, an interview was conducted with the Certified Dietary Manager to review the findings. She acknowledged the findings. On 12/14/23 at 11:20 AM, a tour of the facility nourishment pantries was conducted with the Certified Dietary Manager. The first-floor pantry had a leak in the ceiling coming from the second-floor pantry refrigerator that is located right above it. The second-floor nourishment pantry microwave is dirty with spills of food. On12/14/23 at 12:20 PM, an interview was conducted with the Certified Dietary Manager, and she acknowledged the findings. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 21 of 24 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 12/14/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) for 2 of 2 sampled residents observed receiving high contact resident care activities (Residents #75 and #62). The facility had 20 current residents on Enhanced Barrier Precautions at the time of the survey. Residents Affected - Few The findings included: Review of the policy Enhanced Barrier Precautions dated 09/01/22 documented, Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high contact resident care activities. Definitions: Indwelling medical device - includes but is not limited to central lines, urinary catheter, feeding tube, tracheostomy, and ventilator. High contact care activity - provide opportunities for transfer of MDRO to staff hands and clothing. High contact care activities include: . device care or use, such as . urinary catheter, feeding tube, . 1) During an interview on 12/12/23 at 11:00 AM, Resident #75 was observed in bed. A dressing was noted to the resident's right hip and a urinary drainage device was also noted. Resident #75 stated the staff change her dressing and provide care to the urinary catheter. Review of the record revealed Resident #75 was admitted to the facility on [DATE], with current diagnoses to include Methicillin Resistant Staphylococcus Aureus (MRSA) infection, an MDRO. The current orders revealed Resident #75 had an indwelling urinary catheter since 10/31/23 and the current care plans documented a re-opened right hip pressure injury since 12/09/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. An observation of care for the urinary catheter for Resident #75 was made on 12/13/23 beginning at 4:31 PM with Staff F, Certified Nursing Assistant (CNA). The CNA washed her hands and donned gloves, provided personal care and care for the urinary catheter, and at no time donned a gown, as per their EBP policy. 2) Resident #62 was initially admitted to the facility on [DATE] with diagnoses that included post Cerebral Infarction, Dysphagia, and Aphasia. The admission assessment dated [DATE] revealed the resident was admitted with a Peg tube (Percutaneous Endoscopic Gastrostomy which is a tube that brings nutrition directly into the stomach). Resident #62 has continued to be fed through a PEG tube. An observation of the door to Resident #62's room revealed a sign that said Enhanced Barrier Precautions. There was no cart with gowns in front of the door. The sign revealed everyone must clean their hands, including before entering and when leaving the room and Providers and Staff Must Also: Wear gloves and a gown for the following High Contact Resident Care Activities. Among those activities is feeding tube device care. On 12/11/23 at 3:00 PM, an observation was made of Staff A, a Registered Nurse (RN), entering Resident #62's room. Staff A was observed washing her hands before connecting the tube feeding and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 22 of 24 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 12/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few donning gloves. She hung and connected a bottle of tube feeding for Resident #62. After the tube feeding was hung, Staff A doffed her gloves and washed her hands. On 12/12/23 at 9:54 AM, an observation was made of Staff B, a Licensed Practical Nurse (LPN), entering Resident #62's room. She washed her hands, donned gloves, then disconnected the tubing from the resident's abdomen and discarded the formula. She then doffed her gloves and washed her hands. On 12/14/23 at 1:45 PM, an interview was conducted with Staff B. Staff B was asked what it means when a resident has a sign for enhanced barrier precautions on their door. She replied that it means you are supposed to wear gloves and a gown if there is exposure to something contagious or when doing a PEG tube feeding. When asked if she put a gown on when stopping PEG tube feedings, she said she does not, nobody does. An interview was conducted with the Director of Nursing on 12/14/23 at 4:30 PM who acknowledged staff are not following the enhanced barrier precautions policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 23 of 24 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 12/14/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the pneumococcal vaccine for 1 of 1 sampled resident, as requested by Resident #22. Residents Affected - Few The findings included: During an interview on 12/11/23 12:59 PM, Resident #22 stated he had requested to receive the most current pneumonia (pneumococcal) vaccine at the facility months ago. When asked who he spoke with, Resident #22 named the Assistant Director of Nursing (ADON). Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. Review of the most current comprehensive MDS assessment dated [DATE], documented it was very important for Resident #22 to be involved in all his daily preferences. Review of the record lacked any evidence for the provision of the pneumococcal vaccine. During an interview on 12/13/23 at 12:51 PM, when asked about the provision of the pneumococcal vaccine for Resident #22, the ADON stated she would need to follow up with the Director of Nursing (DON). During an interview on 12/13/23 at 3:16 PM, the DON provided a signed consent for Resident #22 dated 09/26/23, that documented the resident wanted the pneumococcal vaccine. This consent had a hand-written note that documented, Patient not sure if done 3 years ago? The DON explained she was unsure when the resident had last received the pneumococcal vaccine but confirmed Resident #22 wanted to receive the most up to date vaccines. When asked if she had checked Florida Shots (a web site that documents the provision of all vaccines), the DON stated she had not, nor had she followed up on the requested pneumococcal vaccine in any other way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105795 If continuation sheet Page 24 of 24