Inspection·January 14, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility did not ensure dignity was maintained for four residents (#71, #23, #25 and #11) of four residents related to 1. three staff members (O, J, H) assisting two residents (#71, #23) with meals while standing, 2. not ensuring catheter bags for two residents (#71 and #11) were covered with privacy bags, and 3. not ensuring privacy during wound care for one resident (#25), for a total of three days (01/11/22, 01/12/22 and 01/13/22) of four days. Residents Affected - Some Findings included: 1. During multiple facility tours on 01/11/22 at 12:45 p.m., 01/12/22 at 9:03 a.m., 01/12/22 at 12:19 p.m., and 01/13/22 at 12:41 p.m., observations were made of Staff O, Certified Nursing Assistant (CNA) standing while assisting Resident #71 with a meal. An admission Record printed on 01/13/22 showed Resident #71 was admitted to the facility on [DATE] with diagnoses to include: other lack of coordination, Type 2 diabetes, Dysphagia, facial weakness, sequelae of Guillain-Barre syndrome, quadriplegia, major depressive disorder, delusional disorders, aphasia following cerebral infarction, and anxiety disorder. A care plan for Resident #71 with a review date 01/02/22 showed a goal for activities for daily living (ADLs). Resident #71 had a self-care performance deficit and a risk of decline related to DM (diabetes mellitus) and Guillain Barre Syndrome (disorder causing muscle weakness and sometimes paralysis). Interventions stated under Eating that Resident #71 requires staff assistance and is dependent. A Quarterly Minimum Data Set (MDS) for Resident #71, dated 12/21/21, showed under Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G-Functional Status showed Resident #71 was totally dependent for ADLs and required one person assistance for eating. On 01/12/22 at 12:41 p.m., an interview was conducted with Staff O, CNA. Staff O stated that she never sits. Staff O stated she has been trained to sit. Staff O said, The expectation is to sit due to dignity . Staff O confirmed Resident # 71 has not asked her to stand during meal assistance. Staff O said, I know I should sit. On 01/13/22 at 12:41 p.m. an observation was made of Staff O, CNA standing while assisting Resident #71 with a meal. At this time during an interview Staff O stated she stands because there was no chair. Random observations on 01/12/22 at 9:00 a.m. and 11:35 a.m., were made of Staff J, CNA assisting Resident #23 with meals while standing. On 01/12/22 at 2:23 p.m., an interview was conducted with Staff J, CNA. Staff J stated she chooses to stand. Staff J said, It is my choice. I don't think the resident cares. It's my preference. Staff J stated she had not been trained. Staff J stated she did not think standing was a dignity concern. Staff J said, I don't think so. It is not a requirement that I sit. I always stand. On 01/13/22 at 12:08 p.m., an observation was made of Staff H, CNA assisting Resident #23 with a meal while standing. An immediate interview was conducted with Staff H and she stated that she knows she should sit, but there was no chair. Staff H said, I should be sited for dignity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 2 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the admission Record showed Resident #23 was admitted to the facility on [DATE] with diagnoses to include other lack of coordination, dementia, and muscle weakness. A review of the Quarterly MDS for Resident #23, dated 11/03/21, Section C - Cognitive Patterns showed Resident #23 had a BIMS score of 03, indicating severe impairment. Section G - Functional Status showed Resident #23 required extensive assistance for ADLs and Resident #23 was totally dependent for meals with one person assist. A care plan for Resident #23, dated 11/05/21,showed a goal for ADL self-care performance deficit related to weakness, dementia, and anxiety. An intervention for eating showed Resident #23 required assistance with meals with one staff assist. On 01/13/22 at 12:15 p.m. an interview was conducted with the Director of Nursing (DON). The DON said, Staff should be sited. That is the expectation, this is a dignity issue taught in CNA schools. You sit at eye level. The DON stated this is a basic nursing concept. An interview was conducted on 01/13/22 at 12:44 p.m. with Staff K, Registered Nurse (RN). When asked if staff should sit or stand during meal assistance Staff K said, It depends on the resident, I think. I didn't think there is a policy. Staff K stated if a resident has a special plan of care, it will be documented in his or her care plan. A follow-up interview was conducted on 01/14/22 at12:40 p.m. with Staff E, Regional Nurse. Staff E said, Related to dignity with meals, the staff should be sitting. Staff E stated an audit has been started for all the rooms. Staff E confirmed staff stated they did not have chairs. 2. During multiple tours of the facility on 01/11/22 at 11:23 a.m., 01/11/22 at 12:47 p.m., 01/12/22 at 9:03 a.m., 01/12/22 at 11:48 a.m., and 01/13/22 at 9:53 a.m., Resident #71 was observed in his room and his catheter bag was observed not covered with a privacy bag and visible from the hallway. (Photographic Evidence Obtained) An additional review of Resident #71's admission Record showed diagnoses to include: severe sepsis with septic shock, neuromuscular dysfunction of bladder and urinary tract infection. Review of Resident #71's active physician orders as of 1/13/22 showed the following: Catheter care every shift and as needed for neuromuscular dysfunction of bladder, with a start date of 1/13/21, Catheter bag, change as needed with a start date of 1/12/21, and Change catheter as needed with a start date of 1/12/21, A care plan for Resident #71, revised on 12/30/30 and last reviewed on 01/20/22, showed a Focus as [Resident #71] has an indwelling catheter with an intervention to provide catheter care as ordered and PRN (as needed). Another Focus revealed [Resident #71] has an ADL self-care deficit with an intervention for toilet use as Resident #71 required staff assistance for toileting: Dependent. On 01/11/22 at 12:10 p.m., Resident #11 was observed in his room during lunch. His catheter bag was observed on the floor and not covered by a privacy bag. Resident #11 was non-verbal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 3 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/11/22 at 12:50 p.m., Resident #11 was wandering the halls dressed in a hospital gown, open in his back, exposing his brief. Resident #11 was carrying his catheter bag in his hand. The catheter bag was not covered with a privacy bag. Resident #11 was pointing to a full catheter bag asking if it could be emptied. On 01/12/22 at 9:05 a.m., Resident #11 was observed ambulating himself to the bathroom, holding his catheter bag in one hand, the tubing was dragging on floor. Resident #11 mumbled, Help me. At this time Staff J, CNA said to Resident #11, I will be right with you, and as of 9:26 a.m. Staff J had not returned to assist Resident #11. On 01/12/22 at 12:10 p.m., Resident #11 was observed in the hallway, ambulating with his catheter bag in one hand. Resident #11 was wearing a hospital gown, opened in the back. Resident #11 was trying to communicate. Resident #11's catheter bag was not covered with a privacy bag. His catheter tubing was noted kinked an obstructing urine flow. On 01/12/22 at 12:15 p.m., Staff L, Activities Director responded to Resident #11 as the resident ambulated in hallway holding his catheter bag up. Staff L said, I'm not sure what he needs. Staff L stated that CNAs and nurses empty catheters. Staff L said, I will let them know. On 01/13/22 at 9:36 a.m., Resident #11 was observed sitting on his bed. The catheter bag was placed on his bed. (Photographic Evidence Obtained) On 01/13/22 at 10:23 a.m., Resident #11 was observed ambulating in the hallway holding his catheter bag close to his chest area. The catheter was noted to be full and not covered by a privacy bag. On 01/14/22 at 8:52 a.m., Resident #11 was observed in his room sitting on the bed. Resident #11 did not have pants on. Resident #11 was wearing a white T-shirt. Resident #11's door was wide open, and his roommate was in his wheelchair in the middle of the room. Both residents were non-verbal. Resident #11's catheter bag was observed on his feet without a privacy bag and was full. Resident #11's gown and soiled brief were noted on the TV stand. Resident #11 was not able to express his concerns. On 01/14/22 at 9:12 a.m., an interview was conducted with Staff N, Agency CNA. Staff N was observed going room to room collecting trash. Staff N stated she was assigned to Resident #11. When asked if she had assisted him with getting dressed this morning, Staff N stated she was going there next. Staff N was notified that Resident #11 did not have pants on. Staff N said, I know, I will get to him. Review of the admission Record for Resident #11 showed an admission date of 09/30/21. Resident #11's diagnoses included autistic disorder, muscle weakness, unsteadiness on feet, cognitive communication deficit, adult failure to thrive, neuromuscular dysfunction of bladder and colostomy status. A MDS, dated [DATE], showed Resident #11 had a BIMS score of 05, indicating severe impairment. Section G-Functional Status showed Resident #11 was totally dependent on staff for toileting. The active physician orders for Resident #11 as of 01/13/22 showed the following: Catheter care every shift and as needed with a start date of 9/30/21, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 4 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0550 Catheter bag: change as needed with a start date of 9/30/21. Level of Harm - Minimal harm or potential for actual harm A care plan for Resident #11, initiated on 10/08/21, showed an ADL self-care deficit related to confusion, impaired cognition due to autism. The intervention showed that Resident #11 requires staff assistance for toileting and dressing. An initial review of the Resident's care plan showed no care plan for catheter, care, or maintenance. An additional review showed a Focus for resident has a [indwelling] catheter with an initiated date of 1/13/22 with interventions to include: position catheter bag and tubing below the level of the bladder and away from entrance room door. Residents Affected - Some On 01/13/22 at 11:24 a.m., an interview was conducted with Staff K, RN. Staff K stated nurses and CNAs should make sure the catheter is emptied. Staff K said, No, a resident should not be emptying their own catheter. Staff K stated they should be assisting the residents with catheter care so that they can monitor for infections and document output amount. A follow- up was conducted on 01/13/22 at 12:20 p.m. with the DON. The DON stated ambulatory residents should be wearing a leg bag. The DON stated it [catheter bag] should be in a bag [privacy] to provide some dignity. The DON further stated catheters should be covered whether the resident is in bed or not. Review of the facility document titled, Catheter Care, Urinary, with a revision date of 09/05/17, showed a procedure to provide privacy and explain procedures. Review of an undated document titled, Eating Support showed 12.) . Sit so you are at the same level as the resident. Review of a facility policy titled, Resident Rights, dated 11/30/2014, showed it is the policy of the company to 1.) make residents and their legal representatives aware of resident's right, and 2.) Ensure that resident's rights are known to staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 5 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide services with reasonable accommodation of a resident's need and preference related to smoking during the assigned smoking times for one resident (#59) of a total sample of 15 residents who smoked for four days (01/11/22, 01/12/22, 01/13/22 and 01/14/22) out of four days. Residents Affected - Few Findings included: During a facility tour on 01/11/22 at 10:32 a.m., Resident #59 was observed in his room waiting to be assisted out of bed and to be dressed. Resident #59 stated, I want to get out and have my cigarette. I missed my 9:00 a.m. cigarette. On 01/12/22 at 9:10 a.m., Resident #59 was observed in his room, lying in bed. Resident #59 said, They won't let me go to smoke. I have to get dressed, and no one is assisting me. Resident #59 stated if he missed the smoke time at 9:00 a.m., he has to wait until 1:00 p.m. On 01/12/22 at 12:51 p.m., Resident #59 complained that he still had not had a cigarette. Resident #59 said, They said I missed it, because I was not up and dressed. Review of the admission Record for Resident #59 showed an admission date of 11/21/21 with a diagnoses to include of acute hematogenous osteomyelitis, right ankle, and foot, contracture of muscle, right and left thigh, and anxiety disorder. A review of Resident #59's Quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognition. Section G - Functional Status showed Resident #59 required extensive assistance for activities of daily living (ADLs) including dressing. Resident #59 was totally dependent for transfers and had impairment on both sides for functional limitation in range of motion. A care plan for Resident #59, initiated on 02/04/20 and last revised on 02/25/21, showed a Focus for ADL self-care performance deficit due to impaired balance, limited mobility, musculoskeletal impairment, hx (history) of hip replacement and hip dislocation that was not repaired. The interventions indicated Resident #59 required assistance for bed mobility to turn and reposition. Resident #59 required staff assistance to dress, and required assistance by two staff with mechanical lift to move between surfaces. Another Focus initiated on 01/22/20 and revised on 02/18/21 was [Resident #59] . He is social with others and is willing to participate in out of room activities. He is a smoker and does smoke in designated area. In addition, a Focus listed as [Resident #59] is a smoker. Resident is non-compliant with facility smoking policy. A goal in the care plan showed Resident #59 will not smoke without staff supervision through the review date of 3/10/22. The interventions included: Instruct resident about the facility policy on smoking: locations, times, safety concerns, and the resident requires supervision while smoking. On 01/13/22 at 10:30 a.m., Resident #59 was observed in his room. Resident #59 stated he missed his 9:00 a.m. cigarette again this morning. Resident #59 said, I would like to have my cigarette. This happens all the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 6 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 01/13/22 at 10:32 a.m. with Staff H, Certified Nursing Assistant (CNA). Staff H stated she has not been told anything about assisting Resident #59 to the smoke area; if he missed his 9:00 a.m. cigarette. Staff H said, I think there is a smoke aide, but I don't know who it is. Staff H stated [Resident #59] was not ready to go out at 9:00 a.m. for his smoke break. Staff H stated [Resident #59] missed his smoke time because she was assisting other residents. Staff H stated [Resident #59] required two staff to get out of bed, and she was waiting for assistance. An interview was conducted with Resident #59 on 01/13/22 at 11:00 a.m. Resident #59 stated the facility smoking schedule is four times a day. Resident #59 said, You can't smoke more than that. Resident #59 confirmed he had not been offered to go out since he missed his opportunity at 9:00 a.m. Resident #59 stated most mornings they [staff] do not get him up in time, and he ends up missing his cigarette, and/or they are late in getting him dressed. Resident #59 stated it upsets him because he is not allowed to go until the next appointed time, (approximately 4 hours later). Resident #59 stated he needs assistance to get out of bed, and he can wheel himself down there, but it takes him a long time. Review of an undated document titled, Smoking Times, showed the residents can smoke at 9:00 AM, 1:00 PM, 4:00 PM and 8:00 PM. On 01/13/22 at 12:33 p.m., residents were observed waiting to go outside to smoke, lined up in a hall outside the Social Services Director (SSD) office. An interview was conducted with the SSD. The SSD stated that facility smoke times are as scheduled at 9:00 a.m., 1:00 p.m., 4:00 p.m. and 8:00 p.m. The SSD stated that residents do not go outside of the smoke hours. The SSD confirmed that if they [residents] miss the scheduled time, they wait until the next smoke time. An interview was conducted on 01/13/22 at 12:35 p.m. with the Director of Rehabilitation (DOR). The DOR sated there has been no extra smoke breaks. The DOR said she wasn't sure why. The DOR stated if the residents miss their turn, or if they are not by the door during smoke hours, they don't get another chance. The DOR said, I don't think it is right. Maybe they should be accommodated. On 01/13/22 at 12:24 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated that Resident #59 should be up by 9:00 a.m. so he can make it for his cigarette break, if he is able. The DON stated that if he [Resident #59] misses his smoke break, they should accommodate him. The DON said, It is not his fault. We should make sure he is dressed and ready. An interview was conducted on 01/13/22 at 2:25 p.m. with the Nursing Home Administrator (NHA). The NHA said, He [Resident #59] should be accommodated. If he is not up by 9:00 a.m. for whatever reason. The NHA stated they should still be able to honor his right to smoke. On 01/14/22 at 9:23 a.m., Resident #59's call light was noted on. Resident #59 was observed in bed, noted visibly upset with a frowned face. Resident#59 said, I am still in bed. I have missed my morning cigarette. This is not right. On 01/14/22 at 9:25 a.m., an interview was conducted with Staff N, CNA Agency. Staff N stated it was her second day at the facility. Staff N stated she knew Resident #59's light had been on probably 30 minutes. Staff N stated the residents in this hall need a lot of care. Staff N said, [Resident #59] is a two-staff assist. I'm waiting for help. At this time there was no other staff observed in the hall and Resident #59 missed his opportunity to smoke. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 7 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the policy and procedure titled, Smoking - Supervised, with a revision date of 02/07/20, showed the center will provide a safe, designated smoking area for residents. Smoking is only allowed in designated areas and during designated times. Review of a facility policy titled, Resident Rights, dated 11/30/2014, showed that it is the policy of The Company to 1.) Make residents and their legal representatives aware of resident's right, and 2.) Ensure that resident's rights are known to staff. Event ID: Facility ID: 105895 If continuation sheet Page 8 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 observations, interviews and record review, the facility failed to ensure appropriate treatment and services of an indwelling catheter for two residents (#11, and #71) of seven residents with indwelling catheters. Findings included: 1. On 01/11/22 at 12:10 p.m., Resident #11 was observed in his room during lunch. His catheter bag was observed on the floor and not covered by a privacy bag. Resident #11 was non-verbal. On 01/11/22 at 12:50 p.m., Resident #11 was wandering the halls dressed in a hospital gown, open in his back, exposing his brief. Resident #11 was carrying his catheter bag in his hand. The catheter bag was not covered with a privacy bag. Resident #11 was pointing to a full catheter bag asking if it could be emptied. On 01/12/22 at 9:05 a.m., Resident #11 was observed ambulating himself to the bathroom, holding his catheter bag in one hand, the tubing was dragging on floor. Resident #11 mumbled, Help me. At this time Staff J, CNA said to Resident #11, I will be right with you, and as of 9:26 a.m. Staff J had not returned to assist Resident #11 and Resident #11 proceeded to empty his own catheter bag. On 01/12/22 at 12:10 p.m., Resident #11 was observed in the hallway, ambulating with his catheter bag in one hand. Resident #11 was wearing a hospital gown, opened in the back. Resident #11 was trying to communicate. Resident #11's catheter bag was not covered with a privacy bag. His catheter tubing was noted kinked an obstructing urine flow. Resident #11 was observed not to be wearing a leg bag as he ambulated in the hallway. On 01/12/22 at 12:15 p.m., Staff L, Activities Director responded to Resident #11 as the resident ambulated in hallway holding his catheter bag up. Staff L said, I'm not sure what he needs. Staff L stated that CNAs and nurses empty catheters. Staff L said, I will let them know. On 01/13/22 at 9:36 a.m., Resident #11 was observed sitting on his bed. The catheter bag was placed on his bed. (Photographic Evidence Obtained) On 01/13/22 at 10:23 a.m., Resident #11 was observed ambulating in the hallway holding his catheter bag close to his chest area. The catheter was noted to be full and not covered by a privacy bag. On 01/14/22 at 8:52 a.m., Resident #11 was observed in his room sitting on the bed. Resident #11 did not have pants on. Resident #11 was wearing a white T-shirt. Resident #11's door was wide open, and his roommate was in his wheelchair in the middle of the room. Both residents were non-verbal. Resident #11's catheter bag was observed on his feet without a privacy bag and was full. On 01/14/22 at 9:12 a.m., an interview was conducted with Staff N, Agency CNA. Staff N was observed going room to room collecting trash. Staff N stated she was assigned to Resident #11. When asked if she had assisted him with getting dressed this morning, Staff N stated she was going there next. Staff N was notified that Resident #11 did not have pants on. Staff N said, I know, I will get to him. Staff N was asked if she had noticed his catheter was full. Staff N, CNA said, Yes, I will get to him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 9 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 Review of the admission Record for Resident #11 showed an admission date of 09/30/21. Resident #11's diagnoses included autistic disorder, muscle weakness, unsteadiness on feet, cognitive communication deficit, adult failure to thrive, neuromuscular dysfunction of bladder and colostomy status. A MDS, dated [DATE], showed Resident #11 had a BIMS score of 05, indicating severe impairment. Section G-Functional Status showed Resident #11 was totally dependent on staff for toileting. The active physician orders for Resident #11 as of 01/13/22 showed the following: Catheter care every shift and as needed with a start date of 9/30/21, Catheter bag: change as needed with a start date of 9/30/21, Suprapubic Catheter 16fr (French size) with 10 cc (cubic centimeter) balloon dx (diagnosis) urine retention with a start date of 9/30/21, Monitor catheter for patency and drainage with a start date of 9/30/21, and Irrigate catheter for blockage / leakage with 5-10 cc of normal saline as needed with a start date of 9/30/21. A January 2022 Treatment Administration Record (TAR) for Resident #11 showed catheter care was not documented on the day shift for 1/4/22 and 1/10/22, and the night shift on 1/1/22, 1/2/22, and 1/8/22. The TAR showed monitoring the catheter for patency and drainage did not occur on the day shift for 1/4/22 and 1/10/22 and the night shift for 1/1/22, 1/2/22 and 1/8/22. The TAR showed monitor urine for s/s (signs/symptoms) and notify MD (medical doctor) every shift did not occur on the day shift of 1/4/22 and 1/10/22 and the night shift of 1/1/22, 1/2/22 and 1/8/22. There were no codes on the TAR for those missed timeframes to indicate the reason. The TAR indicated irrigation of the catheter PRN did not occur from January 1 to January 13, 2022 as of 2:16 p.m. An initial review of the care plan for Resident #11, showed an ADL self-care deficit, initiated on 10/08/21, related to confusion, impaired cognition due to autism. The intervention showed that Resident #11 requires staff assistance for toileting and dressing. This initial review of the resident's care plan showed no care plan for catheter, care, or maintenance. On 01/13/22 at 11:24 a.m., an interview was conducted with Staff K, RN. Staff K stated nurses and CNAs should make sure the catheter is emptied. Staff K said, No, a resident should not be emptying their own catheter. Staff K stated they should be assisting the residents with catheter care so that they can monitor for infections and document output amount. 2. On 01/11/22 at 11:23 a.m. Resident #71 was observed in his room and his catheter bag was visible from the hallway and full of blood. He stated he has been bleeding and he didn't think they were doing anything about it and reported he was feeling pain. He stated he asked to go to the ER (emergency room) and he had not seen a urologist. A review of an emergency room visit report, dated 01/08/22, revealed Resident #71 was seen for a UTI and malfunction of the [indwelling] catheter. An additional observation and interview on 01/11/22 at 12:47 p.m. revealed Resident #71 in his room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 10 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 and the catheter bag was not covered and on the floor. It was confirmed the nurse flushed his catheter today. On 01/12/22 at 2:37 p.m., an interview was conducted with Resident #71. Resident #71 stated he had pain in his lower abdomen and when he had this problem before, his catheter was clogged. Resident #71 stated he asked to go to the ER (emergency room) last week on January 8th, saying, They finally agreed and sure enough, my catheter was clogged. They changed it at the ER. On 01/13/22 at 9:53 a.m. Resident #71 was observed in his room and the catheter bag was not covered and contained amber colored urine. He stated he has been in pain in his lower abdomen. An admission Record printed on 01/13/22 showed Resident #71 was admitted to the facility on [DATE] with diagnoses to include: other lack of coordination, quadriplegia, severe sepsis with septic shock, neuromuscular dysfunction of bladder and urinary tract infection. Review of Resident #71's active physician orders as of 1/13/22 showed the following: Urology Appt (appointment) scheduled for follow up 1/13/22 at 10:30 a.m. with an order date of 12/29/21, Follow up with Urology in 1 month with an order date of 12/1/21, Keflex capsule 500 mg (milligram) by mouth every 6 hours for UTI (urinary tract infection) for 5 days, order date of 1/8/22, Catheter care every shift and as needed for neuromuscular dysfunction of bladder, with a start date of 1/13/21 with an original start date of 12/20/21, Catheter bag, change as needed with a start date of 1/12/21, and Change catheter as needed with a start date of 1/12/21, and [Indwelling Catheter] 14fr with 10cc balloon dx neurogenic bladder with an order date of 1/13/21. A January 2022 Treatment Administration Record (TAR) for Resident #71 showed catheter care was not documented on the day shift for 1/4/22 and 1/10/22, and the night shift on 1/1/22, 1/2/22, and 1/8/22. The TAR There were no codes on the TAR for those missed timeframes to indicate the reason. The TAR did not indicate if the catheter bag was changed as needed from 1/1/22 to 1/13/22 as of 1:36 p.m. The was a physician order on the January 2022 Medication Administration Record (MAR) that showed, Flush with 10cc of normal saline every shift and as needed every shift, with a start date of 12/20/21 and an end date of 1/4/22. There wasn't an active physician order noted on the MAR or TAR related to flushing the indwelling catheter. A Quarterly Minimum Data Set (MDS) for Resident #71, dated 12/21/21, showed under Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G-Functional Status showed Resident #71 was totally dependent for ADLs and required a one person physical assistance for toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 11 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 A care plan for Resident #71, revised on 12/30/30 and last reviewed on 01/20/22, showed a Focus as [Resident #71] has an indwelling catheter with an intervention to provide catheter care as ordered and PRN (as needed), incontinence care as needed, monitor for s/sx (signs/symptoms) of discomfort on urination and frequency, monitor/document for pain/discomfort due to catheter and monitor/record/report to MD for s/sx UTI. Another Focus revealed [Resident #71] has an ADL self-care deficit with an intervention for toilet use as Resident #71 required staff assistance for toileting: Dependent. Review of a checklist titled, Indwelling Catheter Care Skills Competency Checklist, dated 08/23/21, showed #10: Ensure urinary drainage bag remains below the bladder. Review of the facility document titled, Catheter Care, Urinary, with a revision date of 09/05/17, showed a procedure to provide privacy and explain procedures. A follow- up was conducted on 01/13/22 at 12:20 p.m. with the DON. The DON stated ambulatory residents should be wearing a leg bag. The DON stated if a resident has a catheter the care plan should show the care that should be provided and by whom. The DON stated it [catheter bag] should be in a bag [privacy] to provide some dignity. The DON further stated catheters should be covered whether the resident is in bed or not. The DON stated [indwelling catheter] care should be completed every shift, including changing the [indwelling catheter] every shift or as needed. The DON stated the unit manager should make sure the nurses are following physician orders. The DON stated she would review the care plans to make sure catheter care is included. Following the interview with the DON, an additional review of the care plan showed a Focus for Resident #11 as: has a [indwelling] catheter with an initiated date of 1/13/22 with interventions to include: position catheter bag and tubing below the level of the bladder and away from entrance room door and check tubing for kinks. Review of an undated job description for a Clinical Nurse showed the primary purpose of the position is to provide direct nursing care to the residents . to ensure that the highest degree of quality care is maintained at all times. Review of a job description for a Nurse Tech 1 - Certified Nursing Assistant, dated November 1, 2006, showed the primary focus of the position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. Review of a facility policy titled, Resident Rights, dated 11/30/2014, showed that it is the policy of the company to (1.) make residents and their legal representatives aware of resident's right. (2.) Ensure that resident's rights are known to staff. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 12 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered, and two errors were identified for two (Resident #21 and #49) of three residents observed. These errors constituted a medication error rate of 8.00 percent. Residents Affected - Few Findings included: On 1/13/22 at 08:30 a.m., an observation of medication administration with Staff A, Registered Nurse (RN), was conducted with Resident #21. Staff A, (RN) was observed administering Advair HFA Aerosol 115-21 MCG (microgram) ACT one (1) application inhale orally two times a day for diagnosis of Shortness of Breath. (SOB). After the medication was administered Resident #21 did not rinse her mouth and spit out with water after inhalation of the medication. An immediate interview with Staff A, (RN) was conducted and Staff A, (RN) stated I forgot, when she was asked why she did not follow pharmacy package directions on the medication. An interview was obtained at the same time with the resident who revealed that she often forgets she is supposed to rinse her mouth and spit out the contents after she takes the medication (photographic evidence was obtained). On 1/13/22 at 09:30 a.m., an observation of medication administration with Staff B, Licensed Practical Nurse (LPN), was conducted with Resident # 49. Staff B, (LPN) was observed administering Isosorbide Mononitrate Extended Release (ER) Tablet 24 Hour 30 MG (milligram), one (1) tablet by mouth once a day for Essential (Primary) Hypertension. Staff B, (LPN) crushed all the resident's medications and placed them in vanilla pudding. An immediate interview was conducted once Staff B, (LPN) exited Resident #49's room. During the interview Staff B, (LPN) revealed that she did not realize that the medication was ER and should never be crushed. WebMD uses for medication Isosorbide Mononitrate Extended Release (ER) Tablet 24 Hour 30 MG, Page 02, reads: Swallow this medication whole with a glass of water 4 ounces/120 milliliters) unless your doctor directs you otherwise. Do not crush or chew this medication. Doing so can release all of the dug at once, increasing the risk of side effects. Accessed at Https:///Isosorbide Mononitrate ER Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD An interview was conducted on 1/13/22 at 3:30 p.m., with the Director of Nursing (DON), and the Regional Director of Clinical Services, who were both informed of the two (2) medication errors observed. The Regional Director of Clinical Services stated they (nursing staff) should be following instructions on the container of the medication, and ER medications should not be crushed. During an interview with facility's Pharmacy Consultant conducted on 1/14/22 at 12:48 p.m., she confirmed that both medications were administered incorrectly by nursing staff. She further indicated her expectation is nursing staff do not crush Extended Release (ER) medications, and that all nurses should be up to date on the instructions of the medications they are administering. Review of the facility's policy titled 6.0 General Dose Preparation and Medication Administration, with revision date 1/01/22, Page 02 of 03, was reviewed and read under 4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 13 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as se t forth in the facility's medication administration schedule. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 14 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review and interviews, the facility failed to ensure ordered medication was available to dispense on an as needed (PRN) basis for one resident (#61) of four residents reviewed for the provision of ordered medications. Findings included: Review of the face sheet in the admission record for Resident #61 revealed a diagnosis of pressure ulcer of right buttock, stage 3. A review of the Minimum Data Set (MDS) assessment, Section C, Cognitive Patterns, dated 12/11/21 reflected a Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact. Review of physician's orders in the medical record revealed an order dated 12/23/21 for cyclobenzaprine hcl 5 mg (milligram) every 8 hours as needed for muscle relaxer related to muscle weakness, generalized. On 1/11/22 at 11:35 AM an interview was conducted with Resident #35. She said a nurse told her the prescription for the muscle relaxer disappeared after it was delivered from the pharmacy, and said it took a week and a half to get them reordered and delivered. A review of the Proof of Delivery Shipment Summary showed 30 pills of cyclobenzaprine were delivered on 12/31/21 for Resident #61. An interview was conducted with Staff E, regional nurse consultant on 1/14/22 at 10:23 AM. Staff E said medication is delivered on the next run and it would never be more than a day or two. She reviewed the 12/31/21 invoice, and stated, It should never take that long. If the nurses see it's out, they should order it stat. We have already started inservicing them to check their medications and anything that is low or not going to make it to the next delivery, should be ordered stat. Review of the medication administration record (MAR) for Resident #35 for the month of December 2021 reflected the medication had been administered on December twenty-third and twenty-fourth. The next dose was not given until January fourth. On 1/14/22 at 11:26 AM an interview was conducted with Staff F, regional nurse consultant. Staff F said they might have pulled them from the EDK (emergency drug kit). A telephone interview was conducted with Staff G, pharmacy front end manager on 1/14/22 at 12:55 PM. Staff G said the order was originally entered on 12/23. The pharmacy dispensed it that day. It was sent on 12/24. It was requested again on the twenty-sixth, but insurance suspended it until the thirty-first. The quantity was 30 each time. Review of the Proof of Delivery Shipment Summary from the pharmacy showed 30 cyclobenzaprine pills were delivered on 12/24/21 for Resident #61. On 1/14/22 at 1:32 PM an interview was conducted with Staff F, regional nurse consultant. Staff F said they didn't know about it, stating there is no file for it. We are going to open an investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 15 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0761 Level of Harm - Minimal harm or potential for actual harm A follow up interview was conducted with Staff E, regional nurse consultant on 1/14/22 at 1:43 PM. She said they searched the medication carts to see if the cyclobenzaprine got mixed in with someone else's. She said it was not found. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 16 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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. Based on observations, interviews and policy review the facility failed to ensure the kitchen equipment and area were maintained in a sanitary manner, and food was prepared, distributed and served in accordance with professional standards for food service safety, to include not ensuring the milk cooler maintained appropriate temperatures as evidenced by a temperature of 49 degrees Fahrenheit, and the facility failed to ensure the two nourishment rooms located on the 200 and 500 hall for residents were maintained and clean as well as have foods that were labeled properly, and foods were disposed of properly for three days (01/11/22, 01/12/22 and 01/13/22) of four days of survey. Findings included: On 01/11/22 between 9:28 a.m. and 10:40 a.m., an initial kitchen tour was initiated with the Dietary Manager (DM) and the observations included: *A ceiling vent above the food service area was noted with dirt and debris. The DM stated the maintenance department should be maintaining vents. *A water bottle was observed on top of the cart near the dish machine and noted with a pink solution. The solution was had foam resembling soap. Staff R, Dietary Aide stated the solution was soap. The DM confirmed soap should not be stored in an unlabeled water bottle. The DM said, no and proceeded to throw away the bottle. In addition, another bottle containing a [store-bought cleaning product] was observed next to the dish machine. The DM stated he did not have a SDS (safety data sheet) for the product. The DM stated an employee must have bought it and brought it in. *The dish machine had different types of food to include pasta and greens on the waste trap area. The DM confirmed pasta and greens were not served for breakfast and stated the food residue was from the day before. The DM stated they should be cleaning the washing machine daily. *A tour of the dry good storage area revealed a bag of pasta opened and not dated. A shelf in this area showed cereal-like food pieces spilled on surfaces and on the floor. *A ceiling vent above the stove area was noted with dark matter and with the appearance of bio-growth. *A fryer set on a table next to the stove was noted with dried up oil, fat and grease residue on a foil sheet placed on the bottom shelf, and underneath the foil was burnt food particles and black pieces of debris. *A shelf below the serving tray line was noted with dust, dirt and debris from food particles and remains. *A shelf storing clean food covers and lids was noted behind the food prep sink area. Next to the clean food covers and lids was two boxes of gloves, a staff member's goggles, and a roll of waste bags. The gloves and goggles were resting on a clean pan cover/lid. *A prep shelf next to the food covers, in the back of the kitchen, was noted with dirt, dust, and debris and next to spices and baking supplies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 17 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 *A microwave on a shelf was noted with food residue and dirt. Level of Harm - Minimal harm or potential for actual harm *Next to the microwave was a food temperature log titled, Service Line checklist. The checklist showed food temperatures were not documented as having been checked on 1/5/22, 1/6/22 and 1/7/22. An interview was conducted with the DM on 01/11/22 at 9:42 a.m. The DM stated food temperatures should be logged each time to ensure acceptable service temperatures. The DM said, Checking temperatures helps identify the danger zones. The DM further stated that if it is not logged, it did not happen. Residents Affected - Many *Following the interview with the DM, a mixing blender and a meat slicer were observed on a shelf with dirt, dust, and grimy matter. The DM asked Staff S, [NAME] if he had used the equipment earlier. Staff S stated, No, it's been a while since I used those. The DM stated he would have the equipment cleaned and covered. *A shelf below the equipment was noted with three containers. A black undated, unlabeled container which had dirt and dust on the surface. The DM said the container stores thickener. The DM said, It should be labeled and dated. Another undated container next to the black container was noted labeled as flour. [NAME] matter was noted around the plastic paper in which the product was stored in. The DM confirmed the product in this container was flour. The DM said, It should be dated. A third container labeled sugar showed brown dirt, stains, and debris on the surface. When asked about the brown substance, the DM stated it must be debris falling from the cleaning of the shelf above. The DM said, These products should be stored in a sanitary manner. A shelf above the equipment was noted with several spice bottles. The bottles were noted opened and exposed to the elements. The containers were also noted without dates of when the items were opened. A container labeled flavored base was noted without a lid, and with dried up contents. An unlabeled, undated jar with cinnamon rolls were noted on the counter. An immediate interview was conducted with Staff S, [NAME] on 01/11/22 at 9:43 a.m. Staff S stated he did not know why the spice bottles were left open. Staff S stated that all food items should be labeled and dated per food safety rules. Staff S said, It is important to monitor expiration dates. *An observation at 9:45 a.m. of the walk-in cooler was conducted and revealed dirt, debris, and food particles on the floor of the cooler unit. Staff S, [NAME] stated they would clean it today. Staff S stated he usually cleans the kitchen. The shelves in the cooler showed food and dirt residue on a tray holding condiments. The door frame of the cooler showed black, dark matter. The DM said, It looks like bio-growth. I have tried to keep it clean. It keeps coming back. *An observation at 9:49 a.m. of the main freezer was conducted. The freezer showed excessive build-up of frost and icicles on boxes of food and along the shelves. The boxes were noted wet with condensation and moisture. The door frame was noted with bio-growth. A bag of cookies was noted on the freezer shelf and not closed or dated and the cookies were exposed to the elements. An opened tub of ice cream was noted undated. An immediate interview was conducted with DM and Regional Certified Dietary Manager (CDM). The CDM stated he did not know there was a problem of that magnitude. The DM stated they had a problem with condensation two to three weeks before, but it was repaired. The DM said, This is bad. I know. *In addition at 9:57 a.m., a red tub with water for cleaning was tested. The test showed the cleaning solution did not have enough sanitization and tested below 50 PPM (parts per million). An interview was conducted with Staff Q, Dietary Aide. Staff Q stated they should maintain sanitization levels to ensure clean surfaces. At 9:58 a.m., an observation of the filter in the beverage dispensing machine revealed the surface pores covered with dust, debris and build up matter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 18 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 *At 10:00 a.m. the milk cooler was noted with a temperature above the cooling range and was tested, revealing a temperature of 49 degrees. The CDM and DM confirmed the observation. The CDM stated the milk should be below 41 degrees. The CDM said, 49 degrees is a danger zone. On 01/11/22 at 10:08 a.m., an immediate follow up interview was conducted with the administration related to significant concerns in the kitchen. The Maintenance Director, Staff E, Regional Executive, and Nursing Home Administrator (NHA) toured the kitchen. They were notified of the concerns with the milk above cooling temperatures that was to be served for lunch. The NHA said, This is not our standard. We will have someone out right away. We will not serve that milk. On 01/11/22 at 3:15 p.m., a brief second kitchen tour was conducted. The freezer was still noted with ice build-up, ceiling fans with dust and loose debris and the kitchen equipment including a can opener, blender, and meat slicer were noted with dirt, dust and grease build up. A kitchen tour was conducted on 01/12/22 at 11:26 a.m. A tray line service was observed, and food temperatures were conducted by Staff T, Cook. Staff T stated that when the food does not meet the right temperature readings, she puts it back in the stove or warmer. Staff T said, It is important to make sure food is at the right temperature, so we don't get people sick. On 01/12/22 at 11:31a.m., an observation revealed four vents with dust and debris, and a note on the milk cooler was observed stating, Do not use. The main freezer was noted defrosted, with no icicles or built-up frost and food boxes were noted wet from the condensation. On 01/13/22 at 1:51 p.m. a tour of the nutrition rooms on the 200 Hall and 500 Hall was conducted. Concerns were noted related to undated food items, staff items stored in the resident refrigerators, and a towel underneath the ice bucket noted with bio growth. The following was identified in the 200-Hall Nourishment Room: an open can of soda with a straw and cup over the straw with no name or date, a cup with a lid and liquid inside with no name or date, brown debris on the shelf inside the cabinet, an ice bucket ½ full of ice with no cover, a plastic bag with unknown contents and no label or date, and no thermometer in the freezer. The following was identified in the 500-Hall Nourishment Room: an open bag of pretzels in the cabinet, a frozen dinner with no name or date, an open box of a food item, a single pastry like food item in a plastic sleeve with no date or name, a bag of organic mango chunks and a bag of avocado chunks with no name or date. The filter in the ice machine was noted with dirt and debris and dark stains were observed on the face of the lower cabinets from an unknown substance. A sign on the refrigerator door showed, This Refrigerator is for Resident Items ONLY. It also showed all items must have the resident's name and the date of placement on it, all items will be discarded after three days or if expired or spoiled beforehand, there are to be no staff items in this refrigerator and all items without a resident's name and or date on them will be discarded. A follow-up interview was conducted on 01/13/22 at 2:00 p.m. with the DM and the DM stated the staff should be storing their food in the break room, not in the residents' refrigerators. The DM stated dietary staff were responsible for maintaining the nutrition rooms. The DM confirmed all food items should be clearly dated and labeled. The DM said, Any item that is opened must be dated. The DM stated the towel with bio-growth should be changed. The DM stated the filter in the ice machine should be cleaned. The DM stated that maintenance should do it. The DM said, I will take care of it now. A review of the facility policy, last revised on 09/17, and titled, Environment, showed all food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 19 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 condition. The section titled, Food Storage: Cold Foods, revealed: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food & Drug Administration) Food Code. Procedures included: #2. All perishable foods will be maintained at a temperature of 41 degrees or below. #5. All foods will be stored wrapped or in covered containers. The section titled, Food Storage: Dry Goods, showed #5. All packaged food items will be kept clean, dry, and properly sealed. #6. Storage areas will be neat, arranged for easy identification and date marked as appropriate. #7. Toxic materials will not be stored with food. The section titled, Equipment, all foodservice equipment will be clean, sanitary and in proper working order. #1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's direction and training materials. The section titled, Receiving, safe food handling procedures for time and temperature control will be practiced in . storage of all food items. #5. All food items will be appropriately labeled and dated either through manufacturer's packaging or staff notation. The section titled, Safety, Staff follow safe operating practices. #4. Proper use of chemicals, including (a.) availability of safety data sheets (SDS). (b.) all chemicals are properly labeled. The section titled, Food Safe Handling for Foods from Visitors, residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. #4. When food items are intended for later consumption, the responsible staff member will: label foods with the resident name and the current date. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 20 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observations, record review, interviews, and the plan of correction review, the facility failed to ensure it had a functioning Quality Assurance system. The facility was actively involved in the creation, implementation, and monitoring of an effective plan of correction for deficient practice identified during a recertification survey, conducted on 01/11/2022 to 01/14/2022, and cited at F812. The facility developed a plan of correction with a compliance date of 02/14/2022. During a revisit survey, conducted on 02/24/2022, deficient practice was again identified at F812 related to kitchen equipment and food storage. Findings included: The facility developed a plan of correction that included: -All soiled equipment was cleaned on 01/12/22. -Undated/unlabeled food items were disposed of by dietary manager. -Daily sanitation observations of the kitchen, walk in refrigerator/freezer and nourishment rooms will be conducted by the dietary manager and/or designee. -Dietary staff were reeducated on the cleaning and maintenance of kitchen equipment and labeling/dating of foods. -The Dietary Manager/designee will conduct daily kitchen sanitation audits to ensure appropriate practices are maintained for 4 weeks and then twice per week for 2 months. -The findings of these audits will be reported to the Quality Assurance Performance Improvement Committee until the committee determines substantial compliance has been met. During the revisit survey, a tour of the kitchen was conducted with the Dietary Manager (DM), the Account Manager, and the District Manager on 02/24/2022 starting at 9:10am. Observations included: -A tour of the dry good storage area revealed a bag of pasta opened and not dated and a container of cream icing not dated. -A meat slicer was observed on a shelf with food particles. The Manager reported it was used yesterday and should have been cleaned after use. The DM asked a staff member to clean the meat slicer. -A shelf above the meat slicer was noted with several spices. The following spices did not have dates of when the items were opened: rotisserie chicken seasonings and a ground cinnamon. A bottle of vanilla extract was also on the shelf and did not have a date of when the item was opened. The DM immediately started discarding the items. -A shelf storing clean food covers and lids was noted behind the three-compartment sink area. Next to the clean food covers and lids was a staff member's goggles. The DM removed the goggles from the shelf. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 21 of 22 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 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Seminole 9393 Park Blvd Seminole, FL 33777 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 0867 Level of Harm - Minimal harm or potential for actual harm -An observation of the main freezer was conducted. A box of opened biscuits was noted with the number 21 written on it. The DM stated the box was opened on the 21st of this month. He indicated that that was not the appropriate way to date the food products. A box of opened rolls was noted undated. A plastic Ziplock bag of meat was noted unlabeled and undated. The DM reported that the meat was chicken thighs. A box of opened beef patties was noted undated. This was confirmed by the DM. Residents Affected - Some A review of the facility policy, last revised on 09/17, and titled Environment, showed all food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. The section titled, Food Storage: Cold Foods, revealed: All Time/Temperature Control for Safety (TCS) food, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food & Drug Administration) Food Code. The section titled, Food Storage: Dry Goods, showed #6. Storage areas will be neat, arranged for easy identification and date marked as appropriate. The section titled, Equipment, all foodservice equipment will be clean, sanitary and in proper working order. The section titled, Receiving, safe food handling procedures for time and temperature control will be practiced in . storage of all food times. #5. All food items will be appropriately labeled and dated either through manufacturer's packaging or staff notation. The Plan of Correction (POC) book provided by the facility revealed an In-Service Log that indicated staff were educated on dating of open products on shelves and in coolers on 01/11/22. An In-Service Log dated 01/12/22 noted staff were educated on cleaning of equipment. On 02/24/22 at 2:20 p.m., the DM reported he educated staff on proper dating when they open foods and if they make foods, and stated, They should label the foods with the open date, the date the food was made, and the date it would expire. All staff were educated. They failed to follow the procedure. The DM said he was going to reeducate and do another in-service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 22 of 22