Health inspection·April 3, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a transfer notice was provided to the resident and the resident representative for one (Resident #3) of three residents sampled for emergency transfers. Findings included: Review of Resident #3's admission Record showed he was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Review of paperwork dated 02/02/2025 at 2:38 PM showed the Psychiatric Advanced Registered Nurse Practitioner (ARNP) completed involuntary examination documents for Resident #3 for schizoaffective disorder, resident's inability to determine whether examination is necessary, and a substantial likelihood that without care or treatment the individual will cause serious bodily harm to self or others. The ARNP documented the patient presented with psychosis, significant agitation, aggression and threatening of staff. Resident threw his food tray at a staff member and smeared feces all over his room. Resident was refusing all care or any psychopharmacological interventions. At the time of this event, the facility was unable to meet the resident's needs and presented as a danger to self or others. Resident #3 required a higher level of care for stabilization and safety. Review of a Behavior Note dated 2/2/2025 at 2:47 PM showed Resident #3 was insulting staff, threw his tray with his plate on the floor, and almost injured a staff member. Review of a Situation, Background, Assessment, and Recommendation (SBAR) Summary for Providers dated 02/02/2025 at 4:29 PM showed the primary care provider recommended Resident #3 be transferred to the hospital for an involuntary examination. Review of the medical record showed no evidence of a written Nursing Home Transfer and Discharge Notice being provided to Resident # 3 and his representative for the emergency transfer on 02/02/2025. On 4/3/2025 at 10:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated their process for emergency transfers was to receive an order to send the resident out from the physician, complete a transfer form and change in condition, and notify the resident's responsible party about the transfer. The DON reported the resident's responsible party would also receive a copy of the transfer notice. The DON reviewed Resident #3's medical record and confirmed the written Transfer and Discharge Notice for the 02/02/2025 event could not be located. Page 1 of 27 105895 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/3/2025 at 11:05 AM, an interview was conducted with the Social Service Director (SSD). The SSD stated she started working at the facility on 2/18/2025, after the emergency transfer for Resident #3 on 02/02/2025. She stated when a resident was sent out to the hospital there should be a Transfer and Discharge Notice given, a physician order, and the resident responsible party should be notified. She stated the transfer/discharge forms were placed in her inbox, and she kept a record of the notices in a binder in her office. She stated when she looked in her binder, she did not have a Transfer and Discharge Notice for Resident #3. She confirmed Resident #3's Transfer and Discharge Notice could not be located. 105895 Page 2 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were assesed to need constatnt supervision during smoking received adequate supervision for nine (#10, #13, #8, #12, #14, #9, #11, #15 and #26) of 27 sampled residents. Findings included: Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All residents who wish to smoke at the center will abide by the center's smoking policy. Residents electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial includes but is not limited to warning, revocation of smoking privileges, police intervention, and / or discharge. This agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the terms set forth in the policy. I, undersigned, understand that these safety rules apply to me and the safety of the other residents and violations may result in subsequent education, warnings, and other remedial actions at the discretion of the Executive Director. 1. During an observation on 04/02/2025 at 11:24 a.m. Resident #10 self-propelled herself in her wheelchair into the building from outside. A cigarette lighter was observed in her lap. Resident #10 was observed propelling herself through the building to her room and onward to the end of the 300 hallway. Resident #10 stated she goes outside to smoke. Resident #10 stated she has to sign out LOA to in order to smoke. Resident #10 stated she has to go out to the sidewalk on the busy road. Resident #10 stated, The road was not safe, the cars are so fast, it is dangerous. Resident #10 stated she was allowed to go outside to the sidewalk to smoke from 8 a.m. to 8 p.m. Resident #10 stated she signs out either at the nursing station or the front desk. Resident #10 stated they cannot smoke in the parking lot. Resident #10 stated they are supposed to give their cigarettes and lighter to them (the facility), but she forgot about her lighter today. Resident #10 stated there were about 10 of us who go outside to smoke. 2. An observation on 04/03/2025 at 9:00 a.m. revealed Resident #13 self-propelling himself down the sidewalk. He was observed by a second surveyor to be crossing 4 lanes of traffic at the corner of the facility's lot. Three other residents were observed sitting on the sidewalk in front of the building beside the 6 lanes of traffic smoking. The traffic appeared to be speeding, by travelling at approximately 40-45 mph (miles per hour). Record review of the admission Record showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to diabetes, absence of left and right leg above knee, muscle weakness, Chronic Obstructive Pulmonary Disease, Atrial fibrillation, hypertension, need for assistance for personal care, supraventricular tachycardia, and nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. 105895 Page 3 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0689 Review of the physician orders showed may go out on LOA on 12/11/2024. Level of Harm - Minimal harm or potential for actual harm Review of the Smoking Evaluation for Resident #13 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Residents Affected - Some Review of the Care plan showed Resident #13 was a smoker, initiated on 10/18/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 10/18/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 10/18/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. The resident requires a smoking apron while smoking as of 10/18/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #13 signed it on 10/18/2024. 3. During an observation on 04/02/2025 at 9:00 a.m. Resident #8 was observed exiting the building with his cigarettes in his lap. Review of Resident #8's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease, diabetes, nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J the resident was a tobacco user. Review of the physician orders for Resident #8 showed, may go out on LOA (Leave of Absence) as of 12/11/2024. Review of the Smoking Evaluation for Resident #8 as of 03/09/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #8 showed the resident was a smoker, initiated on 11/08/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 11/08/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 11/08/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #8 signed it on 10/18/2024. 4. Record review of the admission Record showed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to nondisplaced supracondylar fracture, paraplegia, cervical spinal stenosis, need for assistance with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #12 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #12 as of 02/27/2025 showed, the resident smoked. 105895 Page 4 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking Review of the Care plan for Resident #12 showed the resident was a smoker, initiated on 07/10/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 07/10/2024; Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 07/10/2024. Review of the record revealed Resident #12 had not signed the Smoking Agreement/Notice of Policy. The signed policy was requested and not provided. 5. Review of the admission Record showed Resident #14 was admitted to the facility on [DATE] with diagnoses included but not limited to Congestive Heart Failure, hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #14 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #14 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #14 showed the resident was a smoker, initiated on 05/01/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 05/01/2024; the resident requires supervision while smoking as of 05/01/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #14 signed it on 04/30/2024. 6. On 4/02/2025 at 11:38 a.m. and on 4/3/2025 at 12:30 p.m., Resident #9 was observed sitting outside the driveway smoking a cigarette in a high back wheelchair. She was observed located on the driveway leading out into a busy three-lane highway where cars were observed entering and leaving out of the driveway. Resident #9 stated the staff at the facility told her that she has to smoke outside where she is located, because she is not allowed to smoke on the premises. She stated no one had told her where she could safely smoke. Review of the admission Record showed Resident #9 was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease, unspecified, other abnormalities of gait and mobility, muscle weakness (generalized). Review of a Minimum Data Set, dated [DATE] Section C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #9 is cognitively intact. Review of Section J showed Resident #9 has shortness of breath or trouble breathing with exertion. Review of the Smoking Evaluation for Resident #9 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the care plan for Resident #9 showed a focus showing Resident #9 is a smoker, date 105895 Page 5 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some initiated,1/7/2025. The goals showed Resident #9 will not suffer injury from unsafe smoking practices through the review date, date initiated 1/7/2025. Interventions showed to instruct residents about the facility policy on smoking: locations, times, safety concerns, dated initiated 1/7/2025. Review of the admission Record for Resident #10 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to generalized muscle weakness, need for assistance with personal care, chronic obstructive pulmonary disease, unspecified, and other abnormalities of gait and mobility Review of the Smoking Evaluation for Resident #10 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #10 showed a focus for smoking. Review of the care plan goals showed Resident #10 will not smoke without supervision through the review dated, date initiated 11/7/2024. Review of the intervention showed Resident #10 requires supervision while smoking. Date initiated 11/7/2024. 7. Review of the admission Record for Resident #11 showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic venous hypertension (Idiopathic) with ulcer of left lower extremity, history of falling, cerebral infarction, unspecified, wheezing. Review of the Smoking Evaluation for Resident #11 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #11 showed a focus for smoking date initiated 3/25/2025. The goals showed Resident #11 will not suffer injury from unsafe smoking practices through the review date, date initiated 3/25/2025. interventions showed to instruct residents about the facility policy on smoking: locations, time, safety concerns. The resident can (light own cigarette) Has Leave of absence, LOA to go out front to smoke. 8. Review of the admission Record for Resident #15 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease, unspecified, muscle weakness (generalized), other lack of coordination. Review of the Smoking Evaluation for Resident #15 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #15 showed a focus for smoking date initiated 10/21/2024. The goals showed Resident # 15 will not smoke without supervision through the review date 10/21/2024. The interventions showed the resident requires supervision while smoking, date, initiated 11/27/2024. On 4/3/2025 at 2:00 p.m., an interview was conducted with Staff D, the Administrator in Training, AIT. Staff D, AIT stated she did not really know much about the smoking situation so she would have to get someone else to discuss smoking. Staff D stated she came from a non-smoking facility, and she can see that residents smoking in the front next to the road can be a concern. Staff D stated she 105895 Page 6 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some knew Activities keep track of the list of residents who smoke, and nursing does the smoking assessments. She stated the residents who sign out leave of absence (LOA), are the residents who do not want to smoke within the facility's time frames. Staff D stated they even have a hard time getting the LOA cards back from the residents who go outside, and they have a hard time keeping track of their smoking materials. On 4/3/2025 at 2:45 p.m. an interview was conducted with Staff A, The Support Director of Nurses, DON. Staff A stated that when a resident is admitted to the facility and the resident is identified as a smoker, nursing takes them out to do an assessment to see if the resident is a safe smoker or not. After the nursing assessment is completed, nursing notifies the Activity Director so she can go over the smoking policy with the resident and have them sign it during that time. She stated after the residents are provided with the smoking policy, they are placed in a smoking group according to smoking times. Residents that go out to smoke in front of the building have a leave of absence, LOA, order to go out. Staff A stated if a resident had an order and signs out LOA, they can go in front of the building or wherever they want. She stated the residents observed outside have an LOA order and they can go outside in front of the building to smoke. Staff A stated the facility's times for smoking was only for residents who require supervision while smoking. She stated if a resident had an LOA order, they could go out on their own. She stated she had not spoken to the residents about the safety concerns when smoking near the road, which could be a safety issue. She stated she had not asked any of the residents if they had any concerns about smoking next to the road in front of the building. She stated the assessments that show the residents needed constant supervision were completed wrong. Staff A said, It was just human error, she was just clicking off on the quarterly assessment trying to get them all caught up on. She stated residents who smoke should have a smoking assessment, a care plan and a signed smoking policy. An observation was made on 04/02/2025 at 12:55 p.m. revealing an unidentified resident on her way back inside to the facility from smoking. Further observation revealed three other residents were observed outside smoking on the sidewalk in front of the facility's parking lot. Review of the Leave of Absence (LOA) sign-out sheet revealed two of the four residents observed outside had filled the sign-out sheet with their sign-out time. Further review of the LOA sign-out sheet revealed documentation of a sign in time pre-filled, but the residents were observed on the sidewalk smoking. Resident #13 had a sign out time of 11:25 a.m. and a return time of 11:45a.m., but was observed on the sidewalk smoking at 1:02 p.m. Resident #14 had a sign out time of 8:30 a.m. and a return time of 12:50p.m., but was observed on the sidewalk smoking at 1:05 p.m. 9. An interview was conducted on 04/03/2025 at 10:55 a.m. with Resident #26. She stated smoking had become an issue. She stated ever since residents moved from another facility, they went from not having many smokers to having a lot of smokers. Resident #26 stated, They really needed to get a designated smoking aide. She said aides are pulled from the floor and caused residents to not get help if needed during the smoking times. Resident #26 stated she had been told that her aide was overseeing the smoking breaks, and she would be assisted when the aide returned. Review of the admission Record showed Resident #26 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes, and contracture left hand. A review of the quarterly MDS (Minimum Data Set) revealed Resident #26 had a BIMS (Brief interview Mental Status) score of 14, indicating intact mental cognition. 105895 Page 7 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's policy, Smoking-Supervised, revised 02/07/2020 showed The Center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. The Center will have safety equipment available in designated smoking areas including: smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedure: 1. Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. 2. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the Center will include the appropriate information in the care plan. 3. The Center will establish and post designated smoking areas and times. 4. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. 5. The Center will retain and store matches, lighters, etc. for all residents. 6.All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. 7. Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement. 9. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 105895 Page 8 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 4/2/25 at 3:05 p.m., an interview was conducted with the resident council president who stated, Evening shift aids disappear off the floor, except for a few of them. She stated that sometimes staff tell her there's only three nurses, and she needs to wait. She stated that sometimes there are three CNA's for the whole floor, when there's supposed to be more. The resident council president stated staff tell her they are short staffed. Regarding call light concerns, she felt, It's work ethic, not a staffing issue. She stated at the last resident council meeting, they were informed by the administrator that call light audits were being conducted. She stated the staff conducting call light audits told her, The longest wait was 30 minutes. The resident council president stated, Staff don't take anything we say seriously. It's like a joke. On 4/3/25 at 11:35 a.m., an interview was conducted with Staff D, Administrator in Training (AIT) about the manager on duty (MOD) program implemented on 3/22/25. She stated MOD is on weekends and they have a, To do list, to include call light audits. She stated room rounds are conducted Monday through Friday to include call light audits. She stated room rounds were something the facility was already doing but was updated around February 2025. She stated the expectation for call light audits during the week is 12 rooms and 10 rooms on the weekends. The AIT stated, Call light response has been pretty good. She stated if they take longer, It's because they were providing care to another resident. Staff D, AIT stated anyone can answer the call light and this has been discussed in town hall meetings. Staff D, AIT stated they don't have an expectation of how quickly staff should respond to call lights. She stated, Respond as timely as you can. She stated the if a staff member answered a call light and it's not within their scope, they should leave the call light on and get the appropriate person. She stated they are in their third week of call light audits. Staff D, AIT stated she's monitoring rounds and conducts follow-up with residents. She stated the resident council president told her the call light response is improving, and she's received the same feedback from other residents. A review of the facility's grievance log revealed two grievances related to call lights in January and March 2025. On 4/3/25 at 12:02 p.m., an interview was conducted with the Social Services Director (SSD). She stated currently upper management staff were conducting room rounds, to include call light response audits. The SSD stated these staff have assigned rooms. She stated call light responses are observed every morning during room rounds. The SSD stated the room rounds are conducted each shift. She stated room rounds have been helpful, so they are aware of the residents' issues. She stated they found responses to call lights varies, because of staff and shift. She stated room rounds and the MOD conducted call light audits for different rooms and times of day. She stated MOD audits on weekends have helped improve call light concerns. She said the room rounds conducted Monday through Friday have demonstrated improvements in call light concerns. The SSD stated she's received feedback from residents that the call light response has improved. On 4/3/25 at 12:17 p.m., an interview with the SSD revealed grievances are discussed during morning meetings. She stated concerns from resident council meetings are communicated by the activities director, or their assistant, at morning meetings. She stated any outstanding grievances are also discussed. The SSD stated recent concerns from the resident council meetings include the CNA's response to call lights. 105895 Page 9 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/3/25 at 12:38 p.m., an interview was conducted with Staff E, Staffing Coordinator/CNA. She stated staffing is according to the patients per day (PPD). She stated the typical ratio is 10-12 residents for one CNA. She stated for nursing, it's two nurses per unit for a total of four nurses. She stated they don't exceed 40 residents for one nurse. Staff E, Staffing Coordinator/CNA stated one nurse typically has 25 to 31 residents. She stated if there was a staff call out, they send text messages first to see who can come in. Staff E, Staffing Coordinator/CNA, stated if no one can came in, and it's a nurse call out, then one of the unit managers, wound care nurse, Assistant Director of Nursing (ADON) or Director of Nursing (DON) will take over. She stated if it's a CNA call out, they have staff in other departments such as, restorative aid, activities staff, medical records, or central supply, that have their CNA certification. She stated for the staff, such as restorative aid or activities, that are covering as a CNA are not expected to complete both roles. Staff E, Staffing Coordinator/CNA stated she looked at the daily census to re-assess and adjust staffing. She stated she uses the bed board to determine how many residents a CNA and nurse will have. She confirmed she takes into consideration the residents' needs when determining the staffing ratio. She stated on weekends there are more CNAs on the floor, therefore they have less residents. She stated CNAs on weekends typically have 9-10 residents, instead of 12. She stated if there are staffing concerns from residents, those concerns would go to the SSD. She stated concerns directly from staff would come to her, then she would go to the Director of Nursing (DON) to adjust assignments or do room changes. She stated when she came to the facility in December 2024, she brought it to the DON's attention about adjusting assignments. She stated numbers are different now. Staff E, Staffing Coordinator/CNA, stated that CNAs now have a whole unit with a hall partner, instead of having room assignments in multiple units. Regarding resident smoke breaks, she stated everyone has special duties which is indicated on the daily assignment sheet. She stated staff assigned to resident smoke breaks are rotated daily. She stated it's typically a CNA, but anyone could do it. She stated when a CNA leaves the unit to go the resident smoke break, They work it out on the floor. She stated the CNA is expected to let their hall partner or someone know they are stepping off the floor. She stated smoke breaks are 25 minutes, with two smoke breaks per shift. On 4/3/25 at 3:22 p.m., Staff C, Registered Nurse (RN), Regional Director of Clinical Services stated the facility does not have a staffing policy. A review of the facility's policy titled, Complaint/Grievance, with an effective date of 11/30/2014 and a revision date of 10/24/2022, revealed the following, . The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Further review of the grievance under procedure revealed the following, .8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. Based on observations, interviews, and facility record review, the facility failed to ensure sufficient staffing met the needs of the residents as evidenced by: 1. Resident interviews on untimely call light response for five residents (#5, #23, #24, #25 and #26) of six residents sampled, 2. Unresolved grievances related to call light response times for one resident (#5) of two residents reviewed for grievances. Findings Included: An interview was conducted on 04/02/2025 at 9:45 a.m. with Resident #23 and #24. Resident #24 stated that the staffing was often a problem. She stated staff often said they were Short-handed and didn't have time to assist her or she had to wait longer for assistance. Resident #24 stated she was 105895 Page 10 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some often provided with incontinence care only one time during the first shift of the day. Resident #23 confirmed that she had brought up her concerns. He stated that he's an independent resident but had observed they took a long time to assist Resident #24. Record review revealed that Resident #23 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, muscle weakness, and chronic pain syndrome. A review of Resident #23's quarterly MDS (Minimum Data Set) dated 02/21/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating intact mental cognition. A record review for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses hemiplegia and hemiparesis following unspecified cerebrovascular infarction affecting left non-dominant side, muscle wasting and atrophy, non-pressure chronic ulcer of the left heel and midfoot, and polyneuropathy. A review of Resident #24's comprehensive MDS (minimum Data Set) dated 03/04/2025 revealed the resident had a BIMS score of 12, indicating intact mental cognition. An interview was conducted on 04/02/2025 at 10:15 a.m., with Staff I, Licensed Practical Nurse (LPN). She stated staffing was constantly an issue, usually had more than 30 residents. Staff I, LPN stated that shift she had 34 residents. She stated she felt like she was constantly rushing and in a hurry to get everything done. Staff I, LPN stated she often felt like they didn't have the help that they needed to be able to properly take care of all of their residents. An interview was conducted on 04/02/2025 at 10:25 a.m., with Resident #25. Resident #25 stated that she was often told by a Certified Nursing Assistant (CNA) that she didn't have time to help her. She stated the CNA told her they had too many residents and were short staffed. Resident #25 stated she recently had a situation where she sat in the hallway for two hours after asking her CNA to help her back to bed. She stated that she has brought up the lack of response and the poor attitude of aides when they've been asked to assist her to the administration. A record review of Resident #25 revealed that she was admitted to the facility on [DATE] with diagnoses of systemic lupus erythematosus, type 2 diabetes, morbid severe obesity, and polyosteoarthritis. A review of Resident #25's quarterly MDS dated [DATE] revealed the resident to have a BIMS score of 13, indicating intact mental cognition. An interview was conducted on 04/02/2025 at 10:35 a.m., with Staff H, CNA. She stated that she had been with the facility for many years and staffing, Had gotten really bad. Staff H, CNA stated they often only had 4 or 5 CNAs taking all of the residents. Staff H, CNA stated certain sections had a lot of heavy acuity residents where it could be impossible to get everything done. Staff H, CNA stated residents complained about not getting their showers or incontinent care in the time that they wanted. Staff H, CNA stated they could only do their best and couldn't possibly get to each resident quickly when they wanted it. An interview was conducted on 04/02/2025 at 11:15 a.m. with Staff F, LPN. She stated that staffing in the facility was really bad. Staff F, LPN stated she's heard residents complain about staff 105895 Page 11 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some response, but she felt they tried their best. Staff F, LPN stated she always had between 30-34 residents and often felt overwhelmed with the number of residents she had. She stated she frequently had to stay an hour or more past her shift trying to finish her work. An interview was conducted on 04/02/2025 at 10:55a.m. with Resident #26. Resident #26 stated depending on who was working she got her call light answered in, Okay timing. and stated specifically on 3-11 p.m. shift the staffing seemed to be short because staff were always slower to answer the call lights. A record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes, and contracture left hand. A review of the quarterly MDS dated [DATE] revealed that Resident #26 received a BIMS score of 14, indicating intact mental cognition. An observation was made on 04/02/2025 at 11:16 a.m. A bathroom alarm was on and it was observed that Staff K, unit manager, was sitting at the nurse's station. Further observations revealed Staff M, CNA, was walking down the other hallway, looked at the room with the call light on, and continued walking. Another staff member, on their way out the unit, asked Staff M CNA if it was her resident. Staff M, CNA, responded that it was not, but she would find the CNA who was assigned to that room. An interview was conducted on 04/03/2025 at 11:55am with Resident #5. Resident #5 revealed her grievance, about call lights had not been addressed and no one ever followed up with her. She felt there was still an issue with staff not answering the call light in a timely manner and receiving the care she needed when she used it. Resident #5 stated that day she returned from an appointment and asked the CNA to assist her back in to bed, as she had been in her wheelchair for a prolonged period of time. She stated the CNA told her she wouldn't assist her back into bed because the lunch trays were arriving soon. She stated she felt staffing had always been the same and believes there is a care issue. Resident #5 stated she's not sure if it's the number of staff or if it was specific aides that didn't want to do the work. A record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease without dyskinesia, type 2 diabetes, and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. A review of Resident #5's quarterly MDS revealed the resident to have a BIMS score of 08, indicating moderately impaired cognition. An interview was conducted on 04/03/2025 at 2:06 p.m. with Staff J, CNA. She stated that staffing can be bad depending on the day. Staff J, CNA revealed the days when there were low staffing, it made it difficult to get all of her resident care done. She stated that staffing is especially difficult during the 3-11 shift. Staff J, CNA stated during the day if they were short staffed, they had the extra aides like restorative or central supply to help. She stated if the 3-11 shift is short staffed, they don't have, the extra hands. Staff J, CNA stated that if they have 1 or 2 call offs, they wouldn't have the extra hands to help if they need it. An Interview was conducted at 04/03/2025 at 2:39 p.m., with Staff D, Administrator in Training (AIT). The Staff D, AIT was aware of the issues with the call lights. She stated that the facility 105895 Page 12 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0725 Level of Harm - Minimal harm or potential for actual harm completed call light audits as well as educated the staff on anyone being able to answer the call light. Staff D, AIT stated call lights were still being looked at in the Quality Assurance Performance Improvement (QAPI) meetings. She stated they hadn't been doing audits long enough to do any tracking or trending. Staff D, AIT stated she was not aware of a staffing problem, as she felt they met the numbers. She stated they are actively trying to hire more staff, especially for the 3-11 shift where she knew they had needs. Residents Affected - Some 2. On 4/2/25 at 9:58 a.m., an observation of the 300-hall revealed room [ROOM NUMBER] had an active call light. Staff G, Certified Nursing Assistant (CNA) was observed in the 300- hall while the call light was on. Staff F, Licensed Practical Nurse (LPN) were observed in the 300- hall while the call light was on. Further observations revealed a housekeeping staff at the door, across from the room with the call light on. At 10:05 a.m., Staff K, LPN/Unit Manager (UM) was observed sitting at the nurse's station and walked over to room [ROOM NUMBER] to answer the call light. Observations of the 300-hall revealed the three staff were still present in the area where the call light was on. 105895 Page 13 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record review, the facility failed to have a system in place to enable accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts. Findings included: An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, Licensed Practical Nurse (LPN) for the 500 hallway medication cart. Staff L, LPN was observed placing one Medication Monitoring / Control Records log into the 500 hallway narcotic book. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards and 1 bottle of liquid in the narcotic drawer. Staff L counted the cards as well as the bottle of liquid controlled substance, and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring / Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 500 hallway showed the following residents on 04/02/2025 had narcotics added to the medication cart, without a second nurse verifying the medications. Resident #22 had Temazepam added to the cart, Resident #21 had Oxycodone and Lyrica added to the cart, and Resident #20 had Percocet added to the cart. Each resident had a completed narcotics card and a second nurse signature was missing as verification. None of the narcotic cards revealed the strength of each medication. An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, LPN for the 600 hallway medication cart. Staff L, LPN was observed placing three Medication Monitoring / Control Records logs and three individual controlled drug cards into the 600 hallway narcotic book and narcotic drawer. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards in the narcotic drawer. Staff L counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring/Control Records logs and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 600 hallway showed on 04/02/2025 the following residents had narcotics added to the medication cart without a second nurse verifying the medications. Resident #19 had Zolpidem added to the cart, and Resident #18 had Morphine and Oxycodone added to the cart. None of the narcotic cards revealed the strength of each medication. Staff L, LPN stated she had education regarding narcotics/medication administration. Staff L stated the education included they were to have double signatures for the narcotic medications when the medications arrived from the pharmacy. Staff L stated when a narcotic was discontinued or the card was empty they were to have two nurses sign the sheet and the card, and the medication was to be taken to the Director of Nursing (DON) office. An observation was conducted on 04/02/2025 at 10:47 a.m. with Staff M, LPN for the 400 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 31 individual controlled drug cards in the 400 hallway cart. Staff M counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring/Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 400 hallway showed the following residents had narcotics added to the medication cart on 04/02/2025 without a second nurse verifying the medications. Resident #17 had Norco added to the cart. The medication strength was not documented for the medication. Staff M, LPN stated they had education on narcotic counts and counting the narcotic cards with two nurses at shift change. Staff M stated two nurse had to sign when medications come in (from 105895 Page 14 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the pharmacy). Staff M stated if a narcotic card was empty or discontinued two nurses had to sign off and the card goes to the DON's office. An observation was conducted on 04/02/2025 at 11:15 a.m. with Staff F, LPN for the 100 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 44 individual controlled drug cards in the 100 hallway cart. Staff I counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring /Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 100 hallway showed the following residents had narcotics added to the medication cart on 03/31/20255 without a second nurse verifying the medications. Resident #16 had Ativan added to the cart, Resident #11 had Morphine added to the cart, and Resident #7 had Oxycodone added to the cart. The medication strength for the narcotics was not documented on the card. Staff F stated she had education regarding narcotic administration which included two nurses verifying the medications from the pharmacy. She stated two nurses do the narcotic count at shift change. She stated two nurses have to sign and verify the discontinuation of medications. Review of the Education Sign In sheets for Receiving Narcotics and Documentation on 02/13/2025 and 02/18/2025 showed the following: All narcotics received must be received by two nurses. They are added to the narcotic flowsheet by resident names, medication, and how many cards. When giving prn (as needed) pain medication you sign out of narcotic book and in medical record software. If the narcotic order is changed in frequency, put order change sticker on the card. If the narcotic is discontinued bring to DON for destruction. The four nurses observed on 04/02/2025 were on the Education In-service attendance record for 02/13/25. An interview was conducted on 04/03/2025 at 9:56 a.m. with Staff C, Regional Registered Nurse (RRN), Staff A, support DON, and Staff B, Interim DON regarding narcotic administration education. Staff C stated due to an incident they started education on proper narcotic management and re-education. They identified opportunities within the program that the count sheets were not being filled out properly and they were hard to follow. They started re-education on shift-to-shift count, completion of the actual count forms (Medication Monitoring / Control Records), accepting medication (narcotics), taking discontinued medications and empty cards to the DON. Staff C stated they implemented audits to make sure the flow sheet Shift Change Controlled Substance Inventory Count Sheet was documented properly with adding narcotics (plus), deleting narcotics (minus), and second signatures documented. Staff C stated they implemented audits on documentation of delivery slips. Staff C stated they identified opportunities within the building which included documentation of prn's (medications), and low inventory. They were filling out the sheet Shift Change Controlled Substance Inventory Count Sheet daily instead of a continual flow. Prior administration changed it to a daily form, and did not see it as a possible problem. Staff C stated they did audits daily for 2 weeks, twice a week for 2 weeks and were to perform weekly for 4 weeks and monthly for 2 months. Staff A stated they reviewed the Shift Change Controlled Substance Inventory Count Sheet on the audits they were performing. Staff C verified the residents that were added to the Shift Change Controlled Substance Inventory Count Sheet did not have two nurse verification. Staff A stated the surveyors reviewed the Shift Change Controlled Substance Inventory Count Sheet on the off two-week audit. Staff B stated they educated the nurses when the narcotics come into the building from the pharmacy and the bags are sealed. The sealed container can be signed by one nurse and when the bag is opened, two nurses must sign and validate the 105895 Page 15 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some contents. Staff B stated the nurses were educated to initial on both the individual narcotic Medication Monitoring / Control Records and delivery slip inside the bag. Staff B stated on the Shift Change Controlled Substance Inventory Count Sheet the nurse was to add the resident name and drug to the sheet including the quantity of the narcotics. The second nurse was to initial for validation of the medication. Staff B stated a second nurse was also to initial validation if a card was zero with the resident name, drug name, and then removed from the total number of cards found in the narcotic drawer. One nurse signs and the second nurse initials as a witness. Staff B stated the nursing staff was educated to follow this process. Staff A, Staff B, and Staff C verified the Shift Change Controlled Substance Inventory Count Sheet lacked the second signature. After interview with Staff A, Staff B, Staff C, an observation on 04/03/2025 at 10:30 a.m. was performed with Staff B, Interim DON of the narcotic books. The following number of Medication Monitoring / Control Records were not initialed /validated by a second nurse. 100 hallway 17 out of 35 or 49% 200 hallway 9 out of 25 or 36% 300 hallway 11 out of 22 or 50% 400 hallway 19 out of 29 or 66% 500 hallway 17 out of 22 or 77% 600 hallway 10 out of 22 or 45% During an interview on 04/03/25 at 10:47 a.m. with Staff C, RRN she stated they had an ADHOC meeting on 02/10/2025. Staff C stated they were not following the process for counting cards and comparing to the physical card count. Staff C stated they reviewed the current policies and procedures. Staff C stated they educated the nurses to follow policy and procedure. Staff C stated they also did a three day look back. They had a second ADHOC on 02/20/2025. Staff C stated the Unit Managers (UM) were given the task to perform weekly audits and the DON auditing was started. The UM's were auditing daily for 2 weeks, and then biweekly for 2 weeks they were to progress to weekly for 4 weeks and then monthly for 2 months. Staff C stated the UM's were supposed to be looking at the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated the UM audits included Controlled substance count is correct? Documentation on the Medication Administration Record (MAR) reflects what is signed out on the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated she did not know how many residents were sampled for the audits. Staff C stated they had an ADHOC on 02/27/2025 and reviewed the audits and the process was being followed. Staff C stated they had no issues or concerns noted in Quality Review. Updates were added to the new hire orientation for nurses. Staff C stated we will have to go back to ADHOC. Staff C stated we will have to look at the policies again and re-audit based on the policy. Staff C stated the QA process did not work. Staff C stated we will have an ADHOC today. Staff C stated they reviewed their policy and it does not say they are to have two nurses initial on the individual narcotic Medication Monitoring / Control Records. Staff C stated they over did it and did not follow the policy / procedure. Staff C stated they will re-educate the nurses. Review of the facility's policy, Acceptance of Controlled Drugs, revised on 02/17/2025 showed the following: 105895 Page 16 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some To ensure controlled drugs are properly accounted for in accordance with federal regulations. Procedure: Controlled drugs will be delivered to the facility by the pharmacy in a sealed, tamper proof container. One nurse will electronically sign for the container. Receiving nurse should inspect integrity of the sealed container and not accept a container that may have been opened or tampered with. The container will remain sealed until second nurse is available to open and validate the contents. 2 nurses will open their controlled drug container and reconcile the pharmacy manifest to the controlled drugs sign the manifest. The manifest is placed in the medication room. Controlled medications are then placed into the medication carts by nurses. If discrepancies are found during reconciliation, notify the director of nursing immediately and the pharmacy within 24 hours. Discrepancies may include but are not limited to: missing controlled drugs, incorrect quantities, damaged containers or seals, tote is open or there is evidence of tampering. The Medication Monitoring Control Record from pharmacy will be placed in the Narcotic Book. The Shift Change Control Substance Inventory Control Sheet will identify the addition of the new control drug. It will be kept with the medication monitoring control record in the narcotic book. Review of the facility's policy, Controlled Drug Count, revised 02/19/2025, showed the following: This policy outlines the process for counting and documentation of controlled substances chain of custody from off going nurse to oncoming nurse and additional steps to take if a discrepancy is discovered. Procedure 3. The two nurses to count the number of Medication Monitoring Control Records and boxes / card / etc. A. verify that the number of individual boxes / card / etc. matches the number on the Shift Change Controlled Substance Inventory Count Sheet. Review of the facility's policy, Controlled Drug Disposal, revised 02/19/2025, showed the following: To ensure controlled drugs are disposed of and records maintained to Federal and State Laws and regulations to the director of nursing and the consultant pharmacist. Discontinued Controlled Drugs Discontinued controlled drugs are controlled drugs that have been discontinued, or resident has been discharged . Nurse to remove the control drug from the medication cart along with the Medication Monitoring Control Record. Controlled drug to be given to the director of nursing. Director of nursing to verify the controlled drug and that the amount remaining with a second nurse. Director of Nursing and a second nurse sign the Medication Monitoring Control Record to verify removal. Director of Nursing and a second nurse to document that controlled drug on the pharmacy Electronic Drug Destruction Log. 105895 Page 17 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

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, interviews, and record review, the facility failed to establish and implement a Quality Assurance and Performance Improvement Program (QAPI) that enabled accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts. Findings included: Review of the facility's policy, QAPI Goals, 2025 QAPI Plan, not dated, showed the following: At Aspire at Seminole we are committed to focusing on clinical care, quality of life and resident choice. On behalf of those we serve, we are committed to using QAPI to improve our performance and practices and to assure wee meet and exceed regulatory requirements and standards. Scope: Aspire at Seminole's QAPI program encompasses all areas that impact quality of care, quality of life, resident choice and care transition with participation from all disciplines. Patient-Driven Care: all patient care is patient-driven to ensure that residents are properly cared for and are a part of their care planning and drive their outcomes. Performance Improvement Projects (PIPs): The QAPI team will review data and benchmarks and determine if gaps or patterns exist in our systems that could result in quality problems or if there are any opportunities to make improvements. I'm seeking care Potential PIPs are identified by the QAPI committee. QAPI team along with the PIP lead is responsible for developing the PIP charter and for assembling the PIP team. The PIP team members will be identified based on the problem, including interdisciplinary members, residents or family members that can bring value and contribute for the opportunity to be assessed and represent staff across all three shifts if needed. PIP results, outcomes are status are reported by the project lead to the monthly Q API committee by submitting an updated performance improvement plan. Performance Improvement Plans will include goals, actions, responsible party, target dates and status / outcome. Completed Performance Improvement Plans will be filed in the QAPI notebook and will be monitored periodically to assure achievements are being sustained. If an issue arises within the center needs immediate attention, and Ad Hoc QAPI meeting will be put into place to review the concern and put immediate action into place to ensure proper quality of care for residents. Systematic Analysis: The PIP Team will analyze the problem area by conducting a root cause analysis, identify solutions and develop a performance improvement plan to be implemented. 105895 Page 18 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, Licensed Practical Nurse (LPN) for the 500 hallway medication cart. Staff L, LPN was observed placing one Medication Monitoring / Control Records log into the 500 hallway narcotic book. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards and 1 bottle of liquid in the narcotic drawer. Staff L counted the cards as well as the bottle of liquid controlled substance, and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring / Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 500 hallway showed the following residents on 04/02/2025 had narcotics added to the medication cart, without a second nurse verifying the medications. Resident #22 had Temazepam added to the cart, Resident #21 had Oxycodone and Lyrica added to the cart, and Resident #20 had Percocet added to the cart. Each resident had a completed narcotics card and a second nurse signature was missing as verification. None of the narcotic cards revealed the strength of each medication. An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, LPN for the 600 hallway medication cart. Staff L, LPN was observed placing three Medication Monitoring / Control Records logs and three individual controlled drug cards into the 600 hallway narcotic book and narcotic drawer. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards in the narcotic drawer. Staff L counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring/Control Records logs and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 600 hallway showed on 04/02/2025 the following residents had narcotics added to the medication cart without a second nurse verifying the medications. Resident #19 had Zolpidem added to the cart, and Resident #18 had Morphine and Oxycodone added to the cart. None of the narcotic cards revealed the strength of each medication. Staff L, LPN stated she had education regarding narcotics/medication administration. Staff L stated the education included they were to have double signatures for the narcotic medications when the medications arrived from the pharmacy. Staff L stated when a narcotic was discontinued or the card was empty they were to have two nurses sign the sheet and the card, and the medication was to be taken to the Director of Nursing (DON) office. An observation was conducted on 04/02/2025 at 10:47 a.m. with Staff M, LPN for the 400 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 31 individual controlled drug cards in the 400 hallway cart. Staff M counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring/Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 400 hallway showed the following residents had narcotics added to the medication cart on 04/02/2025 without a second nurse verifying the medications. Resident #17 had Norco added to the cart. The medication strength was not documented for the medication. Staff M, LPN stated they had education on narcotic counts and counting the narcotic cards with two nurses at shift change. Staff M stated two nurse had to sign when medications come in (from the pharmacy). Staff M stated if a narcotic card was empty or discontinued two nurses had to sign off and the card goes to the DON's office. An observation was conducted on 04/02/2025 at 11:15 a.m. with Staff F, LPN for the 100 hallway medication cart. The Shift Change Controlled Substance Inventory Count Sheet showed there were 44 individual controlled drug cards in the 100 hallway cart. Staff I counted the cards and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drug cards were compared to the individual Medication Monitoring /Control Records log and they matched. The Shift Change Controlled Substance Inventory Count 105895 Page 19 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Sheet for the 100 hallway showed the following residents had narcotics added to the medication cart on 03/31/20255 without a second nurse verifying the medications. Resident #16 had Ativan added to the cart, Resident #11 had Morphine added to the cart, and Resident #7 had Oxycodone added to the cart. The medication strength for the narcotics was not documented on the card. Staff F stated she had education regarding narcotic administration which included two nurses verifying the medications from the pharmacy. She stated two nurses do the narcotic count at shift change. She stated two nurses have to sign and verify the discontinuation of medications. Review of the Education Sign In sheets for Receiving Narcotics and Documentation on 02/13/2025 and 02/18/2025 showed the following: All narcotics received must be received by two nurses. They are added to the narcotic flowsheet by resident names, medication, and how many cards. When giving prn (as needed) pain medication you sign out of narcotic book and in medical record software. If the narcotic order is changed in frequency, put order change sticker on the card. If the narcotic is discontinued bring to DON for destruction. The four nurses observed on 04/02/2025 were on the Education In-service attendance record for 02/13/25. An interview was conducted on 04/03/2025 at 9:56 a.m. with Staff C, Regional Registered Nurse (RRN), Staff A, support DON, and Staff B, Interim DON regarding narcotic administration education. Staff C stated due to an incident they started education on proper narcotic management and re-education. They identified opportunities within the program that the count sheets were not being filled out properly and they were hard to follow. They started re-education on shift-to-shift count, completion of the actual count forms (Medication Monitoring / Control Records), accepting medication (narcotics), taking discontinued medications and empty cards to the DON. Staff C stated they implemented audits to make sure the flow sheet Shift Change Controlled Substance Inventory Count Sheet was documented properly with adding narcotics (plus), deleting narcotics (minus), and second signatures documented. Staff C stated they implemented audits on documentation of delivery slips. Staff C stated they identified opportunities within the building which included documentation of prn's (medications), and low inventory. They were filling out the sheet Shift Change Controlled Substance Inventory Count Sheet daily instead of a continual flow. Prior administration changed it to a daily form, and did not see it as a possible problem. Staff C stated they did audits daily for 2 weeks, twice a week for 2 weeks and were to perform weekly for 4 weeks and monthly for 2 months. Staff A stated they reviewed the Shift Change Controlled Substance Inventory Count Sheet on the audits they were performing. Staff C verified the residents that were added to the Shift Change Controlled Substance Inventory Count Sheet did not have two nurse verification. Staff A stated the surveyors reviewed the Shift Change Controlled Substance Inventory Count Sheet on the off two-week audit. Staff B stated they educated the nurses when the narcotics come into the building from the pharmacy and the bags are sealed. The sealed container can be signed by one nurse and when the bag is opened, two nurses must sign and validate the contents. Staff B stated the nurses were educated to initial on both the individual narcotic Medication Monitoring / Control Records and delivery slip inside the bag. Staff B stated on the Shift Change Controlled Substance Inventory Count Sheet the nurse was to add the resident name and drug to the sheet including the quantity of the narcotics. The second nurse was to initial for validation of the medication. Staff B stated a second nurse was also to initial validation if a card was zero with the resident name, drug name, and then removed from the total number of cards found in the narcotic drawer. One nurse signs and the second nurse initials as a witness. Staff B stated the nursing staff was educated to follow this process. Staff A, Staff B, and Staff C verified the Shift Change 105895 Page 20 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0867 Controlled Substance Inventory Count Sheet lacked the second signature. Level of Harm - Minimal harm or potential for actual harm After interview with Staff A, Staff B, Staff C, an observation on 04/03/2025 at 10:30 a.m. was performed with Staff B, Interim DON of the narcotic books. The following number of Medication Monitoring / Control Records were not initialed /validated by a second nurse. Residents Affected - Some 100 hallway 17 out of 35 or 49% 200 hallway 9 out of 25 or 36% 300 hallway 11 out of 22 or 50% 400 hallway 19 out of 29 or 66% 500 hallway 17 out of 22 or 77% 600 hallway 10 out of 22 or 45% During an interview on 04/03/25 at 10:47 a.m. with Staff C, RRN she stated they had an ADHOC meeting on 02/10/2025. Staff C stated they were not following the process for counting cards and comparing to the physical card count. Staff C stated they reviewed the current policies and procedures. Staff C stated they educated the nurses to follow policy and procedure. Staff C stated they also did a three day look back. They had a second ADHOC on 02/20/2025. Staff C stated the Unit Managers (UM) were given the task to perform weekly audits and the DON auditing was started. The UM's were auditing daily for 2 weeks, and then biweekly for 2 weeks they were to progress to weekly for 4 weeks and then monthly for 2 months. Staff C stated the UM's were supposed to be looking at the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated the UM audits included Controlled substance count is correct? Documentation on the Medication Administration Record (MAR) reflects what is signed out on the Shift Change Controlled Substance Inventory Count Sheet. Staff C stated she did not know how many residents were sampled for the audits. Staff C stated they had an ADHOC on 02/27/2025 and reviewed the audits and the process was being followed. Staff C stated they had no issues or concerns noted in Quality Review. Updates were added to the new hire orientation for nurses. Staff C stated we will have to go back to ADHOC. Staff C stated we will have to look at the policies again and re-audit based on the policy. Staff C stated the QA process did not work. Staff C stated we will have an ADHOC today. Staff C stated they reviewed their policy and it does not say they are to have two nurses initial on the individual narcotic Medication Monitoring / Control Records. Staff C stated they over did it and did not follow the policy / procedure. Staff C stated they will re-educate the nurses. 105895 Page 21 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to abide by their smoking policy of ensuring residents are provided a safe, designated smoking area for nine (#10, #13, #8, #12, #14, #9, #11, #15 and #26) of 27 sampled residents. Residents Affected - Some Findings included: Review of the facility's policy, Smoking-Supervised, revised 02/07/2020 showed the Center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. The Center will have safety equipment available in designated smoking areas including: smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedure: 1. Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. 2. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the Center will include the appropriate information in the care plan. 3. The Center will establish and post designated smoking areas and times. 4. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. 5. The Center will retain and store matches, lighters, etc. for all residents. 6.All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. 7. Residents will be advised upon admission that violations of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement. 9. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All residents who wish to smoke at the center will abide by the center's smoking policy. Residents electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial includes but is not limited to warning, revocation of smoking privileges, police intervention, and / or discharge. This agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the terms set forth in the policy. I, undersigned, understand that these safety rules apply to me and the safety of the other residents and violations may result in subsequent education, warnings, and other remedial actions at the discretion of the Executive Director. 1. During an observation on 04/02/2025 at 11:24 a.m. Resident #10 self-propelled herself in her wheelchair into the building from outside. A cigarette lighter was observed in her lap. Resident #10 was observed propelling herself through the building to her room and onward to the end of the 300 hallway. Resident #10 stated she goes outside to smoke. Resident #10 stated she has to sign out LOA to in order to smoke. Resident #10 stated she has to go out to the sidewalk on the busy road. Resident #10 stated, The road was not safe, the cars are so fast, it is dangerous. Resident #10 stated she was allowed to go outside to the sidewalk to smoke from 8 a.m. to 8 p.m. Resident #10 stated she signs out either at the nursing station or the front desk. Resident #10 stated they cannot smoke in the 105895 Page 22 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some parking lot. Resident #10 stated they are supposed to give their cigarettes and lighter to them (the facility), but she forgot about her lighter today. Resident #10 stated there were about 10 of us who go outside to smoke. 2. An observation on 04/03/2025 at 9:00 a.m. revealed Resident #13 self-propelling himself down the sidewalk. He was observed by a second surveyor to be crossing 4 lanes of traffic at the corner of the facility's lot. Three other residents were observed sitting on the sidewalk in front of the building beside the 6 lanes of traffic smoking. The traffic appeared to be speeding, by travelling at approximately 40-45 mph (miles per hour). Record review of the admission Record showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to diabetes, absence of left and right leg above knee, muscle weakness, Chronic Obstructive Pulmonary Disease, Atrial fibrillation, hypertension, need for assistance for personal care, supraventricular tachycardia, and nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders showed may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #13 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan showed Resident #13 was a smoker, initiated on 10/18/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 10/18/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 10/18/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. The resident requires a smoking apron while smoking as of 10/18/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #13 signed it on 10/18/2024. 3. During an observation on 04/02/2025 at 9:00 a.m. Resident #8 was observed exiting the building with his cigarettes in his lap. Review of Resident #8's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease, diabetes, nicotine dependence. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J the resident was a tobacco user. Review of the physician orders for Resident #8 showed, may go out on LOA (Leave of Absence) as of 12/11/2024. Review of the Smoking Evaluation for Resident #8 as of 03/09/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #8 showed the resident was a smoker, initiated on 11/08/2024. 105895 Page 23 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 11/08/2024; The resident was able to: (light own cigarette), has LOA to go out front to smoke as of 11/08/24 and revised on 03/25/2025. Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 11/08/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #8 signed it on 10/18/2024. 4. Record review of the admission Record showed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included but not limited to nondisplaced supracondylar fracture, paraplegia, cervical spinal stenosis, need for assistance with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #12 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #12 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking Review of the Care plan for Resident #12 showed the resident was a smoker, initiated on 07/10/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 07/10/2024; Notify charge nurse immediately if it was suspected resident has violated facility smoking policy as of 07/10/2024. Review of the record revealed Resident #12 had not signed the Smoking Agreement/Notice of Policy. The signed policy was requested and not provided. 5. Review of the admission Record showed Resident #14 was admitted to the facility on [DATE] with diagnoses included but not limited to Congestive Heart Failure, hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section J that the resident was a tobacco user. Review of the physician orders for Resident #14 showed, may go out on LOA on 12/11/2024. Review of the Smoking Evaluation for Resident #14 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the Care plan for Resident #14 showed the resident was a smoker, initiated on 05/01/2024. Interventions included but not limited to: Instruct resident about the facility policy on smoking: locations, times, safety concerns as of 05/01/2024; the resident requires supervision while smoking as of 05/01/2024. Review of the Smoking Agreement/Notice of Policy showed smoking is allowed by the center to accommodate those who wish to smoke, and Resident #14 signed it on 04/30/2024. 6. On 4/02/2025 at 11:38 a.m. and on 4/3/2025 at 12:30 p.m., Resident #9 was observed sitting outside the driveway smoking a cigarette in a high back wheelchair. She was observed located on the driveway leading out into a busy three-lane highway where cars were observed entering and leaving out of 105895 Page 24 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the driveway. Resident #9 stated the staff at the facility told her that she has to smoke outside where she is located, because she is not allowed to smoke on the premises. She stated no one had told her where she could safely smoke. Review of the admission Record showed Resident #9 was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease, unspecified, other abnormalities of gait and mobility, muscle weakness (generalized). Review of a Minimum Data Set, dated [DATE] Section C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #9 is cognitively intact. Review of Section J showed Resident #9 has shortness of breath or trouble breathing with exertion. Review of the Smoking Evaluation for Resident #9 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of the care plan for Resident #9 showed a focus showing Resident #9 is a smoker, date initiated,1/7/2025. The goals showed Resident #9 will not suffer injury from unsafe smoking practices through the review date, date initiated 1/7/2025. Interventions showed to instruct residents about the facility policy on smoking: locations, times, safety concerns, dated initiated 1/7/2025. Review of the admission Record for Resident #10 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to generalized muscle weakness, need for assistance with personal care, chronic obstructive pulmonary disease, unspecified, and other abnormalities of gait and mobility Review of the Smoking Evaluation for Resident #10 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #10 showed a focus for smoking. Review of the care plan goals showed Resident #10 will not smoke without supervision through the review dated, date initiated 11/7/2024. Review of the intervention showed Resident #10 requires supervision while smoking. Date initiated 11/7/2024. 7. Review of the admission Record for Resident #11 showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic venous hypertension (Idiopathic) with ulcer of left lower extremity, history of falling, cerebral infarction, unspecified, wheezing. Review of the Smoking Evaluation for Resident #11 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #11 showed a focus for smoking date initiated 3/25/2025. The goals showed Resident #11 will not suffer injury from unsafe smoking practices through the review date, date initiated 3/25/2025. interventions showed to instruct residents about the facility policy on smoking: locations, time, safety concerns. The resident can (light own cigarette) Has Leave of absence, LOA to go out front to smoke. 105895 Page 25 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8. Review of the admission Record for Resident #15 showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to encounter for orthopedic aftercare following surgical amputation, chronic obstructive pulmonary disease, unspecified, muscle weakness (generalized), other lack of coordination. Review of the Smoking Evaluation for Resident #15 as of 02/27/2025 showed, the resident smoked. Resident was able to light cigarettes safely with a lighter. Resident smokes safely. Resident was determined to be a safe smoker. Constant supervision needed while smoking. Review of a care plan for Resident #15 showed a focus for smoking date initiated 10/21/2024. The goals showed Resident # 15 will not smoke without supervision through the review date 10/21/2024. The interventions showed the resident requires supervision while smoking, date, initiated 11/27/2024. On 4/3/2025 at 2:00 p.m., an interview was conducted with Staff D, the Administrator in Training, AIT. Staff D, AIT stated she did not really know much about the smoking situation so she would have to get someone else to discuss smoking. Staff D stated she came from a non-smoking facility, and she can see that residents smoking in the front next to the road can be a concern. Staff D stated she knew Activities keep track of the list of residents who smoke, and nursing does the smoking assessments. She stated the residents who sign out leave of absence (LOA), are the residents who do not want to smoke within the facility's time frames. Staff D stated they even have a hard time getting the LOA cards back from the residents who go outside, and they have a hard time keeping track of their smoking materials. On 4/3/2025 at 2:45 p.m. an interview was conducted with Staff A, The Support Director of Nurses, DON. Staff A stated that when a resident is admitted to the facility and the resident is identified as a smoker, nursing takes them out to do an assessment to see if the resident is a safe smoker or not. After the nursing assessment is completed, nursing notifies the Activity Director so she can go over the smoking policy with the resident and have them sign it during that time. She stated after the residents are provided with the smoking policy, they are placed in a smoking group according to smoking times. Residents that go out to smoke in front of the building have a leave of absence, LOA, order to go out. Staff A stated if a resident had an order and signs out LOA, they can go in front of the building or wherever they want. She stated the residents observed outside have an LOA order and they can go outside in front of the building to smoke. Staff A stated the facility's times for smoking was only for residents who require supervision while smoking. She stated if a resident had an LOA order, they could go out on their own. She stated she had not spoken to the residents about the safety concerns when smoking near the road, which could be a safety issue. She stated she had not asked any of the residents if they had any concerns about smoking next to the road in front of the building. She stated the assessments that show the residents needed constant supervision were completed wrong. Staff A said, It was just human error, she was just clicking off on the quarterly assessment trying to get them all caught up on. She stated residents who smoke should have a smoking assessment, a care plan and a signed smoking policy. An observation was made on 04/02/2025 at 12:55 p.m. revealing an unidentified resident on her way back inside to the facility from smoking. Further observation revealed three other residents were observed outside smoking on the sidewalk in front of the facility's parking lot. Review of the Leave of Absence (LOA) sign-out sheet revealed two of the four residents observed outside had filled the sign-out sheet with their sign-out time. Further review of the LOA sign-out sheet revealed documentation of a sign in time pre-filled, but the residents were observed on the 105895 Page 26 of 27 105895 04/03/2025 Aviata at Seminole 9393 Park Blvd Seminole, FL 33777

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sidewalk smoking. Resident #13 had a sign out time of 11:25 a.m. and a return time of 11:45a.m., but was observed on the sidewalk smoking at 1:02 p.m. Resident #14 had a sign out time of 8:30 a.m. and a return time of 12:50p.m., but was observed on the sidewalk smoking at 1:05 p.m. 9. An interview was conducted on 04/03/2025 at 10:55 a.m. with Resident #26. She stated smoking had become an issue. She stated ever since residents moved from another facility, they went from not having many smokers to having a lot of smokers. Resident #26 stated, They really needed to get a designated smoking aide. She said aides are pulled from the floor and caused residents to not get help if needed during the smoking times. Resident #26 stated she had been told that her aide was overseeing the smoking breaks, and she would be assisted when the aide returned. Review of the admission Record showed Resident #26 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes, and contracture left hand. A review of the quarterly MDS (Minimum Data Set) revealed Resident #26 had a BIMS (Brief interview Mental Status) score of 14, indicating intact mental cognition. 105895 Page 27 of 27