Health inspection·June 9, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/09/2025 at 12:35 p.m., an interview was conducted with the SSD. He stated the 05/22 grievance for Resident #1 was communicated to the SSA. On 06/09/2025 at approximately 12:40 p.m., an interview was conducted with the SSA with the Nursing Home Administrator (NHA) in the room. The SSA stated Resident #1 had reported regarding two staff members, she did not like the behavior; the conversations they were having, their likes and dislikes for the residents. The SSA stated she relayed the concern to the Administrator In Training (AIT). The AIT put it on the grievance form. The SSA said I did not personally investigate. During the interview, the NHA said, the grievance would have gone to the unit manager. On 06/09/2025 at 2:22 p.m., an interview was conducted with the NHA regarding Resident #1's grievance dated 5/22. A request for documentation pertaining to an investigation for the grievance revealed there was no documentation. He stated there was nothing further. He confirmed he was the Abuse Coordinator. He stated he was out of the building from 05/22 and came back on 05/27. He stated the AIT was the assigned Abuse Coordinator in his absence. An interview was conducted on 06/09/2025 at approximately 1:36 p.m. with the NHA regarding the reportable investigation he had conducted for the allegation reported by Resident #1 on 05/29. The NHA said, Resident #1 had reported on 05/29/2025 she had a care concern about Staff A, CNA and Staff B, CNA. (Resident #1) reported them talking about residents and staff by name. At the time, she wanted her brief changed and she found out she was on her period. They refused to wipe her. That was the initial complaint. Both staff were suspended. The NHA said we did interviews with other residents and staff. Other residents had identified same issues. We chose people in the same assignment. An interview was conducted on 06/09/2025 at approximately 2:30 p.m. with the AIT, she stated she did not interview (Resident #1), and she did not investigate. She stated she did not do anything about the complaint. Subsequently, at 3:58 p.m. the AIT stated she helped the SSA fill out the grievance form for resident #1 for the 05/22. She stated it looked like (Staff F, LPN, UM) did the investigation. On 06/09/2025 at 1:26 p.m., an observation was conducted of Resident #1. She confirmed she had submitted a grievance to complain about two aides on 05/22. She stated no one came and talked to her about the concern. She stated she had not received a response from the facility about her grievance submitted on 5/22. A review of a complaint/ Grievance Report dated 05/28/2025 by (Staff G, CNA), documented a concern for treatment and care for Resident #9 showing: CNA reports that resident was covered in feces and he had been sitting for a while before anyone came to change him. The staff member assigned responsibility for the investigation was Staff F, LPN, UM. The investigation: This resident was found to be covered in feces. The Aide assigned to resident was (Staff B, CNA). She was educated about the importance of providing prompt care. Expectation showed: aide will work endeavor to ensure proper care. Written teachable moment was provided to aide, signed as completed 06/03/2025. The section to be completed on whether the grievance was reportable to the state agency was not marked with either a yes or no indication. A review of Resident #9's clinical chart documented an admission of 05/2023. His diagnosis list included but not limited to Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Morbid obesity, and muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 2 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Brief Interview for Mental status, dated 08/16/2024, documented a score of 13, with a comment Intact cognitive response. A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance deficit and at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting . incontinent to bowel, initiated 04/04/2023. A review of Staff B, Certified Nursing Assistant's (CNA) personnel file was conducted with the Human Resource Director (HRD). Present in the file was a document, Teachable Moment, dated 05/29/2025 for Staff B, CNA, which documented a description of action: (Resident #9) was found to be covered in feces. Good practice is we check and change residents every 2 hours. Resident states he had been asking to be changed all morning, and he had not been changed. When the 3-11 p.m. aide came on duty, you were already out of the building. She didn't get to do bedside round (receive report) and upon entering the resident's room, found resident covered in feces. The form was not signed by any person as presenting the document or receiving the document. During the review of the Teachable Moment with the HRD, she stated she did not know about the form. She stated, teachable moments are nursing documents. The HRD stated, I assume it was nursing that wrote it up with the expectation of presenting. I cannot tell you who wrote it up. An interview conducted was conducted with the NHA On 06/09/2025 at 6:33 p.m. He stated residents should be changed, At least every two hours. When asked, if a resident alleges, he had been sitting in a bowel movement (BM) since 12:00 p.m., and not changed until between 3:00 and 3:30 p.m., if it was appropriate care, he stated, I would say it is not. It has the potential to be neglect. He stated the incident was not reported. He said, I went and talked to the resident. And he said, he went to the bathroom in his brief. He said the girls were busy on the floor; he has a boisterous voice; (Staff G, CNA) thought he was yelling; and she went in and changed him. The NHA stated he asked the resident if he felt like he was neglected, and he said no, and he did not know why someone had reported it. He confirmed the staff member assigned to Resident #9 on 05/28/2025 during the 7:00 a.m. to 3:00 p.m. shift was Staff B, CNA. A review of the Complaint/ Grievance policies and procedures, last revised on 10/24/2022, documented the policy: The Center will support each resident's right to voice a complain/ grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and inform the resident of progress towards resolution. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility Abuse Policy. The resident should have reasonable expectations of care and services, and center should address those expectations in a timely reasonable and consistent manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 3 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to protect residents from neglect and verbal abuse by two staff members (A & B) for eight residents (#1, #2, #3, #4, #5, #6, #8, and #9) out of eight sampled for abuse and neglect. Findings included: On 6/9/25 at 10:00 a.m. Resident #1 was observed lying in bed and covered with blankets. The resident reported abusive and neglectful behavior had occurred last week, had been on menstrual cycle, and was left saturated with blood all day. The resident stated having had problems several times with Staff A Certified Nursing Assistant (CNA) and Staff B CNA being disrespectful, calling names, had talked about this resident's children, and talked about other residents and staff all the time. Resident #1 stated the staff members spoke about how fat they (other residents) were and how difficult it was to roll them. The resident stated the staff members behavior had been reported before, did not remember when, and did not know what the facility response was to the report. Resident #1 stated the staff members worked with the resident every day and spoke of others every day all the time. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to cerebral infarction due to unspecified occlusion or stenosis of right medial cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic post-traumatic stress disorder (PTSD), aphasia following cerebral infarction, and need for assistance with personal care. Review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] showed the resident scored 13 of 15 for a Brief Interview of Mental Status (BIMS) indicating an intact cognition. The MDS showed the resident was dependent upon staff for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, sit to lying, and toilet transfers. The resident required substantial/maximal assistance for rolling left to right. The resident was frequently incontinent of urine and always incontinent with bowel. Review of Resident #1's care plan revealed the following: Resident has PTSD. Trigger for PTSD may become easily agitated when staff not providing care timely (and) become anxious from loud yelling from others. An intervention dated 5/20/24 instructed Provide CNA care timely. Resident #1 has an Activities of Daily Living (ADL) self-care performance deficit related to Cerebrovascular accident (CVA) with (w/) hemi, impaired balance, history of left humerus fracture, aphasia, dysphagia, bipolar disorder, major depressive disorder, generalized anxiety disorder, chronic PTSD, behaviors, (and) insomnia. The interventions included: 2 staff in the room while providing any care as the resident is totally dependent on staff and requires extensive (ext.) total assistance by 1 staff with personal hygiene and oral care (revised 6/20/24). An interview was conducted with the Nursing Home Administrator (NHA) on 6/9/25 at 1:36 p.m. The NHA stated on 5/29/25 Resident #1 had asked the Staffing Coordinator to assist her to the NHA office where she reported an incident had occurred with Staff A and B. Resident #1 stated she had put the call light on to be changed. The resident reported during care Staff A and Staff B were talking about residents and staff by name. The resident had asked to have brief changed, found out she was on her menstrual period and the staff members refused to wipe her. The NHA stated during the investigation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 4 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some other residents and staff had voiced same (similar) issues. The NHA stated both staff members were suspended then terminated. The NHA reported other residents voiced the following concerns regarding Staff A and Staff B. An interview was conducted with the NHA on 6/9/25 at 7:03 p.m. the NHA stated an unidentified CNA who had showered Resident #1 after reporting the incident on 5/29/25, reported there was blood in the resident's brief. On 6/9/25 at 10:14 a.m. Resident #2 was observed lying in a bariatric bed. The resident stated staff some staff were unprofessional, they do talk about other people, a couple of staff members whom this resident had not seen recently. The resident stated they were disrespectful regarding other residents. Review of Resident #2's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to morbid (severe) obesity due to excess calories, unspecified chronic obstructive pulmonary disease, and unspecified affecting left nondominant side hemiplegia. Review of Resident #2's quarterly Minimum Data Set, dated [DATE] revealed a 7 of 15 BIMS score, indicating a severe cognitive impairment. Review of the resident's care plan showed the resident required maximum to total assistance for bed mobility, personal hygiene, and incontinent toilet use. On 6/9/25 at 10:35 a.m. Resident #3 had stated Staff A and Staff B are rude and do not clean area well when changing her. The resident reported commenting to the staff members about doing it right the first time and they responded with rude comments. Review of Resident #3's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to morbid (severe) obesity due to excess calories, need for assistance with personal care, not elsewhere classified lymphedema, and unspecified neuromuscular dysfunction of bladder. Review of Resident #3s quarterly Minimum Data Set, dated [DATE] revealed a 15 of 15 BIMS score indicating an intact cognition. Review of the resident's Kardex (a guide to patient care details), revealed the resident required a bariatric bed with a low air loss mattress, required 2 staff members for turn and repositioning, was dependent on 2 staff for incontinent toileting, and staff were to converse with the resident while providing care. On 6/9/25 at 1:36 p.m. the NHA stated Resident #4 had reported Staff A and Staff B would care for her together and if they changed her once, that was it. The resident stated they made her feel bad when she soiled self. On 06/09/2025 at 10:05 a.m., Resident #4 stated the facility got rid of the girls that were not talking appropriately. The resident was not descriptive about what happened, just that they were gone and they no longer worked at the facility. When asked if she had been abused or neglected, she said, neglected. Resident #4 said, they would only change me once. Review of Resident #4's Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was admitted on [DATE] and scored 12 of 15 on the Brief Interview of Mental Status (BIMS) indicating an intact cognition. The comprehensive assessment revealed the resident was dependent on staff for toileting hygiene, bathing/showering, lower body dressing, and required substantial/maximum assistance for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 5 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 personal hygiene. The MDS revealed the resident was always incontinent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm On 6/9/25 at 1:36 p.m. the NHA stated Resident #5 had reported Staff A and Staff B did not get her out of bed when requested and they did not put her back correctly. She stated the resident, a bariatric patient liked the bed set up in a way the resident felt comfortable and that the staff members had made her feel like a burden. Residents Affected - Some On 6/9/2025 at 11:09 a.m. Resident #5 was observed lying in bed. The resident stated staff were disrespectful, not abusive, giving an example as they ignore you when the call light is on. The resident stated the staff spoke about other residents. Review of Resident #5's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to morbid (severe) obesity due to excess calories, body mass index (BMI) 50.0 to 59.9 adult, need for assistance with personal care, and unspecified systemic lupus erythematosus. On 6/9/25 at 1:36 p.m. the NHA stated Resident #6 had reported Staff A and Staff B did not clean him well and would leave bowel movement on buttocks. The resident had recalled an incident when the staff members left him in the shower room alone and when asked to be changed, they made him feel like a burden. The NHA stated Resident #6 was a double above-knee amputee and should be supervised in the shower. Review of Resident #6's Quarterly MDS dated [DATE] showed the resident was admitted on [DATE]. The assessment revealed the resident had scored 12 of 15 on the BIMS indicating an intact cognition and required partial to moderate assistance for toileting hygiene, shower/bathing, and lower body dressing. The MDS showed the resident was an above the knee bilateral amputee. On 6/9/25 at 1:36 p.m. the NHA stated Resident #8 reported both Staff A and Staff B antagonized him and other residents when they asked for assistance. On 6/9/25 at approximately 4:30 p.m. Resident #8 was observed sitting in wheelchair dressed in seasonally appropriate clothing. The resident reported the ability to do a lot for self. He stated the facility had a problem with a couple of girls but understood they were gone. He did not explain what the problem was. Review of Resident #8s Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was admitted on [DATE] and had scored 13 of 15 on BIMS, indicating an intact cognition. The assessment revealed the resident was independent with toileting and personal hygiene, requiring supervision with shower/bathing. The active diagnoses showed morbid (severe) obesity due to excess calories. On 6/9/25 at 1:36 p.m. the NHA stated Resident #9 reported Staff A and Staff B had left him soiled in brief and told him to wait for the next shift. The resident stated the two staff members would shut off the call light, was quick to change him when soiled, and would talk about others when caring for him making him feel like he was not even in the room. Review of Resident #9's Annual MDS dated [DATE] revealed the resident was admitted on [DATE] and had scored 12 of 15 on BIMS assessment indicating an intact cognition. The annual assessment revealed the resident had range of motion limitations to bilateral upper and lower extremities, was dependent upon staff for toileting hygiene, showering, and lower body dressing, and required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 6 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some substantial/maximum assistance with upper body dressing and personal hygiene. The MDS showed the resident had an indwelling catheter and was always incontinent of bowel. The active diagnoses for the resident included morbid (severe) obesity due to excess calories, paraplegia, and Parkinson's disease. Review of the resident census showed Resident #1, #2, #3, #4, #5, #6, #8, and #9 resided on the same unit and specifically on the 200 and 300 hallways of the unit. During the interview on 6/9/25 at 1:36 p.m. the NHA stated the facility had asked other staff members similar questions asked of the residents regarding Staff A and Staff B. The NHA stated the following written staff statements were submitted: - Staff C, Licensed Practical Nurse (LPN) reported both Staff A and Staff B talked to residents in an unprofessional way, resident meal trays were left in front of them for about 45 minutes and (they) speak to the residents crazy. - Staff D, CNA reported when Staff A and Staff B work together they are rude to residents and how they talk to some residents was verbally aggressive or rude unprofessional. - Staff E, Medical Records/CNA reported Staff B did not want to care for difficult residents and Staff A did not want to care (named) resident, would refuse to go into the room to pass trays. When (Staff E) was working the floor Staff A and Staff B would disappear during meal and care times, they would complain about caring for Resident #1, talk bad about the resident, complain about how hard it was to care for the resident. Staff E reported they were very verbal about it, and spoke openly in front of everyone usually around the nursing station. An interview was conducted with Staff E on 6/9/25 at 2:28 p.m. Staff E stated Staff A and Staff B would refuse to care for some residents. Staff B would intentionally make a (named unsampled) resident wait for hours before getting the resident up. The staff member reported not informing anyone, there wasn't really anything to report. Staff E reported informing Staff B the resident was ready, and Staff B would say she would get to him. The staff member stated she didn't know if this behavior was reportable. The staff member stated there was hostility between the nurses, the CNAs, and Staff A and B, when they were told to do something they didn't get done, and it went on for a while. The staff member reported Staff A and B would work together with all their assigned patients and went room to room doing patient care, they had issues with Resident #1, and Resident #1 had issues with them. Resident #1 did not like them to be assigned to her, but they continued to assigned to the resident. Staff E stated it was out of our (CNAs) hands once it was reported. The NHA, who was present during this interview responded by shaking head acknowledging he was aware. An interview was conducted with Staff C, LPN on 6/9/25 at 2:45 p.m. The staff member clarified crazy (in written statement) meant they were occasions she would hear Staff A and B speak rudely to patients. Staff C remembered one incident where a resident had told Staff B she was like a lap dog and Staff B had responded to not ask her for anything if I'm a lap dog. She stated she wrote a statement on Staff B being rude but no one followed up with her regarding the statement. Staff C stated it was always hard to talk to Staff A and B. She stated she did talk to management, but the facility has never had steady management but did not feel anything got done. An interview was conducted with the NHA on 6/9/25 at 3:05 p.m. The NHA reported switching assignments for Staff A and B. They had called the compliance hotline they were pissed about being separated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 7 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The NHA stated they were aware of the working environment between Staff A and B and the unit but did not know about the issues with the residents at the time. An interview was conducted on 6/9/25 at 4:06 p.m. with Staff F, LPN/Unit Manager (UM). The staff member reported getting a complaint at 3 p.m. regarding a resident being full of feces, and Staff B had left before doing rounds with oncoming shift. Staff F LPN/ UM reported receiving complaints from different shifts about things not being done by Staff A and B. She stated sometimes the staff members could not be found when call lights were going off (like a Christmas tree down there) and nurses would come to her regarding the staff members. Staff F reported having reported constantly to the current NHA, and have informed the Director of Nursing (DON) and HR. An interview was conducted on 6/9/25 at 5:25 p.m. with Human Resources (HR). HR reported getting lots of things under door but denied having received anything regarding Staff A and B. Review of the policy and procedure, N-1265 - Abuse, Neglect, Exploitation & Misappropriation, revised 11/16/2022, documented the policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. The policy defined the following: - Mental Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. - Verbal Abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age ability to comprehend or disability. - Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: - Failure to take precautionary measures to protect the health and safety of the resident. - Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed. - Failure or refusal to provide a service for the purpose of punishing or disciplining a resident, unless withholding of a service is being used as part of a documented integrated behavioral management program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 8 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 Procedure: Level of Harm - Minimal harm or potential for actual harm Acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including dismissal and possible criminal prosecution. Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse.Acts such as teasing, humiliating, degrading, or intentionally ignoring a resident may constitute abuse and will be dealt with no less severely than acts causing physical harm. Residents Affected - Some Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as caused by improper or excessive action. All actions in which employees engage with residents must have their legitimate goal, the healthful, proper, and humane care and treatment of the resident. 2. Training: Employees of the center will receive education and training on Resident Rights, Resident Abuse, and abuse Reporting during orientation and annually thereafter. Additional education and training will be provided as deemed necessary. Employee obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. 3. Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation. The following systems have been implemented: - Resident Council - Grievance/Concern program including posted information on the grievance official. - Sufficient numbers of staff to meet the needs of the residents. - Department Heads and supervisors that monitor staff to identify inappropriate behavior. - Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse. - Posted information on how to contact appropriate State agencies. 4. Identification: All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Nursing/ designee. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 9 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Nursing will serve as the Abuse Coordinator. 5. Investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. A Social Service representative may be offered in the role of resident advocate during any questioning of or interviewing of residents. Investigations will be accomplished in the following manner Preliminary Investigation: - Immediately upon an allegation of abuse or neglect, the suspect9s) shall be segregated from residents pending the investigation of the resident allegation. - The nurse or Director of Nursing/ designee shall perform and document a thorough nursing evaluation and notify the attending physician. - An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report should be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator. Investigation: The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect9s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/ she shall also secure physical evidence. Upon completion of the investigation, a detailed report shall be prepared. 6. Protection: Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending investigation. - The resident will be evaluated for any signs of injury, including a physical exam and/ or psychosocial assessment, as appropriate. - Increased supervision of the alleged victim and residents. - Room or staffing changes, if necessary, to protect the resdient9s) form (sic) the alleged perpetrator. - Protection from retaliation. - Provide the resident with emotional support and counseling during and after the investigation, if needed. 7. Reporting/ Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 10 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred. Event ID: Facility ID: 105895 If continuation sheet Page 11 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, record review and interviews, the facility failed to ensure an allegation of neglect was reported to the appropriate Agencies for one (#9) of ten sampled residents. Residents Affected - Few Findings included: A review of Resident #9's clinical chart documented an admission of 05/2023. His diagnosis list included but not limited to Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Morbid obesity, and muscle weakness. A review of a Brief Interview for Mental status, dated 08/16/2024, documented a score of 13, with a comment Intact cognitive response. A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance deficit and at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting . incontinent to bowel, initiated 04/04/2023. A review of Staff B, Certified Nursing Assistant's (CNA) personnel file was conducted with the Human Resource Director (HRD). Present in the file was a document, Teachable Moment, dated 05/29/2025 for Staff B, CNA, which documented a description of action: (Resident #9) was found to be covered in feces. Good practice is we check and change residents every 2 hours. Resident states he had been asking to be changed all morning, and he had not been changed. When the 3-11 p.m. aide came on duty, you were already out of the building. She didn't get to do bedside round (receive report) and upon entering the resident's room, found resident covered in feces. The form was not signed by any person as presenting the document or receiving the document. During the review of the Teachable Moment with the HRD, she stated she did not know about the form. She stated, teachable moments are nursing documents. The HRD stated, I assume it was nursing that wrote it up with the expectation of presenting. I cannot tell you who wrote it up. An interview conducted on 06/09/2025 at 6:15 p.m. with the NHA, while reviewing the Teachable moment for Staff B, he stated teachable moment was invalid. It was not signed; it was a worthless piece of paper that should not have been in the file. He said he did not know who had filled it out; after reading it he said he should have been in on it. On 06/09/2025 at approximately 6:20 p.m., an interview was conducted with Staff G, CNA. She recalled the concern with how she had found Resident #9. She said, I came in at 3:00 p.m.; I was assigned (the back hall where Resident #9 resides). I heard someone yelling. I thought it was (Resident #9), so, I went in and checked on him. It was between 3:00 and 3:30 p.m., it was the first thing I heard. He was covered in feces from the waist, some of it was on his thighs, it was like diarrhea. He told me he had been like that since noon. Some of the feces was dried on, some of it was not, I had to scrub him. The sheets were covered in it too. I changed everything. She stated normally there is report given during shift change, but at the time, there was no one to provide the report. She stated she shared the information with the nurse, Staff C, LPN and she went and got the Unit Manager, Staff F, LPN. Staff G stated she wrote a statement and gave it to the Unit Manager, Staff F. A review of a complaint/ Grievance Report dated 05/28/2025 by (Staff G, CNA), documented a concern (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 12 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for treatment and care for Resident #9 showing: CNA reports that resident was covered in feces and he had been sitting for a while before anyone came to change him. The staff member assigned responsibility for the investigation was Staff F, LPN, UM. The investigation: This resident was found to be covered in feces. The Aide assigned to resident was (Staff B, CNA). She was educated about the importance of providing prompt care. Expectation showed: aide will work endeavor to ensure proper care. Written teachable moment was provided to aide, signed as completed 06/03/2025. The section to be completed on whether the grievance was reportable to the state agency was not marked with either a yes or no indication. An interview conducted was conducted with the NHA On 06/09/2025 at 6:33 p.m. He stated residents should be changed, At least every two hours. When asked, if a resident alleges, he had been sitting in a bowel movement (BM) since 12:00 p.m., and not changed until between 3:00 and 3:30 p.m., if it was appropriate care, he stated, I would say it is not. It has the potential to be neglect. He stated the incident was not reported. He said, I went and talked to the resident. And he said, he went to the bathroom in his brief. He said the girls were busy on the floor; he has a boisterous voice; (Staff G, CNA) thought he was yelling; and she went in and changed him. The NHA stated he asked the resident if he felt like he was neglected, and he said no, and he did not know why someone had reported it. He confirmed the staff member assigned to Resident #9 on 05/28/2025 during the 7:00 a.m. to 3:00 p.m. shift was Staff B, CNA. The NHA stated the process for reporting an allegation was, I report it to our clinical team and the Regional Nurse Consultant, who is their Risk Manager. Then, I write up my initial findings, submit on the AIRS (AHCA Incident Reporting System) system; notify the Department of Children and Families, police, and any other parties necessary, and then. begin the investigation. The NHA confirmed this incident was not reported. Review of the policy and procedure, N-1265 - Abuse, Neglect, Exploitation & Misappropriation, revised 11/16/2022, documented the policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. 7. Reporting/ Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105895 If continuation sheet Page 13 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 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 0609 accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred. 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 14