Inspection·March 3, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/2/22 at 11:56 a.m., the Director of Nursing (DON) and the Regional Nurse were interviewed regarding expectations of the clinical staff for urinary catheter care and care of urinary drainage bags. They stated a privacy/dignity bag should be in place if the resident was out of their room. A review of the facility's policy and procedure for Catheterization (initiated 11/30/2014 and last revised on 9/19/2017), revealed: Foley bag (urinary catheter drainage bag) to be covered by a privacy bag to preserve dignity of resident. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 2 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations during four of four days, record reviews, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for eleven (Residents #14, #65, #57, #100, #30, #1, #7, #27, #32, #45, and #252) of 46 residents in the sample. Specifically, the facility failed to maintain housekeeping and maintenance services in resident rooms and common areas. The findings include: On 2/27/22 at 12:20 p.m., Resident #1's bathroom was observed with a soap dispenser bag lying on the toilet tank. Grab bars were discolored, the floor was soiled, and the air conditioning vent was covered in grey debris. (Photographic evidence obtained) On 2/27/22 at 12:24 p.m., Resident #7's bathroom was observed with a toilet that was soiled above the water line. (Photographic evidence obtained) On 2/27/22 at 12:40 p.m., Resident #100's bathroom was observed with a vent covered in grey, thickened debris. The drain cover under the sink was broken. Grab bars had a rusted appearance, and the sink faucet was encrusted with calcification (buildup of calcium/minerals from hard water). (Photographic evidence obtained) On 2/27/22 at 12:50 p.m., Resident #14's bathroom was observed with a vent covered in grey, thickened debris. The drain cover under the sink was broken. Grab bars had a rusted appearance, and the sink faucet was encrusted with calcification. On 2/27/22 at 1:00 p.m., Resident #65's bathroom was observed with a calcium-encrusted faucet on the sink and brown rust on the grab bars. The ceiling vent was covered in grey, thickened debris. (Photographic evidence obtained) On 2/27/22 at 2:00 p.m., Resident #57's room was observed. The air conditioner was covered with a thick, dark brown substance all over the outside of the casing and inside the vents. The resident reported the air conditioner had not been cleaned in a year. (Photographic evidence obtained) On 2/27/22 at 3:16 p.m., Resident #30's bathroom was observed. A toilet plunger was lying on the floor with a handle covered in brown debris. Pest droppings and dead pests were observed behind the toilet. (Photographic evidence obtained) On 2/28/22 at 9:15 a.m., Resident #1's bathroom was observed. The soap dispenser bag remained on the toilet tank, the floor remained stained and discolored, and the seal around the base of the toilet was soiled. (Photographic evidence obtained) On 2/28/22 at 9:15 a.m., Resident #27's bathroom was observed. The floors were covered with a black substance, brown splatter was observed on the wall behind the toilet, and clean linen, stacked on the toilet tank, was touching the splattered substance. The sink faucet was calcium-encrusted, the grab bars were rusted, and the air conditioning vent was covered with grey, thickened debris. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 3 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm On 2/28/22 at 9:30 a.m., Resident #100's bathroom was observed to be unchanged since the 2/27 observation at 12:40 p.m. (Photographic evidence obtained) On 2/28/22 at 9:30am in Resident #14's bathroom was observed to be unchanged since the 2/27 observation at 12:50 p.m. Residents Affected - Some On 2/28/22 at 9:45 a.m., Resident #65's bathroom was observed to be unchanged since the 2/27 observation at 1:00 p.m. (Photographic evidence obtained) On 2/28/22 at 12:28 p.m., Resident #30's bathroom was observed. Pest droppings and dead pests remained behind the toilet and the floor was soiled. (Photographic evidence obtained) On 3/2/22 at 9:20 a.m., Resident #57's air conditioner was rechecked after having conducted multiple observations on 2/28/22, and 3/1/22. The air condiitoner had not been cleaned and remained with a brown substance coating the surface of the casing and vents. Housekeeper EE was mopping the floor in the resident's room. When she was asked who was responsible for cleaning the air conditioning unit, she stated maintenance cleans them. She confirmed that the casing on the air conditioning unit was covered with a dark, soiled substance, and she started wiping it with her white cloth and spray. After she sprayed the air conditioner and wiped an area, the white cloth became black. She reported the vents were soiled and needed to be cleaned. On 3/3/22 at 2:00 p.m., the 800 hallway was observed. Hand sanitizer dispensers had dripped sanitizer down the walls onto the grab bars and the floor. Significant buildup was observed. Ceiling grates had a black substance on them. On 3/3/22 at 2:05 p.m., Resident #32's room was observed with patches in the wall. The resident stated it had been that way for the last six months. (Photographic evidence obtained) On 3/3/22 at 2:15 p.m., Resident #45's bathroom was observed with a calcium-encrusted sink faucet and rusted grab bars. The ceiling vent was covered in grey, thickened debris, and the walls and floor were soiled. (Photographic evidence obtained) On 3/3/22 at 2:15 p.m., Resident #252's bathroom was observed with a calcium-encrusted sink faucet and a rusted toilet paper holder and grab bars. The ceiling vent was covered in grey, thickened debris, and the walls and floor were soiled. (Photographic evidence obtained) On 3/3/22 at 2:30 p.m., the 500 hallway was observed. Hand sanitizer dispensers had dripped sanitizer down the walls onto the grab bars and the floor. Significant buildup was observed. On 3/3/22 at 3:00 p.m., the 400 hallway was observed. Hand sanitizer dispensers had dripped sanitizer down the walls onto the grab bars and the floor. Significant buildup was observed. On 3/3/22 at 3:15 p.m., the 700 hallway shower room was observed with a kickplate falling off the door. The Environmental Services Director (ESD) was interviewed on 3/3/22 at 10:30 a.m. He was asked about the cleaning of the air conditioners and he stated maintenance replaced the filters, and housekeeping was responsible for cleaning the casing and outside covering. If the covering was really bad, it could be replaced. The ESD walked into room [ROOM NUMBER] and observed the air conditioning unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 4 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some He confirmed it was soiled even after housekeeping had cleaned it. He stated it needed cleaning and spoke with the resident in the room about taking the cover off at 2:00 p.m. and trying to clean it. The resident was agreeable. The ESD stated, If it is not cleanable, we will replace the cover. The Housekeeping Manager was interviewed on 3/3/22 at 1:40 p.m. She stated she had worked in the facility for four years. She was the person responsible for stripping and waxing the floors, her Tech was mainly responsible for emptying trash and cleaning baseboards, and housekeeping staff were responsible for light cleaning. They were not permitted to use bleach or harsher chemicals to deep clean. The approved chemicals were Virex (one-step disinfectant/deodorizer cleaner concentrate) and [NAME] (nonhazardous wash solvent that removes wax, grease, oil and silicone). He stated all facility hallways were being cleaned and disinfected according to facility practices. They cleaned the outside of the ceiling vents and the outside casing of the air conditioning units with a duster. Things like caulking around the toilets, descaling the faucets, grab bars and inside air conditioning vents and equipment were addressed by Maintenance/Environmental Services. The Housekeeping Manager stated it was the Maintenance Manager's responsibility to discover problems with the air conditioning units in resident rooms. According to the Housekeeping Manager, the maintenance department did not rely on housekeeping to inform them. The Activities Director was interviewed on 3/3/22 at 1:45 p.m. She stated she had worked in the facility since October 2021. She further stated the activities room and refrigerator did not get the attention from housekeeping as often as she would like. She did her best to clean up herself. The activities room floors were sticky and soiled. The refrigerator had a brown substance all over the exterior, and the ceiling vents were covered with grey, thickened debris. Two vents had a black substance in the center of them. Housekeeper U was interviewed on 3/3/22 at 2:45 p.m. She stated she had worked in the facility for two years. She usually did the basics, which included bathroom sanitation, floor sweeping with an adjuster tool, and dusting over the bed tables. The window blinds and air conditioning covers were cleaned once weekly. She was also responsible for changing out soiled privacy curtains. The ESD was interviewed on 3/3/22 at 3:20 p.m. during a tour of the facility. He stated he had been working there for one month and had one technician working under him. He further stated he was doing his best and acknowledged that the building (including resident rooms) had many issues that needed repair. The ESD toured the 500 and 800 hallways including resident rooms. He stated he would replace hallway ceiling grates throughout the facility, as well as bathroom faucets and grab bars. He had plans to replace all hand sanitizer stations in the facility, so the product did not drip on the floor, walls and handrails. He stated it was the housekeeping staff's responsibility to notify him when air conditioning units needed repair and filter cleaning. The units were cleaned monthly. The job descriptions for Environmental Director I and II and Environmental Technician were reviewed. The job descriptions revealed that the Director of Environmental Services Is delegated the administrative authority, responsibility and accountability necessary for carrying out assigned duties. Responsibilities included upkeep of the facility, building, building systems and grounds. A review of Environmental Technician job description revealed the job duties included Replace burned out light bulbs to include exit lights, over head lights . and to perform cleaning duties wherever necessary. Service heating and cooling units/systems . (Copies obtained) A review of the facility's policy for Maintenance Service (Revised December 2009) revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 5 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include, but are not limited to: Level of Harm - Minimal harm or potential for actual harm b. Maintaining the building in good repair and free of hazards. Residents Affected - Some d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. f. Establishing priorities in providing repair service. i. Providing routinely scheduled maintenance service to all areas. The Maintenance Director is responsible for maintaining the following records/reports: b. Work order requests c. Maintenance schedules A review of the facility's 5 & 7 Steps of Cleaning revealed the following: * 7 Step (Resident Bathroom) 3. Dust mop floor. Corn broom tough to reach areas i.e. corners, edges and behind the commode. 5. Clean sink and plumbing. Work high to low. Sink should be cleaned with Virex solution. 6. Clean commode and/or urinal areas. use toilet bowl cleaner and [NAME] mop to properly sanitize area. 7. Wet mop floor. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 6 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records and interviews with staff, the facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASARR) in order to determine appropriateness of placement in a nursing facility and to provide the most appropriate setting and support for one (Resident #34) of five residents identified with serious mental disorders requiring a Level 2 screen, from a total of 45 residents in the sample. Residents Affected - Few The findings include: 1. A medical record review for Resident #34 found she was admitted to the facility on [DATE], with a re-entry date of 2/16/22. Her diagnoses included anxiety, paranoid schizophrenia, major depressive disorder and mild intellectual disability. Resident #34 had a Level I PASRR dated 11/18/21. The screening tool indicated under section I.A. Mental Illness (MI) or Suspected MI, that Resident #34 had diagnoses of bipolar and depressive disorders. Section II. question 2.a. was marked Yes, indicating Resident #34 experienced functioning limitations in major life activities that would otherwise be appropriate for the individual's developmental stage. The form instructed that the completion of a Level II PASARR screening was required prior to admission to the nursing facility if any box in section I.A or 1.B (MI or Suspected MI) was checked, and there was a Yes checked in Section II.1, II.2 or II.3, unless the individual met the definition of a provisional admission or a hospital discharge exemption. Section III, PASARR Screen Provisional Determination noted Resident #34 did have a hospital discharge exemption. The instructions stated that should the resident be admitted under the 3-day exemption, and the stay in the nursing facility (NF) was anticipated to exceed 30 days, the NF must notify the Level I screener on the 25th day of the resident's stay, and the Level II evaluation must be completed no later than the 40th day after admission. The discharge exemption statement was signed by the attending physician on 11/18/21. Further review of the clinical record found no Level II screening was completed within 40 days of the residents admission, as required. An interview was conducted with the Director of Admissions on 3/3/22 at 10:10 a.m. She reported that new admission PASARRs were received from the hospital and Social Services would obtain a Level II if needed. A Level II had to be completed within 30 days after admission. She reviewed Resident #34's PASARR and stated a Level II was needed. I will go look in her closed chart to see if there is a Level II. The Social Services Director is not in the building. Kepro was called via telephone on 3/3/22 at 11:12 a.m., and a staff member was asked to review 5 PASARRs for a Level II. The employee at Kepro reviewed the 5 PASARRs and reported that Resident #34 indicated a need for a Level II from the latest date of the PASARR, which was 11/18/21. An interview was conducted with the Admissions Director on 3/3/22 at 11:21 a.m. She confirmed that a Level II PASARR was indicated but was not done. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 7 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to provide personal grooming for one (Resident #30) of a sample of 46 residents. Resident #30 was dependent on staff for care, and his fingernails were long with a thick black substance underneath, which could have resulted in scratches and a potential infection. Residents Affected - Few The findings include: Resident #30 was observed in his room on 2/28/2022 at 9:15 a.m. He was lying in bed with an indwelling urinary catheter, which was hanging on the bed rail covered by a privacy bag. He pulled his covers down and his fingernails were approximately an inch long with a thick black substance underneath them. The resident was observed in his room lying in bed on 3/1/2022 at 8:58 a.m. His nails are still long and unclean. He acknowledged that they were long and stated he would allow staff to cut them. The resident was observed in his room lying in bed on 3/2/2022 at 9:00 a.m. He reported that no one had cut his fingernails or cleaned them. They were still long and filled with a black substance underneath. A medical record review was conducted, which noted an admission date of 6/10/2021. Resident #30's diagnoses included pulmonary fibrosis, functional quadriplegia, malignant neoplasm of the prostate, and alcohol abuse. A Minimum Data Set (MDS) assessment, dated 12/16/2021, noted that Resident #30 required extensive assistance from staff with personal hygiene and grooming. The resident's comprehensive care plan was reviewed. It had been updated on 12/23/2021. Resident #30 had a focus area of Activities of Daily Living (ADL)/Self-Care Performance Deficit related to impaired mobility and weakness. One of the care plan interventions was to check nail length and trim and clean on bath day as necessary. An interview was conducted with Certified Nursing Assistant (CNA) GG on 3/3/2022 at 1:15 p.m. He reported that residents' nails are cut by CNAs on bath/shower days. He stated he floated to different areas of the facility and did not work with Resident #30 on a consistent basis. Today he was relieving a staff member (for lunch) who was doing one-to-one supervision with a another resident. CNA GG was asked to come to Resident #30's room when the staff member he was covering for returned. An interview was conducted with CNA GG at 2:40 p.m. on 3/3/2022. He reported that Resident #30's nails were cut by another CNA, but the black substance underneath them was hard and grown into the skin and was unable to be removed. The resident's hand would have to be soaked to loosen and remove the black substance. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 8 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interviews, the facility failed to ensure provision of care and treatment in accordance with professional standards of practice for one (Resident #256) of 46 residents reviewed, by failing to obtain orders for the care and monitoring of a peripherally inserted central catheter (PICC) line. Resident #256 was admitted from the hospital with a PICC line for antibiotic therapy to treat a urinary tract infection (UTI). The facility was administering intravenous (IV) antibiotics and flushing the PICC line without a physician's order. There was no physician's order for PICC line dressing changes, and no dressing change occurred for 11 days, despite the facility's policy for catheter site dressing regimens. Residents Affected - Few The findings include: A review of Resident #256's medical record revealed he was admitted to the facility from an acute care hospital on 2/18/2022 with an admitting diagnosis of urinary tract infection (UTI). He was receiving antibiotics that required intravenous access. No physician's orders were found in the resident's record for assessment, monitoring, flushing, or dressing changes related to the intravenous (IV) access. A review of the resident's February 2022 electronic medication administration and treatment administration records (eMAR and eTAR) revealed no orders to change or monitor the IV dressing or to flush the IV line. On 2/27/2022 at 4:00 p.m., Resident #256 was observed in bed. A PICC line was observed in his right upper arm. The dressing was dated 2/18/2022. On 2/28/2022 at 8:35 a.m., Resident #256 was observed in bed. A PICC line was observed in his right upper arm. The dressing was dated 2/18/2022. On 2/28/2022 at 1:00 p.m., during an interview with Resident #256, he was asked if his PICC line dressing, located on his right upper arm, had been changed since he arrived at the facility. He stated no. He was asked if he recalled what day he was admitted to the facility. He replied, Yes, it's been ten days. He was asked if he recalled what day the PICC line was placed in his right upper arm. He replied, The same day I came to this facility, ten days ago. They put it in at the hospital before I came here. On 3/1/2022 at 2:10 p.m., during an interview with Registered Nurse (RN) A, he was asked if he was caring for Resident #256 today. He replied yes. He was asked if he was the nurse who hung the resident's 2:00 p.m. IV antibiotic, and he replied yes. He was asked how often PICC line dressings were changed, and he stated, Every two to three days, so every 48 to 72 hours. RN A was observed taking down the resident's IV antibiotic upon completion at 2:20 p.m. He was observed flushing the IV with 10 cc (cubic centimeters) of normal saline. The nurse was asked for the date on the IV dressing. He lifted the resident's sleeve and stated, Oh, the date on the dressing is February 18th. On 3/1/2022 at 2:25 p.m. during an interview with LPN L, she was asked how often midline IV dressings should be changed. She stated, once a week. On 3/1/2022 at 2:45 p.m., an interview was conducted with the Regional Corporate Coordinator. She was asked how often midline IV dressings should be changed. She stated, I can go pull the policy for you, but it should have been changed on admission to our facility, every seven days from that date, and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 9 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/3/2022 at 4:05 p.m., during an interview with LPN/Unit Manager N, she stated, Anyone can put the orders in. She was asked whether this resident's orders for the care and monitoring of the PICC line, the PICC line dressing changes and the IV flushes should be on the eMAR/aTAR. She stated, Yes, they should be. She was asked if there was a system check in place to ensure orders were put in the eMAR/eTAR. She stated, If a resident is admitted in the evening, the DON (Director of Nursing) and I review the orders the next day. When asked why there were no orders for the care and monitoring of the PICC line, she stated, Human error. It's my job to update the orders and I got behind. A review of the facility's policy titled Guideline for Preventing Intravenous Catheter-Related Infections (revised April 2014) section Catheter Site Dressing Regimens revealed: 1. Change initial dressing after catheter placement within 24 hours. 8. Replace transparent dressings on tunneled or implanted CVCs (central venous catheters) every 5-7 days unless the dressing is loose or soiled. According to MedlinePlus at https://medlineplus.gov (accessed on 3/25/22 at 2:50 p.m.), A peripherally inserted central catheter (PICC) is a long, thin tube that goes into your body through a vein in your upper arm. The end of this catheter goes into a large vein near your heart. The PICC carries nutrients and medicines into your body. A dressing is a special bandage that blocks germs and keeps your catheter site dry and clean. You should change the dressing about once a week. You need to change it sooner if it becomes loose or gets wet or dirty. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 10 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents with limited range of motion received the appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #89) resident reviewed, out of 14 residents with contractures, from a total of 46 residents in the sample. Specifically, the facility failed to apply and remove Resident #89's left wrist splint as ordered, which could result in the worsening of her contracture. The findings include: An interview was conducted with Resident #89 and her family representative on 2/28/2022 at 1:00 p.m. During the interview, the family representative stated the resident had a splint that she was supposed to wear on her left wrist at night. The family representative stated she came to visit and put the splint on Resident #89 every night around 6:00 p.m., because the staff either did not know how to put it on, or they just did not put it on. A review of Resident #89's medical record revealed an admission date of 10/30/2021. Her primary diagnosis was documented as hemiplegia/hemiparesis following a nontraumatic intracerebral hemorrhage (bleeding in the brain - stroke) affecting her left, non-dominant side. A review of the resident's Minimum Data Set (MDS) assessment, dated 11/5/2021, revealed that she did not ambulate (walk), and she required extensive assistance or was totally dependent with activities of daily living (ADLs). A functional limitation in range of motion (ROM) to both the upper and lower extremities on her left side was noted. The resident's brief interview for mental status (BIMS) score was documented as 15 out of a possible 15 points, indicating intact cognition. During the MDS look-back period, occupational therapy was documented as having been provided for 85 minutes, and physical therapy was provided for 160 minutes, however no restorative nursing (including splint or brace assistance) was documented as having been provided. A review of the 5-day MDS assessment dated [DATE], revealed documented therapy minutes as follows during the look-back period: Physical therapy totaled 155 minutes Occupation therapy totaled 165 minutes Restorative nursing, including splint or brace assistance was not provided A review of the quarterly MDS assessment dated [DATE], revealed documented therapy minutes as follows during the look-back period: Physical therapy was not provided Occupation therapy totaled 105 minutes Restorative nursing, including splint or brace assistance was not provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 11 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The resident's BIMS score was documented as 10 out of a possible 15 points, indicating moderate cognitive impairment. According to the therapy department's Notification of Discharge, the resident was discharged from physical therapy and occupational therapy services to the LTC (long-term care) Restorative/ Functional Management Program (FMP). The last date of treatment in therapy was noted as 1/29/2022, and the therapy communication to the Restorative Nursing Program was also dated 1/29/2022. It recommended to Continue gentle range of motion for Left Upper Extremity (LUE) and donning Left (L) hand/wrist orthotic (splint) 4-5 hours at night. A review of the February 2022 Medication Administration Record (MAR), and the Treatment Administration Record (TAR), revealed no documentation indicating the application or removal of the resident's Left Upper Extremity splint as per the above-mentioned therapy discharge paperwork and recommendations. The resident's active comprehensive care plan was reviewed. She was not care planned for therapy services, restorative nursing services, or for the use of a wrist splint. The resident's certified nursing assistant (CNA) task list was reviewed, but the application/removal of a left wrist splint was not documented. During an interview with the resident's Unit Manager (UM) on 3/3/2022 at 1:10 p.m., the UM reviewed the resident's medical file and the restorative order. The therapy recommendation for the splint was communicated to nursing via the therapy discharge form, but it was not transcribed to the MAR or TAR. An interview with the Occupational Therapist (OT) was conducted on 3/3/2022 at 1:33 p.m. During the interview, the OT stated, The FMP (Functional Maintenance Program) is communicated to nursing either before or at the time of discharge from therapy. It is given to the nurses. It is then communicated, and staff is trained. The FMP is posted in the resident's room, preferably on the inside of the closet door for the resident's privacy. If it isn't in the closet, there is a copy at the nurses' station. The Unit Manager is responsible for ensuring the staff is trained according to the FMP. The Director of Nursing (DON) also receives a copy of the FMP. During an observation of the resident's room at 1:50 p.m. on 3/3/2022, the FMP was not posted on the inside of the closet door or in any location within the room. The Unit Manager was interviewed at 1:53 p.m. on 3/3/2022. During the interview, the UM was asked about the process for communication between Therapy and the Nursing Restorative Program. The UM could not verbalize the process, stating she did not know, because she had not received a restorative communication since she began working in the facility. An interview with Certified Nursing Assistants (CNAs) BB, Z, and Y, at 2:50 p.m. on 3/3/2022, revealed that they were not aware of a Functional Maintenance Program or a Restorative Therapy Program. They are not aware of any residents who required functional maintenance, splinting, or restorative care. An interview was conducted with the Regional Director of Clinical Services (RDCS) at 3:30 p.m. on 3/3/2022. During the interview, the RDCS stated, The FMP is communicated to the floor staff. Therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 12 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communicates the FMP to the CNAs directly. Therapy ensures the CNA staff is trained. If there is a restorative program, the restorative aide will train the CNAs. All staff CNAs are trained on restorative. Staff CC is the 3:00 p.m. to 11:00 p.m. therapy aide. An interview was conducted with CNA CC at 4:15 p.m. on 3/3/2022. During the interview, CNA CC stated she was not aware of a Functional Maintenance Program (FMP) or a Nursing Restorative Program. She further stated she was a CNA and the therapy coordinator. CNA CC confirmed that she did not do any splinting, restorative care, or care pertaining to functional maintenance for the residents. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 13 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice, for two (Residents #354 and #53) of six residents receiving respiratory treatment, from a total of 46 residents in the sample, by failing to administer oxygen at the flow rate ordered by the physician. Residents Affected - Few The findings include: 1. An interview was conducted with Resident #354 at 11:53 a.m. on 3/2/2022. During the interview, the oxygen concentrator was observed with a flow rate set at 3 liters per minute (LPM). When asked about the flow rate currently set on her concentrator, the resident stated she liked it set at 3 LPM. She used oxygen at 3 LPM at home and she could breathe better. She stated she couldn't breathe with the flow rate set at 2 LPM. When asked if the staff adjusted her oxygen, the resident replied, No, it has always been set at 3 liters. A review of the resident's medical record revealed an admission date of 2/11/2022 and pertinent diagnoses including chronic obstructive pulmonary disease COPD), heart failure, and pneumonia due to Coronavirus 2019. The resident's transfer form from the hospital (CMS form 3008, dated 2/9/2022), showed that the resident was admitted from the hospital to the facility with an order for oxygen at a flow rate of 2 LPM. The physician's 2/11/2022 oxygen order read, Respiratory: 2 Liters Oxygen-Continuous. A review of the resident's comprehensive care plan revealed a focus area for Oxygen Therapy related to Congestive Heart Failure, Pneumonia, and Obesity. The care plan documented the following: Oxygen settings: O2 (oxygen) via Nasal Prongs @ (at) 2L (2 liters) continuously). An interview was conducted with Licensed Practical Nurse AA (LPN) Agency) on 3/2/22 at 2:00 p.m. During the interview, LPN AA was asked how often and when she reviewed the oxygen levels on her residents' oxygen concentrators. She stated she checked the concentrators once every shift. When asked about the time frame, she said she checked them whenever she gets a chance. LPN AA visited Resident #354's room and verified the oxygen concentrator was set at 3 LPM. She then went to the computer on the medication cart and verified the physician's orders in the electronic medical chart. The physician's orders oxygen was to be administered at 2 LPM. LPN AA then reviewed the resident's transfer form (CMS form 3008) and verified the admission order for oxygen at 2 LPM. 2. A record review for Resident #53 revealed an admission date of 1/12/2022 with diagnoses including pulmonary fibrosis, shortness of breath (SOB), acute and chronic respiratory failure, COPD, emphysema, and pneumothorax. A review of the five-day Minimum Data Set (MDS) assessment, dated 1/18/2022, revealed a Brief Interview for Mental Status score of 12 out of a possible 15 points, indicating mild to moderate cognitive impairment. The resident was noted with SOB (shortness of breath) with exertion when sitting, when lying flat, and he received treatments that included oxygen. Resident #53's physician's orders were reviewed and included an order for oxygen at 2 LPM via nasal cannula, continuously every shift (starting on 2/20/2022). The physician's orders also instructed clinical staff to Check pulse oximetry every day shift for monitoring, change tubing and mask and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 14 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 nasal cannula weekly and as needed. Level of Harm - Minimal harm or potential for actual harm A review of the resident's hospital transfer form (CMS form 3008), dated 1/12/2022, revealed oxygen at 2% continuous. (Copy obtained) Residents Affected - Few A review of the resident's active Care Plan, dated 1/13/2022, revealed a focus area for Oxygen Therapy with interventions including: Monitor for signs and symptoms of respiratory distress and report to doctor as needed. Oxygen settings via nasal prongs at 2 Liters as needed. An observation of the resident's oxygen flow rate was made on 2/27/2022 at 1:52 p.m. The flow rate was set at 4 LPM. The resident stated it should be set at 3 LPM. On 3/1/2022 at 2:51 p.m., the resident's oxygen flow rate was set at 3 LPM. (Photographic evidence obtained) On 3/2/2022 at 4:32 p.m., the oxygen flow rate was set at 3 LPM, and on 3/3/2022 at 2:35 p.m., the flow rate was set at 3 LPM. An interview was conducted with Registered Nurse (RN) A on 3/3/2022 at 10:30 a.m. RN A stated he changed nasal cannulas at least once a week and he usually put a date on the tubing or tape at that time. He further stated the date was also written on the tubing bag. RN A reported that he checked oxygen flow rates and blood oxygen saturation levels every shift, usually about every four hours, but at least once per shift. He was asked what setting Resident #53's oxygen should be set on and he stated, I believe the resident's oxygen should be on 2 to 3 Liters; I think it's 2 Liters. An interview was conducted with the Director of Nursing (DON) on 3/3/2022 at 10:35 a.m. She was asked when staff were expected check oxygen flow rates. She stated, Periodically throughout the shift, but at least once a shift. An interview with LPN O was conducted on 3/3/2022 at 2:32 p.m. He confirmed by checking the electronic medical record, that Resident #53's oxygen order was for 2 LPM. LPN O was asked to check Resident #53's oxygen concentrator and flow rate. Upon entering the resident's room at 2:34 p.m., the resident's oxygen flow rate was set at 3 LPM. At 2:36 p.m., when LPN O entered the room and was asked to check the flow rate, he stated the rate was 2.5 LPM. He adjusted the flow rate down to 2 LPM. A review of the facility's Oxygen policy (revised on 8/28/2017), revealed, Start oxygen flow rate at the prescribed liter flow for administration device. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 15 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and facility policy review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #41) sampled from a total sample of 46 residents. Residents Affected - Few The findings include: On 2/27/2022 at 3:40 p.m., Resident #41 was observed lying in bed awake. His right knee was swollen with a lidoderm patch covering it. Resident #41 stated, I used to get pain pills but they took them away. I don't know why, but my knee is very painful. I need a knee replacement eventually, but for now, I don't know why they only use this patch and not any pain pills. Resident #41 was asked if he had explained his pain to the clinical staff and asked for pain medicine. He stated, Yes, I've asked and they say I don't have any (pills). They never ask me about my pain, no one questions me about my pain. Resident #41 was asked to rate his pain right now on a scale of zero to 10 with zero meaning no pain at all and 10 meaning the worst possible pain. He stated, It's about an 8, it usually is. On 2/28/2022 at 8:35 a.m., Resident #41 was observed lying in bed. He was asked how his pain was today. He pulled back his sheets to reveal his right knee, which was swollen, and stated, Oh it hurts. It still hurts. He was asked how he would rate his pain on a scale of 0-10. He stated, I'd say it's at a 6 right now. He was asked if he had any pain medications today other than the lidoderm patch. He stated, No, I told you, they took my pills away. On 2/28/2022 at 8:45 a.m. in an interview with the nurse caring for Resident #41 (Licensed Practical Nurse (LPN) B), he was asked if the resident had any pain medications ordered. He stated, No, he has a lidoderm patch (topical anesthetic) for his knee. I'll be removing that soon. On 3/1/2022 at 12:20 p.m., Resident #41 was observed in his room, sitting up in his wheelchair. His right knee was swollen with a lidoderm patch in place. Resident #41 was asked how his pain level was today. He stated, It hurts. It's about a 6 right now. On 3/1/2022 at 2:30 p.m. in an interview with Registered Nurse (RN) A, he was asked if he was caring for Resident #41 today. He stated yes. He was asked if he assessed the resident's pain. He stated, Yes, I do. He has pain with his right knee. I know they recently discontinued his narcotic pain medication. I'm not sure why they did, but he does get Mobic (nonsteroidal anti-inflammatory drug) in the evening that is scheduled, and he has a lidoderm patch. I think he also has a follow-up coming up with his orthopedic doctor about his steroid injection he had in his knee a few weeks ago. On 3/2/2022 at 12:40 p.m. in an interview with the Advanced Practice Registered Nurse (APRN), she was asked if Resident #41 was under her care. She stated yes. She was asked if she could explain why his narcotic as needed pain medication had been discontinued. She looked in his chart and stated, It wasn't discontinued, [the doctor] saw him on February 16th and wrote an order for 60 tablets, which would take him through March 18th. She was asked if that meant the resident should still be receiving Norco 5/325 mg (milligrams), one tablet by mouth every twelve hours as needed for pain. She replied yes. On 3/2/2022 at 12:45 p.m. in an interview with the Director of Nursing (DON), she was asked if she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 16 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few knew why Resident #41's Norco 3/325 mg order was no longer in effect. Upon reviewing his record, she stated, It looks like it was re-ordered, but I don't know if the doctor sent in the hard script. That medication needs a hard copy sent in. I'll go check with his Nurse Practitioner right now and see what's going on with it. A review of Resident #41's medical record revealed he was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty walking, osteoarthitis, and pain in the right knee. A review of his current/active physician's orders revealed the following: 2/25/2022: Lidoderm patch 5%: apply one patch to right knee at bedtime for right knee pain. Apply one patch topically, on every pm (evening), off every am (morning). 1/24/2022: Norco 3-325 mg: give one tablet by mouth every 12 hours as needed for moderate pain for 30 days. 1/4/2022: Mobic 15 mg: give one tablet by mouth daily related to right knee pain. 12/3/2021: NWB RLE (non weight bearing right lower extremity) 12/1/2021: Ortho (orthopedic) consult: right knee edema, history: septic joint 10/18/2021: PT clarification: Pt (patient) to be seen 5 times a week for 12 weeks. 10/16/2021: PT eval and treat as indicated 10/16/2021: OT eval and treat as indicated A review of the Minimum Data Set (MDS) assessment, dated 12/29/2021, revealed a pain assessment showing the resident was coded as receiving scheduled pain medication as well as as needed (PRN) pain medication and non-medicinal pain interventions. The assessment further showed a pain assessment interview was conducted with the resident in which the resident answered yes to Have you had any pain or hurting in the past 5 days? His stated frequency was frequently. The assessment asked the resident to rate his pain on a scale of 0-10, to which he replied 6. A review of the person-centered care plan for showed a focus area of Right Knee Pain noted on 12/2/2021. Goal: The resident will have minimal interruption in normal activities due to pain through the review date (target date: 4/4/22) Interventions: Administer analgesics as per orders. Respond immediately to any complaint of pain. A review of the February 2022 electronic medication administration record (eMAR) revealed an order started on 1/24/2022 for Norco Tablet 5/325 mg: give one tablet by mouth every 12 hours as needed for moderate pain for 30 days. The record showed the resident received this medication 15 times during the month of February 2022 for pain levels ranging from 3 to 8 on a scale of 0-10. The eMAR was observed to have had this order end on 2/23/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 17 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Every Shift Pain Assessment for February 2022, showed a pain level of 5 on 2/26/2022 on the day shift. Further review revealed a pain level of 5 recorded at 5:00 p.m. on both 2/26/2022 and 2/27/2022. A review of a progress note with an encounter date of 2/16/2022, written by the attending physician, revealed, Patient is seen for management and evaluation of pain. Nurse is requesting refill of Norco 5/325 mg every 12 hours PRN (as needed) for moderate pain. Further review of this documented encounter revealed a review of E-FORCSE (e-forcse is reviewed in order to determine the risk factor and also to verify the date of the last refill of the narcotic/controlled medication in question.) The encounter showed an e-forcse score of 220, last refill 2/3/2022, 7 days, prescribe refill as requested. A review of the facility's policy titled Pain Management Guideline (effective 11/30/2014, revised 8/28/2017) revealed: The center strives to improve resident comfort and minimize pain in order to help a resident attain or maintain his or her highest practicable level of well being. The policy purpose stated: To ensure residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 18 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews, medical record review, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments for two (Residents #39 and #94) residents reviewed from a total sample of 46 residents. A facility is required to secure all medications in a locked storage area and to limit access to authorized personnel consistent with state and federal requirements and professional standards of practice. The findings include: On 2/27/2022 at 3:40 p.m., Resident #39 was observed in her room, sitting up in her wheelchair. A bottle of Artificial Tears (expiration date 10/2022) and a bottle of Clear Eyes eye drops (expiration date 1/2024) were observed on her bedside table. She was asked if they were her eyedrops. She stated, Yes, they are mine. I use them in the morning. On 2/27/2022 at 3:55 p.m., Resident#94 was observed lying in his bed. A bottle of Systane eye drops (expiration date 2/2022) was observed on top of his bedside table. The resident was unable to articulate if he was aware that the eye drops were on his bedside table, or why, when asked. On 2/28/2022 at 10:45 a.m., Artificial Tears and Clear Eyes eye drops were observed on the bedside table of Resident #39. On 2/28/2022 at 11:00 a.m., Systane eye drops were observed on the bedside table of Resident #94. On 3/1/2022 at 9:20 a.m., Artificial Tears and Clear Eyes eye drops were observed on the bedside table of Resident #39. On 3/1/2022 at 9:30 a.m., Systane eye drops were observed on the bedside table of Resident #94. On 3/2/2022 at 9:45 a.m., Resident #39 was observed in her room, dressed for the day and sitting up in her wheelchair. Clear Eyes eye drops were observed on her bedside table. Resident #39 was asked if those were her eyedrops. She stated, Yes, these are the ones I use. She was asked if the nurse put them in her eyes for her or if she instilled them herself. She stated, Sometimes me, sometimes the nurse. She was asked if the nurse provided the vial of Clear Eyes for her. She stated, No, I buy these in case they run out, so I know I'll have them. She was asked if staff were aware that she had her own supply in her room. She stated, Well yes, they're right here on my table, and they'll put them in my eyes for me sometimes. On 3/2/2022 at 10:00 a.m. in an interview with Registered Nurse (RN) E, she was asked if Resident #39 had an order for eye drops. She stated yes and brought the resident's name up on the medication adminstration page of her medication cart computer. She stated, She [Resident #39] has the order for for Refresh Tears, here. She was asked if she had administered the Refresh Tears this morning. She stated, Yes, I did. She was asked to pull the eye drops from her medication cart. She stated, I don't have them in my cart. She [Resident #39] has her own in her room. She was asked if she administered the resident's eye drops with a vial that was in the resident's room. She stated yes. She was asked if she left the vial in the resident's room. She stated yes. She was asked if the resident had an order to store medications in her room. RN E stated, I don't know. She was asked if it was okay to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 19 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few leave eye drops in the resident's room if she did not have an order to keep them in her room. She stated, Yes, it's ok. On 3/2/2022 at 11:15 a.m. in an interview with RN E, she was asked if Resident #94 had an order for eye drops. She looked up his orders and stated, Yes, he has the artificial tears as needed and he has the Systane ordered three times a day. She was asked if she had instilled his eye drops this morning. She stated, No, I went in his room and he said no. He said he didn't want them now, and he'd tell me when he wanted them. She was asked if his eye drops were in her medication cart. She stated, No, they are in his room on his side table. She was asked which eye drops were in his room. She stated, This one, the Systane (pointing at order on medication cart laptop). She was asked if he had an order to keep medications in his room. She stated, I don't know, proceeded to look up his physician's orders and then replied, No, he doesn't. She was asked if it was okay to leave his eye drops in his room without an order to keep his medications in his room. She stated Yes. A review of Resident #94's medical record revealed no physician's order for self-administration of any medications. Further review showed the Systane eye drops signed off as having been administered by nursing on 3/1/2022 at 9:00 a.m., 1:00 p.m., and 5:00 p.m., and on 3/2/2022 at 9:00 a.m. and 1:00 p.m. A review of Resident #39's medical record revealed no physician's order for self-administration of any medications. Further review showed the Refresh Tears solution signed off as having been administered by nursing on 3/1/2022 at 9:00 a.m. and 5:00 p.m., and on 3/2/2022 at 9:00 a.m. and 5:00 p.m. A review of the facility's policy and procedure titled Administering Medications (revised April 2019) revealed: Policy Interpretation and Implementation #27: Resident may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the facility's policy and procedure titled Self Administering of Medications at Bedside (effective 11/30/2014, revised 8/22/2017) revealed: Policy: The resident may request to keep medications at bedside for self-administration in accordance with resident rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. Procedure: The MAR (medication administration record) must identify meds (medications) that are self-administered and the medication nurse will need to follow-up with the resident as to documentation and storage of the medication during each med pass. If kept at bedside, medication must be kept in a locked drawer. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 20 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to 1) Ensure wet nesting did not occur, 2) Maintain safe food temperatures, 3) Label and date food items in the [NAME] Wing nourishment room refrigerator/freezer, 4) Dispose of outdated and unlabeled/undated foods items properly, 5) Maintain thermometers in the East and [NAME] Wing nourishment room freezers, 6) Ensure hot water was available in the kitchen handwashing sinks, and 7) Ensure the kitchen trashcan pedal, which opened the trashcan lid, was functional. These failures had the potential to negatively impact all residents who received food from the facility kitchen and nourishment rooms. The findings include: An observation of the kitchen was made on 2/27/2022 at 3:25 p.m. Neither of the two hand washing stations had hot water. The trash can foot pedal was not working at the hand washing station nearest to the kitchen entrance. At 3:45 p.m., a dietary aide was observed putting ice in a bin filled with milk and drinks for dinner service with a dinner start time of 4:45 p.m. The dinner start time was confirmed by the cook. On 3/1/2022 at 11:41 a.m., an observation was made of the kitchen. The Certified Dietary Manager (CDM) was on the tray line with two other employees who were observed wearing face masks under their noses. Wet nesting of plastic domes was observed. The CDM was asked about them and reported, They don't have enough time to dry because its too humid in kitchen. At 11: 45 p.m., two different thermometers in the walk-in refrigerator were observed; one at 40 °F and one at 45 °F. At the time of the observation, [NAME] Q was asked to check the temperature of a random milk carton. The temperature was 43 °F. Due to the high temperature reading, [NAME] Q was asked to pull another milk carton to check for temperature. It was also higher than the 40°F maximum. The District Dietary Manager (DDM), who was present at the time, reported having just received a milk delivery and stated that was the reason for the high temperature of the milk cartons. A copy of the milk delivery slip with a time stamp was requested, but it was never received. On 3/1/2022 at 12:17 p.m., an observation was made of the beverage cart on the 500 Hall. A metal container of milk cartons was observed. The DDM was asked to bring a thermometer to the floor to check the milk cartons for temperature. The temperature of one of the milk cartons was 45 °F. The DDM was asked what temperature the milk should be. He stated, I don't know, 45 °F? He was asked to pull another milk carton from the metal container. The temperature was 40 °F. The ice in the metal milk container was nearly completely melted at the time of food delivery. The DDM took the container of milk back to the kitchen and stated he would get new milk. At 12:20 p.m., the CDM was asked to come to the floor. She was asked to test the temperature of the milk cartons on a different beverage cart on other side of the 500 Hall. The temperature of the milk in that cart was 43 °F. The CDM was asked what temperature the milk should be. She stated, less than 40 degrees, but no more than 40 °F when served. She stated, We didn't put enough ice in the beverage bath. When she was asked about the milk on other halls, the CDM stated, We will pull them. Kitchen staff puts drinks out early and the ice melts. The 500 Hall is the last hall served. The beverage carts for the other halls had already been distributed and beverages on them had been pulled for use by this time. On 3/2/2022 at 3:10 p.m., another observation was made of the two kitchen hand sinks. Neither had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 21 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hot water and the pedal on the trash can was still not working. Another observation was made of wet nesting of plastic serving platters. (Photographic evidence obtained) [NAME] Q entered the kitchen two times without a mask during this time. The CDM was interviewed at 3:15 p.m. on 3/2/2022 and was asked about the lack of hot water at the hand washing sinks. She stated, Yes, there should be hot water. She stated she had spoken with Maintenance but didn't know why there was no hot water. On 3/3/2022 at 4:00 p.m., the Maintenance Director was interviewed and reported the hand-washing sinks had been without hot water for at least two months. He stated he expected a needed replacement in a couple of days and the sinks were expected to be repaired soon. On 3/3/2022 at 9:56 a.m., an observation of the [NAME] Wing nourishment room was made. There was no thermometer in the freezer. Although there was no thermometer, a temperature had been logged for both the refrigerator and freezer areas. The date on refrigerator/freezer temperature log was observed as being incomplete and unclear. The log appeared to be for February 2022. The March 2022 log appeared to be missing. The freezer was observed with several food items in it. One item was apple slices with a use by date of 12/2021. (Photographic evidence obtained) Other food items were observed in bags with names on them, but not all of the bags were dated. (Photographic evidence obtained) The refrigerator contained a box of what appeared to be fried chicken with no date or name on it. Additionally, a bag of fast food items with no name or room number was observed in the freezer, as was a container of yogurt with an expiration date of 2/27/2022. The freezer also contained an undated, green plastic bag with what appeared to be takeout food inside, and an unsealed plastic bag containing cheese was observed with a hand-written date of 1/25/2022. An interview was conducted with Registered Nurse (RN) A on 3/3/2022 at 10:30 a.m. He reported that the night nurses (7:00 p.m. through 7:00 a.m. shift) checked the refrigerator/freezer temperatures in the nourishment rooms. He reported that they also checked the food items and after two days threw them away. An interview with the Director of Nursing (DON) was conducted on 3/3/2022 10:35 a.m. She reported that the night nurses were responsible for the nourishment rooms, disposing of expired foods, and ensuring the refrigerator/freezer temperatures were accurate. The Unit Manager was expected to follow up. The DON was asked for the thermometer for the East Wing nourishment room at this time. She stated she didn't see one and would get one. Certified Nursing Assistant (CNA) Z was interviewed on 3/3/2022 at 10:49 a.m. She reported that as far as she knew, the CNAs had no nourishment room duties. An interview with Licensed Practical Nurse (LPN)/Unit Manager N, was conducted on 3/3/2022 at 11:08 a.m. She reported that both night shift nurses should be checking the temperatures in nourishment room refrigerator as it was a group effort. The food in the refrigerator should be discarded within three days. When asked if there should be two thermometers, one in the refrigerator and another in the freezer, LPN N replied, yes, there should be. The facility policy titled Safe Handling for Foods from Visitors (HCSG Policy 031, effective 9/2017) stated, Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 22 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 * Equipped with thermometers Level of Harm - Minimal harm or potential for actual harm * Have temperature monitored daily for refrigeration of less than or equal to 41 degrees Fahrenheit and freezer of less than or equal to 10 degrees Fahrenheit Residents Affected - Many * Daily monitoring for refrigerated storage duration and discard any food items that have been stored for 7 or more days When food items are intended for later consumption, the responsible facility staff member will: * Ensure that foods are in a sealed container to prevent cross contamination * Label foods with the resident name and the current date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 23 of 24 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Grand Oaks 3001 Palm Coast Parkway SE Palm Coast, FL 32137 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and facility policy review, the facility failed to dispose of garbage and refuse properly. Residents Affected - Few The findings include: An observation of the dumpster was made on 3/2/2022 at 3:30 p.m. The dumpster was behind a locked gate. It was observed with strips of cloth plugging the corner where a dumpster drain plug should be. The cloth strips were soiled and covered with insects. (Photographic evidence obtained) Outside of the dumpster, there were several pieces of trash, including a plastic cup, a chip bag, a large, clear plastic bag, an old tray cart, and plastic shelving. (Photographic evidence obtained) The Certified Dietary Manager (CDM) was interviewed at the time of the observation and reported that she had swept last Friday. She was asked why there was a cloth plug in the dumpster and she stated she did not know. She further stated she did not know why it was the dietary department's responsibility to maintain the dumpster area. She addressed a maintenance staff member about the condition of the dumpster/dumpster area during the walk back to the facility's kitchen. A review of the facility's policy titled Environment (HCSG Policy 028 - effective 9/2017), revealed: * All trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 24 of 24