Inspection·February 8, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm report physical plant areas or equipment in need of repair or service to their supervisor. All items needing maintenance assistance would be reported to Maintenance. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 2 of 9 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 02/08/2024 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record reviews and staff interviews, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every three months for three (Residents #11, #68, and #226) of three residents reviewed, from 34 residents in the total sample. Failure to complete resident minimum data set (MDS) assessments could result in a failure to provide needed care, contributing to residents' inability to maintain their highest practicable physical, mental, and psychosocial well-being. Residents Affected - Few The findings include: A review of the medical record for Resident #11 revealed that the required quarterly assessment, due by 12/10/2023, was not documented as having been completed. A review of the medical record for Resident #68 revealed that the required quarterly assessment, due by 12/7/2023, was not documented as having been completed. A review of the medical record for Resident #226 revealed that the required quarterly assessment, due by 12/10/2023, was not documented as having been completed. During an interview with the Regional Director on 02/08/2024 at 10:43 AM, she confirmed that the required quarterly assessments for Residents #11, #68, and #226 were not completed by the facility. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 3 of 9 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 02/08/2024 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, record review, interviews, and a review of the facility's Oxygen Therapy policy and procedure, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for one (Resident #54) of one resident reviewed for oxygen therapy from a total of 34 residents in the sample. Residents Affected - Few The findings include: An observation and interview was conducted with Resident #54 in her room on 2/5/24 at 11:00 a.m. She reported that her oxygen flow rate was set at 2 liters per minute via nasal cannula. The oxygen flow rate was observed to be set at 2.5 liters per minute. A review of the resident's medical record revealed a re-entry to the facility on 1/5/24 with diagnoses that included acute and chronic respiratory failure, emphysema, congestive heart failure and atrial fibrillation. The resident's active physician's orders were reviewed which noted: Respiratory: oxygen at 2 liters via nasal cannula continuous. The care plan was reviewed, which was updated on 1/25/24. Resident has oxygen therapy related to respiratory illness and receives oxygen via nasal prongs at 2 liters per minute. An observation was made in the resident's room on 2/6/24 at 11:55 a.m. The oxygen flow rate on the oxygen concentrator was set at 2.5 liters per minute. An observation was conducted in the resident's room on 2/7/24 at 8:55 a.m. The oxygen flow rate was set at 2.5 liters per minute. An observation was conducted in the resident's room on 2/7/24 at 4:34 p.m. The oxygen flow rate was set at 2.5 liters per minute. An interview was conducted with Registered Nurse (RN) A at 4:35 p.m. on 2/7/24. She was asked what Resident #54's oxygen flow rate should be per the physician's order, and she replied 2 liters per minute. She was accompanied to the resident's room to observe the oxygen concentrator and flow rate setting. She confirmed that the oxygen was not set at 2 liters per minute as ordered. A review of the policy and procedure for Oxygen Therapy (revised 8/28/17), noted under procedure to review the physician's order and start the oxygen flow rate at the prescribed liter for the administration device. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 4 of 9 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 02/08/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, medical record review, and a review of facility policies and procedures, the facility failed to maintain and implement its infection control program to prevent the development and transmission of communicable diseases and infections, when three employees (Employees C, E, and F) were observed failing to use personal protective equipment (PPE) in transmission base precaution (TBP)/isolation rooms. Supplies for hand hygiene were not provided in the soiled utility room, PPE was not readily available and convenient to the staff for use in TBP rooms, and employees failed to perform hand hygiene when leaving a TBP room. Failure to follow infection control protocols and procedures could leave vulnerable nursing home residents at risk of contracting infections that could be detrimental to their health. Residents Affected - Few The findings include: On 02/05/2024 at 10:25 AM, Certified Nursing Assistant (CNA) C was observed donning PPE appropriately. He then entered room [ROOM NUMBER] to deliver a cup of tea to Resident #171who was under TBP. He donned a gown, an N95 respirator mask, a face shield and disposable gloves. After putting the cup on the tray table, he came out of the room and proceeded to doff the PPE. He stepped into the hallway to doff the PPE. When asked if there was a trash can in the resident's room, he stated Yes, but it did not have a garbage bag in it. He called out to the CNA in the room across the hall to have her bring him a trash bag. After she did, he took the bag and put his PPE in it with his bare hands. He then took the trash can inside the resident's room and put all of the trash (several PPE gowns, gloves, etc.) into the bag. He then put a new trash bag in the can and placed the can back in the room. He tied up the trash bag and set it on the floor. At that point, a CNA came to the room with Resident #171's meal tray and asked CNA C if he could deliver the tray to the resident. He took the tray and went back into the room without donning PPE. He put the tray down on the tray table and spoke to the resident briefly, then walked back out of the room. He then picked up the trash bag on the floor in the hallway and walked down to the soiled utility room approximately 60 feet from the resident's room. He open the door with his bare hand and walked in. He disposed of the bag of trash (including used PPE items) and proceeded to walk out of the soiled utility room. When asked if he washed his hands with soap and water in the soiled utility room, he stated he did not because there were no paper towels in the dispenser. The soiled utility room was then observed and no paper towels were available at the handwashing sink. CNA C stated he was not supposed to wash his hands in the resident's restroom prior to leaving the TBP room. He then walked away back to his assigned area. He did not perform hand hygiene. During an interview with Registered Nurse (RN)/Unit Manager (UM) D on 02/05/2024 at 11:17 AM, she stated Resident #171 was due to be taken off of TBP on 02/08/2024. She confirmed that Resident #171 was on isolation precautions. During an interview with Resident #171 on 02/05/2024 at 3:46 PM, she stated the staff tested her yesterday (Sunday 02/04/2024) to determine whether she still needed to be on isolation precautions. She was not sure if the staff were wearing appropriate PPE when they entered her room. She confirmed that they were not using her restroom to wash their hands prior to leaving her room. On 02/07/2024 at 11:55 AM, CNA E was observed donning PPE appropriately, then entering TBP room [ROOM NUMBER] with a meal tray for Resident #171. When she exited the room, she did not wash her hands with soap and water in the restroom. She came out and used hand sanitizer she had in her pocket. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 5 of 9 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 02/08/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then went across the hall and donned new PPE appropriately and took the meal tray into TBP room [ROOM NUMBER]. After she left room [ROOM NUMBER], she did not wash her hands in the restroom with soap and water or use hand sanitizer. She walked down the hallway to her next task. On 02/07/2024 at 12:29 PM, CNA F was observed coming out of room [ROOM NUMBER], the TBP room for Resident #171. She was not wearing PPE. The storage bin in the hallway outside the room did not have any PPE gowns in the drawer. During an interview with CNA F on 02/07/2024 at 12:38 PM, she confirmed that she did not wear PPE in TBP room [ROOM NUMBER]. She stated she was supposed to wear the PPE when she went into an isolation room. She was supposed to wear the appropriate PPE that was on the signage posted on the outside of the door to the room. She did not know why there was no PPE in the bin outside of the door. She did not know who was responsible for refilling it. She did not go to obtain more PPE to refill the bin. During an interview with CNA J on 02/07/2024 at 1:11 PM, he stated there should be caution signs on the door if the room was a TBP room. The staff member entering the room should have all PPE on before he/she entered the room. He stated he thought the blue gowns were reusable and could be hung up inside the resident's room to be worn again. Staff were trained to use the resident's restroom to wash their hands prior to leaving the room. They were supposed to wash their hands using soap and water. If there were soiled linens to drop off, he delivered them to the soiled utility room and washed his hands again prior to leaving the soiled utility room. He stated it was not acceptable to use hand sanitizer only. During an interview with CNA G on 02/07/2024 at 2:00 PM, she stated they (CNAs) had been trained to wash their hands with soap and water after they left an isolation room. Hand sanitizer gel alone was not acceptable. During an interview with CNA E on 02/07/2024 at 2:08 PM, she had just exited TBP room [ROOM NUMBER]. She had been providing direct incontinence care for Resident #178. She stated she was supposed to wash her hands with soap and water before exiting an isolation room. Hand sanitizer gel was not enough. During an interview with the Director of Nursing (DON) on 02/08/2024 at 2:55 PM, she stated it was not acceptable for the staff to walk through the hall to the soiled utility room after leaving a TBP room before performing hand hygiene. During an interview with the Administrator on 02/08/2024 at 3:00 PM, she stated staff should wash their hands prior to leaving an isolation room. They were to use the facilities in the resident's bathroom. Walking from the isolation room to the soiled utility room to wash their hands was not acceptable. Hand sanitizer alone was not acceptable. She confirmed that all required PPE should be donned prior to entering an isolation room. She was unaware that the PPE bins were empty and needed refilling. A review of Resident #171's physician's order, dated 02/02/2024, confirmed that she should be on isolation. (Copy obtained) A review of Resident #178's physician's order, dated 02/06/2024, confirmed that he should be on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 6 of 9 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 02/08/2024 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 0880 isolation. (Copy obtained) Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled Handwashing/Hand Hygiene (revised 08/2019), revealed: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 3. Hand hygiene products and supplies (sinks, soaps, towels, alcohol-base hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled and b. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. Difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; before donning sterile gloves; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after removing gloves; before and after entering isolation precautions settings; before and after assisting a resident with meals. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: c. when in contact with a resident or the equipment or environment of a resident who is on contact precautions. Equipment and Supplies: 1. The following equipment and supplies are necessary for hand hygiene: b. running water, c. soap, d. paper towels, g. sterile gloves. (Copy obtained) Residents Affected - Few A review of the facility's policy and procedure titled Isolation - Initiating Transmission-Based Precautions (revised 08/2019), revealed: 3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): e. Ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. G. Ensures that an appropriate linen/barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room (Copy obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 7 of 9 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 02/08/2024 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy and procedure review, the facility failed to equip corridors with firmly secured and intact handrails. The facility staff failed to report/service the handrails outside of resident rooms #205 and #511, handrails next to the clean utility linen closet located on the 200 hallways, and handrails located around the 400 hallways' nursing station. Handrails in these locations were observed with jagged ends and sharp edges, posing a risk of injury to residents, staff and other building occupants. Daily facility rounds are important to ensure handrails are firmly secured and in good condition to prevent resident injury. Residents Affected - Some The findings include: On 02/05/2024 at 1:10 PM, an observation was made of the handrails located outside of rooms #205 and #511, which were missing end caps. (Photographic evidence obtained) An interview was conducted with Certified Nursing Assistant (CNA) J on 02/07/2024 at 1:05 PM. He stated residents usually reported maintenance requests to the first staff member they saw. Any staff member could report maintenance requests either verbally to someone in the maintenance department or electronically in the TELS system (electronic building management platform). A tour and an interview were conducted with the Maintenance Director on 02/08/2024 at 12:07 PM. During the tour, three handrail end caps were observed missing on the 200 hallways, two handrail end caps were observed missing around the nursing station on the 400 hallways, and one handrail end cap was missing outside of room [ROOM NUMBER]. The Maintenance Director confirmed the end caps were missing and stated he was not aware of this issue. He stated maintenance requests were reported in the TELS system and that it was his to-do list daily. There was a new maintenance department assistant expected to start at the facility soon. The Maintenance Director stated again that he took care of all requests received the same day. Staff reported maintenance requests to him in person or he received maintenance requests from TELS. An interview was conducted with Registered Nurse (RN)/Unit Manager (UM) D on 02/08/2024 at 12:31 PM. She stated, There is a system called TELS. You log in and report the issue or concern. You can also report to him (Maintenance Director) verbally. The Maintenance Director repairs things the same day. CNAs and nurses report verbally or in TELS. Maintenance requests reported included pest sightings, broken equipment, non-working lights, stopped-up toilets, or anything that needed repair. An interview was conducted with the Administrator on 02/08/2024 at 12:45 PM. She stated there was no capital improvement plan but she had been replacing equipment and items as needed. On 02/08/2024 at 4:08 PM, another observation was made of missing end caps on handrails located outside of rooms #205 and #511. Missing end caps were also observed on the handrails next to the clean utility linen closet located on the 200 hallways and around the 400 hallways' nursing station. (Photographic evidence obtained) A review of the facility's policy and procedure titled Maintenance (effective 11/30/2014), revealed: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will follow all policies regarding routine periodic maintenance. The Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 8 of 9 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 02/08/2024 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 0924 Level of Harm - Minimal harm or potential for actual harm Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor . (Copy obtained) . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 9 of 9