Inspection·May 8, 2025

F 0645 then they determined whether or not a Level II PASRR was required. Level of Harm - Minimal harm or potential for actual harm 3. A review of the medical record revealed that Resident #42 was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder, persistent mood disorder, anxiety disorder, psychosis and dementia. Residents Affected - Some A review of the resident's active physician's orders revealed the following orders: Depakote 125 milligrams (mg), give 2 capsules two times a day (BID) for mood disorder (3/28/25). Trazadone 50 mg, give half a tablet for major depressive disorder (4/14/25). Alprazolam 0.25 mg for anxiety (4/25/25). A review of the resident's Level I PASRR, dated 2/5/24, revealed that Section I had the following diagnoses checked off: Depression and anxiety. Under Section II #3 b. Concentration, persistence and pace: The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks was marked Yes. Section IV of the PASRR screen completion indicated that the resident was admitted to the facility with serious mental illness. During a 5/7/25 interview with the Care Liaison at 3:54 p.m., he stated he had been employed by the facility for a year and half. He stated he reviewed the PASRRs upon residents' admissions to ensure that they did not trigger for a PASRR Level 2 and to ensure that all PASRRs were completed. If there were concerns with PASRRs, he notified the clinical team. He stated when a resident experienced a change while at the facility, the clinical team reviewed the PASRR and updated it accordingly. During a 5/7/25 interview with the Director of Nursing (DON) at 4:13 p.m., she stated PASRRs were reviewed the next business day following a resident's admission during the clinical meeting and as needed if a resident had a change in diagnoses or behaviors that might trigger a Level II PASRR. When asked if there was a protocol/process in place to review (and revise asneeded) current residents' PASRRs for accuracy, she replied that when she started working at the facility, the corporate team and the social worker reviewed the PASRRs for all residents in the facility. She was then asked to provide the PASRRs for the residents identified with concerns. On 5/8/25 at 10:17 a.m., the regional director of social services stated during her audit, she identified concerns with the PASRRs and was working out a process to review all PASRRs. She confirmed that the PASRRs for Residents #21,#32, #89 and #42 were inaccurate. A review of the facility's policy and procedure titled Preadmission Screening and Resident Review (PASRR) Document Name: SS-402 Revision Date: 11/08/2021 Original Date: 11/08/2021, revealed: Policy: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 2 of 5 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 05/08/2025 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 Level of Harm - Minimal harm or potential for actual harm The Center will assure that all Serious Mentally III (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: Residents Affected - Some 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 2. If an individual is declared exempt from a PASRR screening, the Center should make sure that appropriate documentation is on the chart upon admission. Individuals who are exempted from this assessment include: a. Those who are admitted after a release from an acute care hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery. b. Those who are certified by a physician as to be terminally ill with a 6-month prognosis, and are not a danger to self or others. c.Those who are comatose, ventilator dependent, functions at significantly disabling Parkinson's Disease, Huntington's Disease, Amyotrophic Lateral Sclerosis, CHF or COPD. d.Those with a diagnosis of dementia or its related disorders with detailed documentation supporting this diagnosis. 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. 6. Recommendations will be incorporated in the individual resident's plan of care and approaches/interventions developed to meet the identified needs of the individual. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 3 of 5 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 05/08/2025 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 Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system for its current census of 103 residents. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. Residents Affected - Many Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. The findings include: An interview was conducted on 5/07/25 at 2:39 p.m. with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated she had been in this position for ten (10) months. She further stated Maintenance was responsible for the facility's water management program. She provided a policy on Legionella along with education that was provided to the nursing department staff. An interview was conducted on 5/8/25 at 1:20 p.m. with Employee A, Regional Plant Operations. He stated the Legionella policy that the ADON/IP provided was only for the clinical side. He stated the Water Management policy was what was needed for the facility's Infection Control (IC). He was asked about the facility's measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility's water system, as well as a way to monitor the measures they had in place and established ways to intervene when control limits were not met. He stated there were no logs or measures. He stated they would test if there was a suspected concern. He then contacted Employee B by telephone (speaker), who he identified as the facility's Infection Control Plant Supervisor. Employee B immediately stated there was no requirement for the facility to test water temperatures. He stated there was nothing in the American Society of Heating and Air-Conditioning Engineers (ASHRAE) nationally accepted standards that stated it had to be done. He was asked for evidence that the facility was doing/monitoring what was outlined in their policy and procedure titled Water Management Program Document Name: S-314 effective 9/18/2018, Revision Date: 2/23/2020. He was asked how the facility monitored the measures they had in place and established ways to intervene when control limits were not met. Employee B confirmed there were no tests. He again stated this was not an ASHRAE requirement. Employee A also confirmed that there was no evidence of control measures i.e., visible inspections, disinfectants, temperature controls, etc. A review of the facility's policy and procedure titled Water Management Program Document Name: S-314 effective 9/18/2018, Revision Date: 2/23/2020, revealed the following: Procedures included: B.) Assess potential problems before they endanger the domestic water supply system through a preventive maintenance process (TELS). TELS preventive maintenance program consists of the following items designed to maintain the domestic water system: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 4 of 5 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 05/08/2025 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 1. Daily temperature checks for hot water in the resident care areas, kitchen, and laundry areas. Level of Harm - Minimal harm or potential for actual harm 2. Routine preventive maintenance of all mixing values used to provide proper hot water temperature used within the facility. Residents Affected - Many 3. Routine operational checks for all water circulation pumps used to provide water throughout the facility. 4. Routine preventive maintenance for cleaning of A/C drain lines and condensation pans to ensure they remain clean. 5. Routine maintenance on all roof drains including any pitch pans. 6. Routine maintenance on all facility installed drinking fountains. Fountains are to be disinfected daily by housekeeping services. 7. Routine maintenance of domestic in-line water filters, water softener systems, including ice machine filters. 8. Routine maintenance of any decorative water fountain, including proper chlorination of the water supply. 9. Routine maintenance of all wells supplying domestic water to a facility. 10. Routine maintenance of any facility that utilizes a cooling tower to generate HVAC within a facility. D.) Establish water safety control limits (ex. temperature and disinfectant levels) and where control limits should be applied. Develop responses and ways to intervene when measurements are outside the established limits. The following NSPIRE policies or protocols apply: a. Safety and Facilities Management Hot Water Temperature Policy b. Dietary Policy for disinfection of three-compartment sinks c. Housekeeping disinfection policy for water fountains d. Housekeeping policies for disinfecting shower rooms, including tubs and showers e. Testing of decorative water fountains for water chlorine levels as required f. Notifying management whenever any of the control limits fall outside the parameters of safe operating conditions. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105952 If continuation sheet Page 5 of 5