Health inspection·May 19, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm at 3:19 PM by RN A, stating, Resident in wheelchair sitting in dining room in pleasant mood. Another resident slapped resident on right cheek. Resident able to voice concerns, no complaints of pain. No noted bruising to right cheek, just red. Notified family and MD. Both residents, #76 (victim) and #45 (perpetrator) reside in the locked Memory Care Unit. Residents Affected - Few A review of submitted abuse reports failed to reveal a submitted report for this incident. On 05/16/2023 at 2:11 PM, an interview was conducted with RN A regarding this incident. RN A was asked about the policy for reporting abuse when one resident assaults another resident. RN A indicated administration is contacted immediately and the facility has two hours to report the incident. The nurses are responsible for gathering the witness statements and submitting statements to administration and the director of the particular unit. RN A did recall the event that occurred on 01/25/2023. She indicated the resident to resident abuse took place in the small dining area. She stated both residents involved were placed on change of condition (COC) for 72 hours and kept apart. RN A was asked if there have been any other incidents involving resident to resident abuse for resident #45 (perpetrator), and she stated there were none not that she could recall. On 05/16/2023 at 1:15 PM, an interview was conducted with the Social Worker regarding the incident. The Social Worker was asked if resident to resident abuse is reportable. She indicated a resident placing hands on another resident is reportable. On 05/16/2023 at 1:55 PM, an interview was conducted with Certified Nursing Assistant (CNA) C regarding the appropriate staff response to resident to resident abuse. The CNA was asked what steps are taken when abuse occurs or is alleged to have occurred between two residents. The CNA indicated the residents are separated immediately, the nurse is notified for further investigation, and witness statements are gathered for investigation. On 05/16/2023 at 3:30 PM, an interview was conducted with the Administrator. The Administrator was asked about the abuse incident occurring on 01/25/2023. He stated the abuse was not reported to administration, therefore, there was no report made. He stated he was told by nursing staff that the nurses and CNAs were unsure whether the abuse even occurred. The Administrator stated he will do a delayed report by tomorrow morning. On 05/17/2023 at 11:30 AM, a second interview was conducted with RN A. The nurse was asked about her documentation regarding the incident on 01/25/2023. RN A indicated that she did not mean to word the progress note as if she saw the abuse. She indicated she meant to communicate in the progress note that she was only reporting what the victim resident (Resident #76) told her. RN A indicated at that point she could not remember much about the incident since it was so long ago. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 2 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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** Resident #2 Residents Affected - Some On 5/15/23, a record review was conducted for Resident #2. The resident, admitted on [DATE], had diagnoses of major depressive disorder, general anxiety disorder and vascular dementia. The PASARR dated 9/18/20, did not list these diagnosis. The facility did not correct the PASARR upon admission and had not updated the form at the time of this survey. On 5/17/23 at approximately 3:49 PM, an interview was conducted with the DON who stated she does the PASARR if the resident comes from home or a hospice. If they come from the hospitals, they usually come in with a PASARR already completed. The DON stated that they always review to make sure the PASARRs are appropriate and completed and signed. The DON stated she doesn't know who was in charge of it back in 2020, so she can't say who missed it or why it was missed and verbally agreed the PASARR was not accurate and was missing the relevant diagnoses. Based on staff interview and record review, the facility failed to accurately complete the Level I Preadmission Screening and Resident Review (PASARR) forms, which resulted in the facility failing to complete appropriate Level II PASARR forms for residents with mental disorders and/or Intellectual Disabilities for 4 of 5 residents reviewed. (Residents #29, #2, #36, and #4) The findings include: Resident #29 A review was conducted of Resident #29's list of medical diagnoses. This list included Schizoaffective disorder (documented in the chart on 10/10/2022), Generalized Anxiety Disorder (documented in the chart on 10/10/2022), Major Depressive Disorder (documented in the chart on 10/10/2022) and Schizophrenia (documented in the chart on 1/18/2023). A review was conducted of the Psychiatrist's progress note for Resident #29's, dated 8/11/2022. The progress note listed Schizophrenia and Major Depressive Disorder as diagnoses at the time of the assessment. A review was conducted of Resident #29's level I PASARR, dated 10/7/2023. Under section one of the form, only Anxiety was checked as an applicable diagnosis. On 5/17/23 at 11:04 AM, the Director of Nursing (DON) was shown the above information and asked for clarification for the reason Schizophrenia and Depression were not included in section one of the PASARR form. The DON stated that she would look into it. On 5/17/23 at 11:09 AM, the DON returned and stated, It was an honest mistake. I am going to go put in a new one right now. Resident #4 A review was conducted of Resident #4's list of medical diagnoses. This list included Psychotic Disorder with Delusions due to known Physiological Condition (present on admission 9/08/2004), and Unspecified Dementia (present on admission 9/08/2004). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 3 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 Residents Affected - Some A review of Resident #4's PASARR dated 03/03/2015 revealed under Section II A of the form there is no diagnosis listed. On 5/17/23 at approximately 4:10 PM, an interview was conducted with the Director of Nursing (DON) concerning resident #4's PASARR. The DON agreed that the PASARR was not completed correctly and would redo the PASARR along with reviewing all PASARR's facility wide. Resident #36 A review of Resident #36 medical record revealed documented diagnoses on admission on [DATE] of Bipolar Disorder, Schizophrenia, Obsessive Compulsive Disorder, Major Depressive Disorder and Adjustment Disorder with Anxiety. The Level I PASARR for resident #36 only included the diagnosis of Depressive Disorder. On 5/18/2023, a review of the PASARR Policy was completed. Preadmission Screening and Resident Review, document name SS-402, dated 11/8/2021 and revised 11/8/2021. Under the procedure section, item #4 states, If it is learned after admission that a PASARR 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 4 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 observations, resident interviews, staff interviews, and record reviews, the facility failed to provide appropriate wound care and treatment for 1 of 1 residents sampled for non-pressure related skin conditions. (Resident #34) Residents Affected - Few The findings include: On 05/15/2023 at approximately 11:00 AM, an observation was made of a dressing to Resident #34's left forearm. The dressing was not dated, timed, or initialed. When the resident was asked what the dressing was for, she stated, this wound has been there for 5 days and has only been changed once, I bumped my arm on the wall. On 05/16/2023 at approximately 1:49 PM, a second observation was made of a dressing to Resident #34's left forearm with no date, time, or initials. The dressing appeared to be the same dressing noted on the prior observation and was stained and lifted on one side. The resident confirmed that it was the same dressing and it had not been changed. When asked if staff assessed the area or offered to change it, the resident stated, no. A review of resident #34's electronic medical record (EMR) revealed no current order for any wound treatment to the left forearm. There was an active order dated 04/19/2023 for weekly skin sweeps to be done on day-shift every Wednesday and Saturday. A review of Resident #34's TAR (Treatment Administration Record) for May 2023 showed that skin sweeps were documented as completed on 05/03/2023, 05/06/2023, 05/10/2023, 05/13/2023, and 05/17/2023. A review of the skin assessment conducted on 05/17/2023 at 12:44 PM per Registered Nurse A (RN A), revealed a documented skin tear to the left forearm and treatment in place. A review of the skin assessment on 05/13/2023 at 12:45 PM revealed a skin tear to the left forearm with treatment in place and that the skin was not intact. A review of resident #34's TAR showed that the resident did receive care for a wound to the left forearm that was started on 05/03/2023 and discontinued on 05/08/2023. No additional documentation was found in the MAR (Medication Administration Record) or elsewhere in the medical record regarding wound treatment after 05/08/2023. A review of resident #34's care plans revealed: Skin Inspections: The resident requires SKIN inspection as directed, Observe for redness, open areas, scratches, bruises, and report changes to the Nurse-04/21/2021. Potential/Actual impairment to skin r/t (related to) impaired mobility and incontinence: Encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of any injury. and Resident has a skin tear/potential for: Encourage good nutrition and hydration in order to promote healthier skin, if skin tear occurs treat per facility protocol and notify MD (medical doctor), family, keep skin clean and dry, monitor/document location, size and treatment of skin tear-report abnormalities- 03/29/2023. On 05/17/2023 at approximately 10:10 AM, Resident #34 was observed in her wheelchair in the hallway with the wound to her left forearm uncovered and open to air at this time. The wound was observed as a nickel sized skin tear to the left outer forearm, with a partial flap absent, and dark red in color. Resident #34 stated, I just got out of the shower, and I am going to get a dressing for my arm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 5 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 05/18/2023 at approximately 10:22 AM, an interview was conducted with RN A who was Resident #34's assigned nurse. When asked to explain the current treatment Resident #34 was receiving for the wound to her left forearm, she checked the TAR and the MAR (Medication Administration Record) and stated, I don't see an order, but there should be because she has a wound on her left forearm, but I did change it yesterday after she got out of the shower, I cleansed it with wound cleanser, I think it was because she had a shower and she came up to me and asked for a new bandage, applied hydrogel and a border gauze. I dated it, initialed it and timed it, matter of fact I've already done it again today because it fell off. RN A explained the process for discovery of a skin tear is to notify the doctor after the skin assessment, see what treatment needs to be ordered, and put the recommended orders into the computer and it will show on the MAR/TAR so that every nurse knows what needs to be done. RN A stated, I don't see that with Resident #34, we usually change the dressing every other day with skin tears, or more often, PRN (as needed) if they become loose, wet, or dirty. RN A agreed there was no current order for skin tear wound care or documentation of care provided. On 05/18/2023 at approximately 10:39 AM, an observation was made of Resident #34 with a dressing in place to left forearm, dated 05/17/2023, and initialed. Resident #34 stated, the nurse put a new dressing on it yesterday after I requested her to because it fell off while I was in the shower. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 6 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and policy review, the facility failed to provide 6 of 7 residents sampled with palatable meals and snacks that took resident preferences into consideration (Residents #49, #8, #63, #278, #26, and #34). The findings include: Resident #49: On 05/15/2023 at approximately 11:20 AM, an interview with conducted with Resident #49 who talked about concerns regarding poor food quality and preparation. Resident #49 stated, the milk has been served curdled, there aren't enough snacks for the residents, we have several diabetics without any juice on the hall, they don't keep the nutrition room stocked, if I ask one of the Certified Nursing Assistants (CNA) for it, they try to bring it if they have them, but they usually don't have any. The food is ill prepared, the meat is too tough to cut much less chew. Residents are receiving the wrong diets, one (identified Resident #46) even choked on her food because they gave her regular food instead of pureed, that happened just this last week. Staff had to do the Heimlich, this has happened before. They get orders mixed up, broccoli is mush and English peas are served with ice crystals. People are losing weight because they don't like the food, so they just won't eat at all. I am the food committee president and the vice president of resident council, so the residents tell me everything. I've made several grievances about this, and nothing is being done. On 05/16/2023 at approximately 2:00 PM, a follow-up interview was conducted with Resident #49 who stated, yesterday for supper I received a cheeseburger instead of the fish sandwich that I ordered. She reported that she told the District Dietary Manager (District DM F) today, he just shook his head and said that he will try to get this problem fixed. She went on to describe the food committee meeting from this morning stating that multiple managers were in attendance such as District DM F, the Dietary Cook, the Social Worker, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Activities Director. She is hopeful that things will improve and states, some of the solutions they proposed were to increase meetings to twice a month instead of once a month. Me as well as other residents expressed the good and the bad, we are supposed to be getting more fresh fruits, we told them that we are tired of always receiving the same old canned fruits. Also multiple residents requested salsa for taco day, this is something the previous Dietary Manager never let us have, even though we asked multiple times. A review of Resident #49's medical record showed a current order dated 03/24/2022 for Regular diet, Regular texture, Regular/Thin liquids consistency with instructions to give double portions with all meals. Resident #49 had a care plan with a target date of 06/02/2023 stating, Resident is independent with all self-directed activities with an intervention for food, snacks available. On 05/16/2023 at approximately 2:40 PM, an interview was conducted with the Social Worker (SW). The SW confirmed that she was aware of Resident #49's concerns with the food and Resident #49 has made many grievances in the past. The SW stated that she did attend the food committee meeting this morning. When asked if she received any concerns or complaints regarding food quality, preferences, lack of variety, the SW stated, oh yeah, I have a whole page over here that I have to type up from Resident #49. When asked if any other residents shared concerns during this meeting, the SW answered, yes, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 7 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm well, they more or less agreed with Resident #49, but did reiterate some of the same concerns . The SW confirmed Resident #49 was the food committee president. During an interview on 05/17/2023, District DM F stated that he is aware that Resident #49 did not receive the correct meal for dinner yesterday and confirmed that he spoke with Resident #49 earlier. Residents Affected - Some Resident #8 and #63 On 05/16/2023 at approximately 1:20 PM, while observing the lunch meal in the assisted dining room, it was noted that Resident #8's lunch plate did not include all items listed on the tray ticket. The meal ticket listed pureed bread and peas, neither of which were on the resident's plate. Resident #8 was served mashed potatoes, but this item was not on the meal ticket. At this time an interview was conducted with the Certified Nursing Assistant, Employee P (CNA P), who was assisting Resident #8 with lunch and she confirmed items were missing from the tray and stated, I didn't realize it until now. A record review of Resident #8 revealed that she has a current diet order dated 07/28/2020 for Dysphagia Puree texture, Regular/Thin Liquids consistency and a nosey cup with all meals. Resident #8's Quarterly MDS dated [DATE] showed the resident had total dependence when eating which required one person assist and was receiving a mechanically altered diet. On 05/16/2023 at approximately 1:15 PM, an observation was made of Resident #63 in the assisted dining room during lunch. Resident #63's lunch plate did not include all of the food items listed on the meal ticket. An interview was conducted during the observation with CNA Q, who was assisting Resident #63 with lunch. CNA Q confirmed that Resident #63 did not receive sweet potatoes or a peanut butter and jelly sandwich. CNA Q was asked who checks the meal to ensure that residents receive the correct diet including all items listed on the meal ticket. CNA Q replied, we usually do the final check. CNA Q was asked to describe what she does when something is incorrect on the resident's tray or if items were missing, and she responded, I mean I can go get it or let the nurse know but I usually don't worry about it because she (Resident #63) never eats all of her food anyway. CNA Q was then asked if she notified the nurse today of the missing items, and she replied, no, but I can. A record review for Resident #63 revealed she had a current diet order dated 05/10/2023 for Fortified Foods, Dysphagia Puree Texture, regular/thin liquid consistency. On 05/17/2023 at approximately 12:35 PM, an interview was conducted with Licensed Practical Nurse R (LPN R), who confirmed that she was present in the assisted dining room yesterday (05/16/2023) during lunch. LPN R explained that she was not present when the trays were initially served but other employees were in the room at that time. LPN R confirmed that the nurse is supposed to do a second check for tray accuracy prior to serving it to the resident. LPN R was asked if any reports were made to her yesterday of trays being inaccurate or items missing from the residents' trays and she stated, No, I was never notified by any CNA or other staff that diets were wrong or missing things. Resident #278: On 05/17/2023 at approximately 6:35 PM, an observation was made of the tray cart being delivered from the kitchen to the assisted dining area. During this observation, Staff K, a Unit Manager, was observed removing resident trays from the cart and lifting plate covers while looking at the meal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 8 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ticket on the tray. An observation of Resident #278's tray was made and compared to the resident's meal ticket. Resident #278's meal ticket revealed a diet order for Dysphagia Mechanically Altered and the items on the plate did not match the items listed on the ticket. The ticket listed ground smothered turkey patty with poultry gravy, pureed oven browned potatoes, pureed dinner roll/bread with margarine, pureed Vanilla glazed angel food cake, milk, tea, food in bowls. The plate was observed to include chopped dry fish (no sauce) served on a regular hamburger bun, (the bread was not pureed), and all food was on the plate, no bowls were present. Resident #278 received apple sauce instead of pureed cake. (Photographic Evidence was obtained) On 05/17/2023 at 6:38 PM, an interview was conducted with Unit Manager K, in which she confirmed she looked at the tray items and ticket and agreed that the resident did not receive the correct items as on the ticket and that he should have received ground turkey and it should have been served in bowls. When asked if it was safe for him to consume the meal he was served based on his diet ordered, Unit Manager K stated, I would say no because it's not listed on the ticket but I'm not sure, I could've sworn I looked at his ticket, I'm not supposed to be in here right now, the other nurse was still in the independent dining room so I came in here so there would at least be one nurse in here. A review of Resident #278's medical record revealed a current diet order dated 05/10/2023 for Dysphagia Mechanically Altered texture and regular/thin liquids consistency with directions to serve food in bowls. A review of the MDS (Minimum Data Set Assessment) 5-day PPS (prospective payment system) dated 05/14/2023 found in section G (Functional status) eating requires supervision with physical assistance by 1 person. Section K (Swallowing/Nutritional status) indicated that Resident #278 required both a mechanically altered diet and a therapeutic diet. Resident #26: On 05/15/2023 at approximately 11:45 AM, an interview was conducted with Resident #26. When asked about any concerns, Resident #26 stated, the food is not good, it's not seasoned and not cooked well, would like more fried foods, would also like more snacks, would like different types of snacks and more fruits like melon, they always give us the same thing old fruit out of a can. When asked if she has discussed her concerns to any facility staff, Resident #26 states yes, I tell the staff immediately if something is wrong on my tray and also tell the food committee president and they discuss it at every meeting. On 05/18/2023 at approximately 10:10 AM, an interview was conducted with Resident #26 who stated, breakfast was okay I guess but the eggs were horrible, so I only ate the grits, yogurt, and toast. I ordered a grilled cheese sandwich for lunch and the BBQ for dinner, the BBQ is always good. On 05/19/2023 at approximately 11:25 AM, an interview was conducted with Resident #26 who confirmed she got the grilled cheese sandwich she ordered yesterday for lunch, but the cheese tasted bad. She stated, supper was not what I ordered, I got some unknown kind of meat, broccoli and white rice, but ordered BBQ. I told my CNA and asked what kind of meat was on my tray? The CNA said, it's food, in which I replied, well I know it's food but it's not the BBQ that I ordered. The CNA tried to fix it, but she was told by the kitchen they were out of BBQ. A review of Resident #26's medical record showed an active diet order on 09/12/2022 for Consistent Carbohydrates (CCD) diet, Regular texture, and regular/thin liquids consistency. Resident #34: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 9 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 05/15/2023 at approximately 11:00 AM, an interview was conducted with Resident #34, who stated, I wish that we had more choices to choose for meals, they do have a standing list of items that can be requested all the time or you can choose the alternate meal if you don't like the main meal being served but staff don't ask you these preferences unless you are in the dining room, but either way the food is no good, half the time it comes out cold or late, also wish we had better snacks, we are supposed to have pudding on the hall but every time I ask for it, the CNA's go check but say they don't have any. On 05/15/2023 at approximately 12:45 PM, while observing the independent dining room, Resident #34 was noted sitting in a wheelchair at the dining room table, not eating. The resident's plate contained a hamburger and French fries. When Resident #34 was asked about her food, she responded, it's cold, my fries are cold as ice, I can't eat this like that, I don't even have mayonnaise for my burger. When asked if she notified staff, she responds, what's the use, they don't care. A staff member observing dining and standing nearby was notified that Resident #34 had concerns with her meal, and the staff member responded, yeah, they are getting her some mayonnaise right now. It was reported to the same staff member that the resident stated her food is cold, staff member responds, I will get it fixed. On 05/16/2023 at approximately 1:49 PM, a follow up interview was conducted with Resident #34 who stated, I did get the mayonnaise that I requested yesterday for my hamburger, but they never brought me warmer fries or offered to heat them. She explained that she attended the food committee meeting this morning and, they said that we are supposed to be getting more food options, several residents complained about the food being bad, not getting what they order, and that we need more snacks. A review of resident #34's medical record showed a current diet order on 04/13/2023 for a Regular Diet, Regular Texture, with Regular/Thin Liquids consistency. Tray line observations: On 05/17/2023 at 1:00 PM, an interview was conducted with District DM F, who is currently the on-site Director of Food and Nutrition Services, who stated that there is no policy regarding the tray assembly line but the process of the tray assembly line starts with a starter who puts the ticket on the tray and calls out to the cook a specific diet, request, and such. The cook then plates the food and the tray is passed by the starter, down to the drink person who places the drink on the tray, checks the tray for accuracy, covers it and places it on the cart and takes it to the dining room or hall. After the trays are delivered to the appropriate area, the duties are assigned to nursing at that point. An observation of the kitchen dinner tray line was conducted on 05/17/2023 beginning at 5:15 PM. The observation of the tray line revealed there was no quality assurance checks for diet accuracy by Food and Nutrition Services staff prior to the tray being placed on the meal cart for distribution to residents. The cook plated the food. The tray line starter was observed to correct some inaccurate food items plated by the cook. The drink aide placed drinks on the tray but did not compare the tray accuracy against the ticket. No other Food and Nutrition Services staff member was observed to check the accuracy of food items. The tray line was disorganized with multiple distractions from outside the kitchen, which required the drink aide to leave her position on the tray line, exit the kitchen, then return to finish putting drinks on the tray. On 05/19/2023 at approximately 12:55 PM, an observation of the lunch tray line was conducted. There (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 10 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were 4 Food and Nutrition Services staff working the tray line. Employee O, dietary aide, initiated each tray and called out the diet to the cook. Then Employee L (the cook during this meal) plated the food and placed the plate on the tray where Employee G, a dietary aide, would cover the plate and pass the tray to Employee H, dietary aide, who would add the drink and then check the completed tray for accuracy. An interview was conducted with Employee H, dietary aide, during the observation. Employee H stated that she was here from a different nursing home helping and her assignment at this time is the last check for tray accuracy and to supply the drinks. When asked how she verifies tray accuracy, Employee H stated that she is aware that a blue ticket is allergies. She was not sure what the yellow ticket (the ticket that signifies altered fluid consistency is required) meant because they do not use those in her facility but she always reads the ticket to check the correct fluid consistency. During this interview, Employee H was asked to review the tray just received from Employee G, dietary aide. Employee H reviewed the tray and ticket for resident #278 who was on a Dysphagia Mechanically Altered Diet. Employee H was asked what should not be included on a tray for residents ordered a Dysphagia Mechanically Altered Diet. Employee H stated that items listed on the ticket would be on the tray. When Employee H was asked again about this diet, Employee H responded, nothing regular, chopped meat. Employee H was asked if bread could be included in a Dysphagia Mechanically Altered diet (diet for resident #278), Employee H said that she did not know. Employee G and Employee O, both dietary aides, confirmed that they did not know if bread was allowed on the Dysphagia Mechanically Altered diet. Employee L, the cook, stated, bread is allowed but has to be pureed on that diet. Nutrition Room observations: On 05/15/2023 at approximately 12:15 pm, an observation was made of the B-Wing Nourishment Room with Certified Nursing Assistant W (CNA W). There was no pudding or Jell-O observed in the refrigerator or in the storage cabinet. When asked if there was supposed to be snacks in this room for resident consumption, Employee W, states yes, but I don't see any pudding or Jell-O. Two bowls of applesauce were noted in the refrigerator and 5 packets of crackers were in the cabinet. A review of the Nutrition Room Par Levels document revealed the following items with the amount required to be regularly stocked: Pudding - 8 cups Applesauce - 8 cups Jell-O - 8 cups On 05/15/2023 at approximately 12:50 PM, an observation was made of the A-Wing nourishment room. No pudding, applesauce, or jello was noted in the refrigerator or cabinet. An interview with CNA X was conducted at this time. When asked about the delegated responsibility of restocking snacks, CNA X stated, I think the cafeteria restocks it at night, but we can go ask for extra if we need it or it's out. I'm not sure who checks the temperature logs, maybe nursing, or dietary, maintenance might do it. On 05/16/2023 at approximately 10:05 AM, an observation was made of Employee Y (a dietary aide) entering the B-Wing Nourishment room with a cart. Employee Y explained that she is about to stock. When asked how often it is restocked, she explains that it is supposed to be done twice a day, at 10:00 AM and at 2:00 PM by the dietary staff and stocked with supplies to match the par levels on the Nutrition Room Refrigerator Par Levels sheet. Employee Y confirmed there is no pudding or Jell-O present (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 11 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 and multiple other items are low. Level of Harm - Minimal harm or potential for actual harm An interview with District DM F was conducted on 05/17/2023 at approximately 1:00 PM. District DM F was asked about refrigerator stocking and temperature checks/blank logs. District DM F stated it is dietary's responsibility to stock the nourishment rooms with snacks and this is supposed to be done twice a day at 10:00 AM and at 2:00 PM. Residents Affected - Some On 05/17/2023 at approximately 10:45 AM, an interview was conducted with the Administrator who stated, I am aware I've got a problem in the kitchen, and I've got a Performance Improvement Plan (PIP) for it. We just had a resident satisfaction survey on 03/25/2023. He stated the PIP was started on 05/08/2023. Policy reviews: A review of the facility policy titled Menus (HCSG [Health Care Service Group] Policy 004, revised 09/2017) found: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. 3. Menu cycles will include standardized recipes. 4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2015-2020 edition. 5. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious, or ethnic preferences, as appropriate. 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file. 8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas. 9. Menus are kept on file per state regulations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 12 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy titled Dining and Food Preferences (HCSG Policy 005, revised 09/2017) found: Individual dining, food, and beverage preferences are identified for all residents/patients. Procedures: 1. The Diet Requisition form will notify the Dining Services department of food allergies upon admission and prior to any meals served. 2. The Dining Services Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, meal times, including times outside of the routine schedule, food, and beverage preferences. 3. The Food Preference Interview will be entered into the medical record. 4. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. 5. The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups. 6. The Dining Services Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal plan into the plan of care. 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. 8. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. 9. The alternate meal and/or beverage selection will be provided in a timely manner. A review of the facility policy titled Food: Quality and Palatability (HCSG Policy 006, revised 09/2017) found: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's Needs. Definitions: Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 13 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Procedures 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. The Cooks) prepare food in a sanitary manner utilizing the principles of Hazard Analysis and Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code. 3. Food and liquids/beverages are prepared in a manner, form and texture that meets each resident's needs. 4. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention. 5. Hot liquid foods or beverages will be served in containers (mugs, cups, and bowls) that will minimize the potential for spillage. A review of the facility policy titled Meal Distribution (HCSG Policy 013, revised 09/2017) found: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Procedures 1. All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. 2. All food items will be transported promptly for appropriate temperature maintenance. 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. 4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. 5. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. A review of the facility's policy titled Snacks (HCSG Policy 011, revised 09/2017) found: Snacks and beverages will be provided as identified in the individual plans of care. Bedtime also known as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 14 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Procedures 1. The Dining Services department will collaborate with the residents/patients, nursing and management team to identify necessary beverage and snack items to be provided to each resident/patient. 2. The Dining Services department assembles on a daily basis snack items (food and beverages) for delivery to each resident/patient care area. 3. Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. 4. The Dining Services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. 5. The Dining Services department provides a listing of the current diet orders and snacks for each resident to each care area. 6. Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. 7. All snacks will be properly stored for time and temperature control, as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 15 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, diet manual review and facility policy review, the facility failed to ensure sufficient food and nutrition services support staff that had the appropriate competencies and skill sets to accurately prepare, plate and serve modified consistency diets for 2 of 5 residents sampled for mechanically altered diets (Resident #46 and Resident #278). This failure resulted on a choking incident on 05/06/2023 for Resident #46 when she was served an intact meat patty instead of the ground or pureed meat that she was ordered to receive. On Sunday 05/14/2023, the facility contracted Dietary Manager (Dining Services Director) was removed from the position and the rest of the food and nutrition services staff resigned at the same time. The contracting company immediately provided new food and nutrition services staff, many of whom were working in nearby nursing homes. The facility was unable to demonstrate how competencies were assured for the newly employed contracted food and nutrition services staff. During a lunch tray line observation on 05/19/2023, 3 of the 4 food and nutrition services staff who were plating the food were unaware if residents on a Dysphagia (difficulty swallowing) Mechanically Altered Diet were allowed to have whole slices of bread (food and nutrition services staff G, L and O). At the time of the survey, the facility census was 112 with 29 residents identified as having orders for modified textured diets. The facility failure to ensure sufficient food and nutrition services staff who have the appropriate training and competencies for therapeutic modified texture diets can lead to residents receiving the wrong food textures, which puts residents at a likelihood of choking and food aspiration. Choking and aspiration can block the airway, which can cause brain damage from lack of oxygen and/or death. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated, (J). The facility Administrator was notified of the Immediate Jeopardy on 05/19/2023 at 5:00 PM. The Immediate Jeopardy was determined to have begun on 05/06/2023. At the time of the survey exit on 05/19/2023, the Immediate Jeopardy was ongoing. Cross Reference F803, F805, and F867 The findings include: Resident #46: On 05/17/2023 at approximately 11:00 AM, an interview was conducted with Staff D, an RN, concerning the choking incident on 05/06/2023. RN D stated resident #46 choked on a piece of brown meat because I saw it when it came out after performing the abdominal thrusts. RN D confirmed that she saw Resident #46's lunch tray, which consisted of short noodles and a round meat patty that was not ground or chopped. RN D further stated, I believe it was a hamburger patty. A record review of Resident #46's diet order, dated 01/24/2023, was for Consistent Carbohydrates Diet (CCD), Dysphagia Advanced texture, and Regular/Thin Liquids consistency. This order was active at the time of the choking incident on 05/05/2023. On 05/17/2023 at approximately 12:30 PM, an interview was conducted with the Speech-Language Pathologist (SLP) to clarify what types of meat are acceptable on a Dysphagia Advanced Diet. The SLP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 16 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated, all meats should be chopped up or ground, even if ground initially should not be re-formed into a patty. A review of the lunch menu for the date of 05/06/2023 as provided from Employee F, the District Dietary Manager (District DM F) revealed that lunch consisted of Classic Baked Ziti, Tossed Salad with Dressing, Italian Herbed Dinner Roll (with margarine), Cinnamon [NAME] Sugar, Blondie. The alternate lunch meal for the same date was Hamburger on a Bun, Lettuce and Tomato, Ketchup, Pickle Spear, French Fries, Ketchup, [NAME] Pea Salad. A review of Resident #46's lunch meal ticket on 05/06/2023 revealed Resident #46 selected the Alternate meal as evidence by ALT written at bottom of ticket. The diet on the ticket was listed as Consistent Carbohydrates Diet (CCD) Dysphagia Advanced. Dinner Tray Line Observation, 05/17/2023 An observation of the kitchen tray line was performed on 05/17/2023 at 5:15 PM. It was verified with District DM F that no substitutions were provided for this meal. District DM F explained that they have a standing choice item food selection that is always available for residents that do not want the main meal or the alternative for that meal. Food and nutrition services staff on the tray line included (listed in order from start to finish): 1) Employee G- Starter (Dietary Aide from sister facility where she is currently a Manager-In-Training (MIT), on site today due to limited staffing). 2) Employee H -(Dietary Aide from sister facility where she is currently a Manager-In-Training (MIT), on site today due to limited staffing). 3) Employee F - Cook/District DM F 4) Employee I - Drink Aide/Quality Assurance (QA) The observation of the tray line revealed there was no quality assurance (QA) check by dietary staff prior to the tray being placed on the meal cart for distribution to residents. The cook (District DM F) plated the food. The tray line starter, Employee G, was observed to correct some inaccurate food times plated by the cook. The drink aide/QA person, Employee I, placed drinks on the tray but was not observed to compare the tray accuracy against the ticket. No other food and nutrition services staff member was observed to check the accuracy of food items. The tray line was disorganized with multiple distractions from outside the kitchen that required the drink aide to leave her position on the tray line, exit the kitchen, then return to finish putting drinks on the tray. While plating food, it was noted that the quantity of food cooked was not sufficient to meet resident needs and the cook/District DM F called out to Employee U that he needed additional items to be cooked. Employee U and Employee V (who were also both District Dietary Manager's from other nursing homes who were working at the facility due to low staffing) were noted sitting in the food and nutrition services office. Employee U shouts out from the food and nutrition services office, We are trying to work on a schedule! When District DM F was asked how many cooks are normally on staff at dinner, he stated, one cook per shift. When asked if the one cook per shift plating food is also expected to cook additional food at the same time if quantities are insufficient to meet the residents needs, the District DM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 17 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated, yes, unfortunately. When asked if this was safe or even possible, District DM F stated, yes, because most of the foods are prepared or prepped in advance. Employee U was observed entering and exiting the refrigerator and freezer (to obtain food items to cook), cooking frozen turkey patties on a flat top grill, frying French fries and chicken tenders, and frying extra fish fillets due to the tray line running out. Employee V was observed to be making coffee and retrieving the drink carts from the refrigerator and delivering both items to the main independent dining room. The surveyor left the kitchen at the conclusion of independent dining room tray prep and prior to the preparation of trays for the assisted dining room, to make observations of the tray delivery process. Resident #278: On 05/17/2023 at approximately 6:35 PM, an observation was made of the tray cart being delivered from the kitchen to the assisted dining area. During this observation, Staff K, a Unit Manager, was observed removing resident trays from the cart and lifting the plate cover while looking at the meal ticket on the tray. The trays were then passed to a CNA to deliver to the appropriate resident. An observation of Resident #278's tray was made and compared to the resident's meal ticket. Resident #278's meal ticket revealed a diet order for Dysphagia Mechanically Altered and the items on the plate did not match the items listed on the ticket. The ticket listed ground smothered turkey patty with poultry gravy, pureed oven browned potatoes, pureed dinner roll/bread w/ margarine, pureed Vanilla glazed angel food cake, milk, tea, food in bowls. The plate included chopped fish served on a regular hamburger bun, bread was not pureed, and no bowls were present. (Photographic Evidence was obtained) A review of resident #278 medical record revealed a current diet order dated 05/10/2023 for Dysphagia Mechanically Altered texture, regular/thin liquids consistency with directions to serve food in bowls. A review of the MDS (Minimum Data Set Assessment) dated 05/14/2023 found in the section on Functional Status: Eating that Resident #278 requires supervision with physical assistance by 1 person. Section K (Swallowing/Nutritional status) indicated that Resident #278 required both a mechanically altered diet and a therapeutic diet. The care plan dated 04/10/2023 includes a care plan for nutritional problems with interventions to monitor/report/document signs and symptoms of dysphagia and malnutrition, provide and serve diet as ordered- Dysphagia Mechanical Soft texture with regular thin liquids consistency. A review of the description of the diets from the facility's diet manual 2019 [NAME] & Associates, Inc. Diet and Nutrition Care Manual, revealed 4 types per the National Dysphagia Diet Levels. Level 2 is a Dysphagia Mechanically Altered diet (the diet ordered for resident #278) which defines foods allowed as breads should be pureed and meats must be tender, moist, ground or chopped to less than ¼ inch cubes. The manual defined foods to avoid on the Level 2 diet as regular breads that are not pureed and dry, tough meat or any other whole pieces of meat such as bacon, sausage, and hotdogs. Level 3 is a Dysphagia Advanced diet (the diet ordered for resident #46) which states meats allowed must be very tender, small pieces, thin slices, chopped or ground, and well moistened. Food to avoid on the Level 3 include dry tough meat, fish or poultry, any other whole pieces of meat or cheese slices or cubes, and dry, tough, or crusty bread, crackers, or toast. The latest edition of the [NAME] & Associates, Inc. Diet and Nutrition Care Manual was published in 2021, which included the International Dysphagia Diet Standardization Initiative (IDDSI) framework for dysphagia diets which replaces the National Dysphagia Diet. On 05/18/2023 at approximately 10:52 AM an interview was conducted with the SLP, who stated that a Dysphagia Mechanically Altered/Soft diet is a [NAME] area, it is heavily still a pureed diet, try to use that diet as a steppingstone away from puree, may get some softer items, but no items that you (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 18 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few see on a regular diet or dysphagia advanced diet, it's just too hard and complex consistency. Something that requires a lot of chewing you wouldn't see that on that diet. Meats can sometimes come out as pureed and sometimes ground, as far as the specifics I would refer you to the diet manual the kitchen has, because I have to refer to it all the time, like if I'm looking for something that should or shouldn't be on a certain diet. We started using the renaming of diets a couple of years ago. A resident on a Dysphagia Advanced diet sandwich, with chopped fish would be allowed, not sure about it being on the Dysphagia Mechanically Altered diet and how it would be presented. I would have to check the diet manual and the ticket. When the SLP was shown a photograph taken on 05/17/2023 of resident #278's dinner meal with the corresponding meal ticket, she stated, I would expect the bread to be pureed, especially since the dinner roll on the ticket says pureed, however the meat is acceptable, even though it's the incorrect meat its fish instead of ground turkey, because they can have ground meat on the Dysphagia Mechanically Altered/Soft diet, would not expect the solid bun. This resident should not receive a solid sandwich, or a solid bun based on this ticket and picture. The SLP stated that she would still refer to the manual to be certain and that she will be glad to show me her process. She retrieved the diet and nutrition care manual binder from the kitchen and stated, this is what I used to make my little cheat sheet for the in-service that was requested by the Director of Nursing (DON). So, it says for the Dysphagia Mechanically Altered/Soft diet all meats should be tender and soft, ground or chopped to less than a quarter of an inch, and according to the manual breads should be pureed, foods to avoid include regular breads. This is what I personally go by, if I have questions, I pull this. If I were evaluating this resident and this tray was presented to him, I would have stopped him from eating it and pulled the manual. The SLP stated the reason why she would not allow this resident to eat this meal is because the bolus (round mass of chewed food at the time of swallowing) formed during the mastication process (chewing of food) would be a potential choking hazard for a resident with this severity of dysphagia. Lunch Tray Line Observation, 05/19/2023: On 05/19/2023 at approximately 12:55 PM, an observation of the lunch tray line was conducted. There were 4 food and nutrition services staff working the tray line. Employee O, dietary aide, initiated each tray and called out the diet to the cook. Employee L (the cook during this meal) plated the food and placed the plate on the tray where Employee G, a dietary aide, would cover the plate and pass the tray to Employee H, a dietary aide, who would add the drink and check the completed tray for accuracy. An interview was conducted with Employee H, dietary aide, during the observation. Employee H stated that she was here from a different nursing home helping and her assignment at this time is the last check for tray accuracy and to supply the drinks. When asked how she verifies tray accuracy, Employee H stated that she is aware that a blue ticket is allergies. She was not sure what the yellow ticket (the ticket that signifies altered fluid consistency is required) meant because they do not use those in her facility but she always reads the ticket to check the correct fluid consistency. During this interview, Employee H was asked to review the tray just received from Employee G. Employee H reviewed the tray and ticket for resident #278 who was on a Dysphagia Mechanically Altered Diet. Employee H was asked what should not be included on a tray for residents ordered a Dysphagia Mechanically Altered Diet. Employee H stated that items listed on the ticket would be on the tray. When Employee H was asked again about this diet, Employee H responded, nothing regular, chopped meat. Employee H was asked if bread could be included in a Dysphagia Mechanically Altered diet (diet for resident #278), Employee H said that she did not know. Employee G and Employee O, both dietary aides, confirmed that they did not know if bread was allowed either on the Dysphagia Mechanically Altered diet. Employee L, the cook, stated, bread is allowed but has to be pureed on that diet. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 19 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 training and staffing availability: Level of Harm - Immediate jeopardy to resident health or safety On 05/15/2023 at approximately 10:25 AM, an interview was conducted with District DM F, who stated that he is currently the on-site Dietary Manager due to the prior Dietary Manager being removed by the facility per request of Administration (last working day was 05/14/2023). When the former Dietary Manager was removed, 4 additional dietary/kitchen staff quit as well. A current list of food and nutrition services employees and their schedules was requested. District DM F provided this list and stated he is understaffed at the moment but is interviewing for people over the next week. He also reported that the Registered Dietitian (RD) was not on site today. Residents Affected - Few A review of the facility self-assessment stated that the position of the Dietitian or other clinically qualified nutrition professional should be present for 90 hours every two week period, and the food and nutrition services staff should work a total of 686 hours bi-weekly (4 food and nutrition services staff, assuming 8 hours a day, 7 days a week, would work at total of 448 hours over a 2 week period). A follow-up interview on 05/17/2023 at approximately 1:00 PM, was conducted with District DM F in which he provided a new updated list of his food and nutrition services staff which included 9 food and nutrition services staff. However, he was unable to produce a schedule of the listed employees' work hours. When asked about the variances of staff numbers from the first list he supplied, he explained that some of the employees will be brought in from other sister facilities to help with low staffing/mass exodus. He was unable to explain how many hours each staff member listed was anticipated/expected to work. When asked for a policy/procedure regarding the tray line assembly he replied that there is no policy regarding the tray assembly line. District DM F stated, the process of the tray assembly line starts with a starter who puts the ticket on the tray and calls out to the cook the specific diet, request, etc. The cook then plates the food and the tray is passed by the starter, down to the drink person who places the drink on the tray, does a final check for tray accuracy, covers it and places it on the cart and takes it to the dining room or hall. After the trays are delivered to the appropriate area, the duties are assigned to nursing at that point. Tray tickets are color coded blue for allergies, yellow for thickened liquids (either honey or nectar consistency), or white for a regular diet. All tickets will specify if a mechanically altered diet is ordered too. On 05/16/2023 at approximately 10:05 AM, an interview was conducted with Employee Y. She confirmed that she is employed as food and nutrition services staff but that she only works in that position part time because she is also a PCA (Patient Care Assistant). Despite multiple requests throughout the survey, a food and nutrition services staffing schedule had not been provided at the time of survey exit. On 05/8/2023, two Ad Hoc Quality Assessment and Performance Improvement (QAPI) meetings were held regarding issues with food and nutrition services and diet accuracy which led to the choking incident. The first one was led by the DON related to nursing responsibilities regarding checking resident meal trays for accuracy. The second Ad Hoc QAPI meeting was led by the Executive Director regarding food and nutrition services staff. The QAPI team developed an Action Plan from each meeting (referred to by staff as a performance improvement plan, [PIP]), related to nursing and food and nutrition services. Review of the PIP from the Ad Hoc QAPI Meeting related to food and nutrition services dated 05/08/2023 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 20 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1. The section entitled Opportunity for Improvement identified: Resident Satisfaction related to food quality, presentation, and variety of food. 2. The section entitled Data (Assess Current Situation-what were the results/trend) identified: Practices put in place last year to correct dietary concerns not being followed. 3. The section entitled Analysis (Root Cause Analysis) identified: Lack of buy in from current dietary manager. 4. The section entitled Plan identified: See attached PIP for plan. 5. The section entitled Responsible Team Member(s) identified: ED and Dietary Manager. A review of the Four Point Action Plan, developed subsequent to the PIP, dated 05/08/2023 found that the Objective and Goal was identified as Improve overall dining experience for residents. Under the section for Action Steps the QAPI team identified: 1. Currently residents voiced concern, there is no variety, food appearance is not palatable, is often undercooked or overcooked, always available menu not being followed. 2. Dietary Manager/designee will complete the following: -Obtain dietary preferences on current residents -Review diet orders for current residents to ensure meals are being served per MD (Medical Doctor) Orders. -institute and follow the full always available menu for alternate meals 3. Current dietary (food and nutrition services) staff will be in-serviced on the following: -Providing diets that meet the needs of the residents -Adhering to established menus -Honoring preferences -Condiments are available -Silverware on trays -Using plate warmers -Proper delivery of trays to maintain temperature -Proper transport of trays to the floor. -Proper portion size (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 21 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 -Food palatability Level of Harm - Immediate jeopardy to resident health or safety 4. Dietary manager/designee will monitor tray line 1-time daily for 14 days . to ensure tray and tray ticket matches, preferences are honored, needed condiments and silverware are on tray, food temperatures are maintained, portions are correct, and meals are palatable. Food committee will meet weekly for 60 days . to ensure diets are served to meet the needs of the residents and preferences are honored. Findings of the tray monitoring and food committee meetings will be reported to the QAPI committee monthly, until committee determines substantial compliance has been met. Residents Affected - Few On 05/19/2023 at approximately 10:12 AM, an interview was conducted with District DM F, regarding the in-service training for the 05/08/2023 PIP. District DM F stated, The Dietary Manager started the tray Accuracy in-service on the 8th, but that Dietary Manager is no longer here. The Dietary Manager was removed from the building at the request of the facility due to the facility claiming they felt the manager was ineffective. That was on Saturday (05/13/2023). I believe then the kitchen staff all quit, we had one aide that came to work and walked out while on the clock. The training on the tray accuracy is a broad training, it just entails the items on the trays and reading the tickets it was more of a broad overview. Diet textures are part of our education and on-boarding, we continue to educate the staff on textures. The District DM went on to further state, I believe the problem is an issue of reading the tickets, there is a 3-point check in place of the accuracy of the meal for the resident during tray line of the starter who calls the ticket out to the cook and cook who plates it and then the drink aide who does the final check. The manager is to supervise the tray line and then the nursing staff does another check prior to delivery to the resident. Documentation of the in-service training and audits were requested for review from the District DM F. In-service documentation dated 05/18/2023 (10 days after the PIP was developed) was provided by the facility. No tray line audits were provided, but the facility provided documentation for 3 days of meal audits prior to survey entrance. A review of the meal audit documentation found that audits with the indicator: Diets meet the needs of the resident were done following the PIP on 05/09/2023, 05/10/2023 and 05/11/2023. Each audit sampled 10 resident meals for a total sample of 50 meals. On 05/19/2023 at approximately 3:30 PM, an interview was conducted with the Executive Director (ED), about the removal of the Dietary Manager. The ED stated he asked for the Dietary Manager to be removed this past Friday (05/12/2023). The ED went on to state his last day was on Sunday (05/14/2023) prior to Survey entrance on Monday (05/15/2023). The ED further stated that the reason for the request was due to the Dietary Manager not being compliant with their PIP and corrective action plans concerning the issues in the Kitchen and dining program. When the Dietary Manager left on Sunday (05/15/2023), 3 more staff left with him. A review of the facility's policy titled Education and Training (HCSG [Health Care Services Group] Policy 003, revised 09/2017) included: All employees will be provided education and training upon hire and ongoing to ensure that they have the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration the needs of the resident population. Procedures: 1. All employees will be provided with education, training, and tools to perform their roles. Training shall include, but not be limited to, the following: HCSG policies and procedures, Facility policies and procedures, Job responsibilities and duties. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 22 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0802 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2. All employees will receive education and training on federally mandated topics and HCSG required Human Resources topics upon hire and annually. 3. The Dining Services Director will ensure that all employees complete the required monthly education modules as outlined in the corporate training program. 4. Just-in-time education will be provided, as needed, for all dietary staff based on performance improvement opportunities as identified in the ongoing quality assurance process. 5. When training materials are not available in the online training library, the Dining Services Director will maintain records of the sessions, group and individual, including the following information: Topic, Outline of education materials, List of attendees, Signature of attendees. 6. Evidence of education will be retained on file. A review of the facility policy titled Therapeutic Diets (HCSG Policy 008, revised 09/2017) included: Procedures: 3. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. A review of the facility policy titled Meal Distribution (HCSG Policy 013, revised 09/2017) included: 1. All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 23 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, menu review, diet manual review, and policy review, the facility food and nutrition services staff failed to follow the Dysphagia (difficulty swallowing) Advanced Texture and Dysphagia Mechanically Altered diets for 2 of 5 residents sampled for mechanically altered diets (Resident #46 and Resident #278). On 05/06/2023 Resident #46 was served the incorrect diet texture during the lunch meal which resulted in the resident choking on a meat patty necessitating the immediate medical intervention of abdominal thrusts by a Registered Nurse (RN) to clear the meat from the resident's airway. On 05/17/2023, Resident #278, who was ordered a Dysphagia Mechanically Altered diet, did not receive the correct diet texture during the dinner meal. Resident #278 was ordered to receive pureed bread, but instead received a whole hamburger bun. At the time of the survey, the facility census was 112 with 29 residents who had orders for mechanically altered diets. Failure to follow menus for therapeutic modified texture diets can lead to residents receiving the wrong food textures which puts residents at a likelihood of choking and food aspiration. Choking and aspiration can block the airway, which can cause brain damage from lack of oxygen and/or death. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated, J. The Administrator and was notified of the Immediate Jeopardy on 05/19/2023 at 5:00 PM. The Immediate Jeopardy was determined to have begun on 05/06/2023. At the time of the survey exit on 05/19/2023, the Immediate Jeopardy was ongoing. Cross Reference F802, F805 and F867 The findings include: On 05/15/2023 at approximately 11:20 AM, an interview with conducted with Resident #49 who talked about concerns regarding poor food quality and preparation. Resident #49 stated, The food is ill prepared, the meat is too tough to cut much less chew. Residents are receiving the wrong diets, one (identifies Resident #46) even choked on her food because they gave her regular food instead of pureed, that happened just this last week. Staff had to do the Heimlich, this has happened before. They get orders mixed up, broccoli is mush and English peas are served with ice crystals. People are losing weight because they don't like the food, so they just won't eat at all. I am the food committee president and the vice president of resident council, so the residents tell me everything. I've made several grievances about this, and nothing is being done. Resident #46: On 05/18/2023 at approximately 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that on 05/06/2023, Resident #46 was in the independent dining room eating lunch and talking and chewing at the same time. She stated, This is her normal behavior. One of the bites she took she started talking and got a piece of food stuck. The nurse in the dining room responded and performed the Heimlich and was able to get the food dislodged. The DON stated that Resident #46 was placed on 72-hour monitoring after the event. The DON further stated that during their investigation of the event, they identified that the resident was served a hamburger patty. The DON confirmed that Resident #46's diet at the time of the incident was Dysphagia Advanced Diet (a diet that consists of chopped/ground meat) and the resident was not served the correct texture of meat and choked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 24 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 When asked if that would be considered harm, the DON responded yes. Level of Harm - Immediate jeopardy to resident health or safety A record review of Resident #46 revealed the most recent diet order, dated 01/24/2023, was for Consistent Carbohydrates diet (CCD) Dysphagia Advanced texture, and Regular/Thin Liquids consistency. This order was active at the time of the choking incident. Residents Affected - Few On 05/17/2023 at approximately 11:00 AM, an interview was conducted with Staff D, a RN, concerning the choking incident on 05/06/2023. RN D stated resident #46 choked on a piece of brown meat because I saw it when it came out after performing the abdominal thrusts. RN D confirmed that she saw Resident #46's lunch tray, which consisted of short noodles and a round meat patty that was not ground or chopped. RN D further stated, I believe it was a hamburger patty. On 05/17/2023 at approximately 12:30 PM, an interview was conducted with the SLP (Speech-Language Pathologist) to clarify what types of meat are acceptable on a Dysphagia Advanced Diet. The SLP stated, all meats should be chopped up or ground, even if ground initially should not be re-formed into a patty. A review of the lunch menu for the date of 05/06/2023 as provided from Employee F, District Dietary Manager (District DM F) revealed that lunch consisted of Classic Baked Ziti, Tossed Salad with Dressing, Italian Herbed Dinner Roll with margarine, Cinnamon [NAME] Sugar, Blondie. The alternate lunch meal for the same date was Hamburger on a Bun, Lettuce and Tomato, Ketchup, Pickle Spear, French Fries, Ketchup, [NAME] Pea Salad. A review of Resident #46's lunch meal ticket on 05/06/2023 reveals Resident #46 selected the Alternate meal as evidence by ALT written at the bottom of the ticket. The diet on the ticket was listed as Consistent Carbohydrates Diet (CCD) Dysphagia Advanced. Tray line observations and Resident #278: An observation of the kitchen tray line was performed on 05/17/2023 beginning at 5:15 PM. District DM F verified that no substitutions were provided for this meal. The District DM explained that they have a standing choice item food selection that is always available for residents that do not want the main meal or the alternative for that meal. Observation of the tray line revealed the food items were as follows: 1) Fried Fish Fillet 2) Roasted Potatoes (Cubed) 3) Mixed Steamed Vegetables 4) Steamed Squash and Zucchini 5) Extra Mixed Steamed Vegetables 6) Chopped Fish Fillet 7) Grilled Whole Turkey Patty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 25 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 8) Mashed Potatoes Level of Harm - Immediate jeopardy to resident health or safety 9) Pureed Fish Fillet Residents Affected - Few 11) Turkey Gravy 10) Pureed Mix Vegetables The posted menu for dinner on 05/17/2023 included the following: Breaded Fish on a Bun (side of tartar sauce) Oven Browned Potatoes Squash Medley Vanilla Glazed Angel Food Cake The posted alternate menu was: Smothered Turkey Patty Seasoned [NAME] Whole Kernel Corn Dinner Roll/Bread (side of margarine) Missing items on the tray line comparative to the menu were: seasoned rice (regular and pureed), whole kernel corn (regular and pureed), pureed turkey patty, pureed bread, and pureed dessert. Food and nutrition services staff on the tray line included (listed in order from start to finish): 1) Employee G - Starter (Dietary Aide from sister nursing home where she is currently a Manager-In-Training (MIT), on site today due to limited staffing). 2) Employee H - (Dietary Aide from sister nursing home where she is currently a Manager-In-Training (MIT), on site today due to limited staffing). 3) Employee F - Cook/District DM F 4) Employee I - Drink Aide/tray checker The observation of the tray line revealed there was no tray accuracy check by food and nutrition services staff prior to the tray being placed on the meal cart for distribution to residents. The cook plated the food. The tray line starter was observed to correct some inaccurate food times plated by the cook. The drink aide placed drinks on the tray but did not compare the tray food items against the ticket for accuracy. No other food and nutrition services staff member was observed to double (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 26 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few check the accuracy of food items on the meal trays. The tray line was disorganized with multiple distractions from outside the kitchen that required the drink aide to leave her position on the tray line, exit the kitchen, then return to finish putting drinks on the tray. While plating food, it was noted that the quantity of food cooked was not sufficient to meet resident needs and District DM F called out to Employee U that he needed additional items to be cooked. Employee U and Employee V (who were both District Dietary Managers from other nursing homes who were working at the facility due to low staffing) were observed sitting in the food and nutrition services office. Employee U shouted back from the food and nutrition services office, We are trying to work on a schedule! When District DM F was asked how many cooks were normally on duty at dinner, he stated, one cook per shift. When asked if the one cook per shift plating food was also expected to cook additional food at the same time if quantities were insufficient to meet the residents needs, District DM F stated, yes, unfortunately. When asked if this was safe or even possible, District DM F stated, yes, because most of the foods are prepared or prepped in advance. Employee U was observed entering and exiting the refrigerator and freezer (to obtain food items to cook), cooking frozen turkey patties on a flat top grill, frying French fries and chicken tenders, and frying extra fish fillets due to the tray line running out. Employee V was noted to be making coffee and retrieving the drink carts from the refrigerator and delivering both items to the main independent dining room. The surveyor left the kitchen at the conclusion of independent dining room tray prep and prior to the preparation of trays for the assisted dining room, to make observations of the tray delivery process. On 05/17/2023 at approximately 6:35 PM, an observation was made of the tray cart being delivered from the kitchen to the assisted dining area. During this observation, Staff K, a Unit Manager, was observed removing resident trays from the cart and lifting plate covers while looking at the meal ticket on the tray. The trays were then passed to a Certified Nursing Assistant (CNA) to deliver to the appropriate resident. An observation of Resident #278's tray was made and compared to the resident's meal ticket. Resident #278's meal ticket revealed a diet order for Dysphagia Mechanically Altered and the items on the plate did not match the items listed on the ticket. The ticket listed ground smothered turkey patty with poultry gravy, pureed oven browned potatoes, pureed dinner roll/bread with margarine, pureed Vanilla glazed angel food cake, milk, tea, food in bowls. The plate included chopped fish served on a full hamburger bun, bread was not pureed, and no bowls were present. (Photographic Evidence was obtained) A review of resident #278 medical record revealed a current diet order dated 05/10/2023 for Dysphagia Mechanically Altered texture, regular/thin liquids consistency with directions to serve food in bowls. A review of the MDS (Minimum Data Set Assessment) 5-day PPS (Prospective Payment System) dated 05/14/2023 found in the section on Functional Status: Eating that Resident #278 requires supervision with physical assistance by 1 person. Section K (Swallowing/Nutritional Status) indicated that Resident #278 required both a mechanically altered diet and a therapeutic diet. The care plan dated 04/10/2023 includes a care plan for nutritional problems with interventions to monitor/report/document signs and symptoms of dysphagia and malnutrition, provide and serve diet as ordered- Dysphagia Mechanical Soft texture with regular thin liquids consistency. Review of the description of the diets from the facility's diet manual 2019 [NAME] & Associates, Inc. Diet and Nutrition Care Manual, revealed 4 types per the National Dysphagia Diet Levels. Level 2 is a Dysphagia Mechanically Altered diet (the diet ordered for resident #278) which defines foods allowed as breads should be pureed and meats must be tender, moist, ground or chopped to less than ¼ inch cubes. Defines foods to avoid on the Level 2 diet as regular breads that are not pureed and dry, tough meat or any other whole pieces of meat such as bacon, sausage, and hotdogs. Level 3 is a Dysphagia Advanced diet (the diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 27 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 Level of Harm - Immediate jeopardy to resident health or safety ordered for resident #46) which stated, meats allowed must be very tender, small pieces, thin slices, chopped or ground, and well moistened. Food to avoid on the Level 3 include dry tough meat, fish or poultry, any other whole pieces of meat or cheese slices or cubes, and dry, tough, or crusty bread, crackers, or toast. The latest edition of the [NAME] & Associates, Inc. Diet and Nutrition Care Manual was published in 2021, which included the International Dysphagia Diet Standardization Initiative (IDDSI) framework for dysphagia diets which replaces the National Dysphagia Diet. Residents Affected - Few On 05/18/2023 at approximately 10:52 AM an interview was conducted with the SLP, who stated, a Dysphagia Mechanically Altered/Soft diet is a [NAME] area, it is heavily still a pureed diet, try to use that diet as a steppingstone away from puree, may get some softer items, but no items that you see on a regular diet or dysphagia advanced diet, it's just too hard and complex consistency. Something that requires a lot of chewing you wouldn't see that on that diet. Meats can sometimes come out as pureed and sometimes ground, as far as the specifics I would refer you to the diet manual the kitchen has, because I have to refer to it all the time, like if I'm looking for something that should or shouldn't be on a certain diet. We started using the renaming of diets a couple of years ago. A resident on a Dysphagia Advanced diet sandwich, with chopped fish would be allowed, not sure about it being on the Dysphagia Mechanically Altered diet and how it would be presented. I would have to check the diet manual and the ticket. When the SLP was shown a photograph taken on 05/17/2023 of resident #278's dinner meal with the corresponding meal ticket, she stated, I would expect the bread to be pureed, especially since the dinner roll on the ticket says pureed, however the meat is acceptable, even though it's the incorrect meat its fish instead of ground turkey, because they can have ground meat on the Dysphagia Mechanically Altered/Soft diet, would not expect the solid bun. This resident should not receive a solid sandwich, or a solid bun based on this ticket and picture. The SLP stated that she would still refer to the manual to be certain and that she will be glad to show me her process. She retrieved the diet and nutrition care manual binder from the kitchen and stated, this is what I used to make my little cheat sheet for the in-service that was requested by the Director of Nursing (DON). So, it says for the Dysphagia Mechanically Altered/Soft diet all meats should be tender and soft, ground or chopped to less than a quarter of an inch, and according to the manual breads should be pureed, foods to avoid include regular breads. This is what I personally go by, if I have questions, I pull this. If I were evaluating this resident and this tray was presented to him, I would have stopped him from eating it and pulled the manual. The SLP stated the reason why she would not allow this resident to eat this meal is because the bolus (round mass of chewed food at the time of swallowing) formed during the mastication process (chewing of food) would be a potential choking hazard for a resident with this severity of dysphagia. On 05/19/2023 at approximately 12:55 PM, an observation of the lunch tray line was conducted. There were 4 food and nutrition services staff working the tray line. Employee O, dietary aide, initiated each tray and called out the diet to the cook. Then Employee L (the cook during this meal) plated the food and placed the plate on the tray where Employee G, a dietary aide, would cover the plate and pass the tray to Employee H, dietary aide, who would add the drink and check the completed tray for accuracy. An interview was conducted with Employee H, dietary aide, during the observation. Employee H stated that she was here from a different nursing home helping and her assignment at this time is the last check for tray accuracy and to supply the drinks. When asked how she verifies tray accuracy, Employee H stated that she is aware that a blue ticket is allergies. She was not sure what the yellow ticket (the ticket that signifies altered fluid consistency is required) meant because they do not use those in her facility but she always reads the ticket to check the correct fluid consistency. During this interview, Employee H was asked to review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 28 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the tray just received from Employee G. Employee H reviewed the tray and ticket for resident #278 who was on a Dysphagia Mechanically Altered Diet. Employee H was asked what should not be included on a tray for residents ordered a Dysphagia Mechanically Altered Diet. Employee H stated that items listed on the ticket would be on the tray. When Employee H was asked again about this diet, Employee H responded, nothing regular, chopped meat. Employee H was asked if bread could be included in a Dysphagia Mechanically Altered diet (diet for resident #278), Employee H said that she did not know. Employee G and Employee O, both dietary aides, confirmed that they did not know if bread was allowed either on the Dysphagia Mechanically Altered diet. Employee L, the cook, stated, bread is allowed but has to be pureed on that diet. Policy review: A review of the facility's policy titled Menus (HCSG [Health Care Services Group] Policy 004, revised 09/2017) included: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. 3. Menu cycles will include standardized recipes. 4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2015-2020 edition. 5. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious, or ethnic preferences, as appropriate. 6. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 29 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file. Residents Affected - Few 8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas. 9. Menus are kept on file per state regulations. A review of the facility policy titled Dining and Food Preferences (HCSG Policy 005, revised 09/2017) included: 7) The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences. A review of the facility policy titled Food: Quality and Palatability (HCSG Policy 006, revised 09/2017) included: Food and liquids/beverages are prepared in a manner, form and texture that meets each resident's needs. A review of the facility policy titled Therapeutic Diets (HCSG Policy 008, revised 09/2017) included: All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet (e.g. sodium), or to increase specific nutrients in the diet (e.g. potassium), or to provide food that a resident is able to eat (e.g. mechanically altered diet). Mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physicians' or delegated registered or licensed dietitian's order. Procedures 1. The Licensed Nurse accepts the diet order from the authorized prescriber. 2. The Licensed Nurse completes and signs the Diet Requisition Form, including the full diet order, food allergies, and specific food preference requests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 30 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0803 3. Level of Harm - Immediate jeopardy to resident health or safety Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. Residents Affected - Few A review of the facility policy titled Meal Distribution (HCSG Policy 013, revised 09/2017) included: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Procedures: 1. All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. 2. All food items will be transported promptly for appropriate temperature maintenance. 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. 4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. 5. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 31 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on meal observation, staff interview, resident interview, clinical record review, review of the diet manual, and policy review, the facility failed to prepare and serve food designed to meet individual needs for 2 of 2 residents sampled who required mechanically altered diets (Residents #46 and #278). Resident #46 had diet orders for ground meat due to dysphagia (difficulty swallowing). On 05/06/2023, Resident #46 was served a whole hamburger patty and had a subsequent choking event requiring abdominal thrusts to remove airway blockage. Resident #46 had diet orders for a Dysphagia Advanced diet which required all meats to be mechanically altered by chopping or grinding methods. On the evening of 05/17/2023, Resident #278 was served a sandwich with whole slices of bread for dinner. Resident #278's meal ticket had diet orders for a Dysphagia Mechanically Altered diet which requires all breads to be pureed. At the time of the survey, the facility census was 112 with 29 residents who had orders for mechanically altered diets. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated, J. The Administrator was notified of the Immediate Jeopardy on 05/19/2023 at 5:00 PM. The Immediate Jeopardy was determined to have begun on 05/06/2023. At the time of the survey exit on 05/19/2023, the Immediate Jeopardy was ongoing. Cross reference F802, F803 and F867. The findings include: Resident #46: On 05/18/2023 at approximately 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that on 05/06/2023, Resident #46 was in the independent dining room eating lunch and talking and chewing at the same time. She stated, This is her normal behavior. One of the bites she took she started talking and got a piece of food stuck. The nurse in the dining room (Registered Nurse D) responded and performed the Heimlich and was able to get the food dislodged. The DON stated that Resident #46 was placed on 72-hour monitoring after the event. The DON further stated that during their investigation of the event, they identified that the resident was served a hamburger patty. The DON stated that she had spoken with the Speech Language Pathologist (SLP), who was following Resident #46 at the time, that the SLP coordinated with us in developing education on the diet in-services for the staff. The DON confirmed that Resident #46's diet at the time of the incident was Dysphagia Advanced Diet (a diet that consists of chopped/ground meat) and the resident was not served the correct texture of meat and choked. When asked if that would be considered harm, the DON responded yes. A record review of Resident #46's electronic medical record revealed the resident was admitted on [DATE] with diagnoses of cerebral infarction (stroke), Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD, a lung disease that causes airflow blockage and breathing-related problems), and Dementia. Resident #46's diet order, dated 01/24/2023, was for Consistent Carbohydrates Diet (CCD), Dysphagia Advanced texture, and Regular/Thin Liquids consistency. This order was active at the time of the choking incident on 05/06/2023. A progress note for Resident #46 titled Nutritional Review, dated 02/01/2023 at 10:21 AM, from the Registered Dietitian, recommended a CCD (Carbohydrate Controlled Diet)/Dysphagia Advanced diet. A nursing progress note dated 04/03/2023 at 9:59 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 32 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few documented coughing during meals and recommended a Speech Therapy evaluation. Nursing progress notes dated 05/02/2023 at 12:00 PM (before the choking incident) stated, Therapy recommends Modified Barium Swallow (MBS) (an objective radiological diagnostic tool that assesses the ability to swallow various foods and liquids) for possible aspiration and coughing with meals. MBS scheduled for 05/08/2023 at 10:30 AM, family, NP (Nurse Practitioner) and therapy notified of appointment. The nursing progress note regarding the choking incident from 05/06/2023 at 12:30 PM labeled LATE ENTRY (entered on 05/08/2023 at 8:19 PM), stated, This RN (Registered Nurse) is supervising the independent dining room and towards the end of lunch time, patient exhibited the universal choking sign and trying to reach for a drink to relieve choking. Subsequently, this RN cleared all the drink/food away from patient and yelled for help from nearby/adjacent assisted dining room, where other staff are present feeding other residents. While performing abdominal thrust, [Nurse 2] came in and was able to provide assistance and, after 4 abdominal thrusts, food is cleared from airway. Airways patent, patient was able to breathe and say a word. Patient stabilized and able to resume eating her food. Patient is awake, alert, and coherent after incident. Diet order verified and patient on Advanced Dysphagia Texture. Family member informed On 05/17/2023 at 11:00 AM, an interview was conducted with Registered Nurse D (RN D), who stated Resident #46 choked on a piece of brown meat, she saw it when it came out after performing the abdominal thrusts. She states that she did not serve Resident #46 her lunch tray on 05/06/2023 and was unable to identify who may have served it. RN D stated that she saw the resident's lunch tray and Resident #46 was served short noodles and a round meat patty that was not ground or chopped, it was in circular form like a hamburger patty. RN D stated that Resident #46 was on her assignment for the day on 05/06/2023, so she was able to monitor the resident for the rest of her shift and no distress was noted. Further record review found that Resident #46 had a care plan initiated on 02/17/2023 for swallowing problems related to a choking episode while eating snack. The care plan was revised on 05/09/2023 to include the choking episode on 05/06/2023. Interventions for this care plan include, diet to be followed as prescribed. A review of a nursing progress note dated 05/13/2023 explained that Resident #46 was transferred to a local hospital emergency room for evaluation due to shortness of breath, low oxygen saturation, and lethargy. A review of the facility nursing progress note on 05/14/2023 at 3:31 AM revealed that Resident #46 was admitted into the Intensive Care Unit at a local hospital with a diagnosis of Pneumonia. A request for Hospital Medical Records was submitted to the hospital on [DATE] at 9:00 AM, however the records had not been received at the time of survey exit and therefore were not available for surveyor review. An interview with Resident #46 was unable to be conducted due to hospitalization. Review of the Lunch Menu for the date of the choking incident, 05/06/2023 revealed: The main meal for lunch was Classic Baked Ziti, Tossed Salad with Dressing, Italian Herbed Dinner Roll with margarine, Cinnamon [NAME] Sugar, Blondie. Alternate lunch meal for the same date was Hamburger on a Bun, Lettuce and Tomato, Ketchup, Pickle Spear, French Fries, Ketchup, [NAME] Pea Salad. A review of the substitution log provided by District Dietary Manager F (District DM F) on 05/17/2023 at 9:15 AM revealed that no substitutions were made by food and nutrition services staff on 05/06/2023. A review of Resident #46's lunch meal ticket on 05/06/2023 revealed Resident #46 selected the Alternate meal as evidence by ALT written at the bottom of the ticket. The diet on the ticket was Consistent Carbohydrates Diet (CCD) Dysphagia Advanced. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 33 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0805 Level of Harm - Immediate jeopardy to resident health or safety On 05/16/2023 at approximately 3:00 PM, an interview was conducted with the Speech-Language Pathologist (SLP), who explained that a Dysphagia Advanced diet should always have chopped or ground meats, softer side items, and nothing hard. She also described that a Dysphagia Mechanical soft diet is something that she would order when she is attempting to upgrade a resident from a Pureed Diet to a Dysphagia Advanced Diet. The SLP stated that she was authorized to order diets and the physician signs off on them. Residents Affected - Few On 05/17/2023 at 10:20 AM, a further interview was conducted with the SLP. When asked about her last assessment of Resident #46, she stated that she was currently on her case load prior to her hospitalization. The SLP stated, she was on a Dysphagia Advanced diet and was doing well with it because the foods are softer and the meat is ground, she was referred to me this time by nursing staff due to an increase in difficulty swallowing and was coughing more when eating. I remember during a dining observation that she would cough and clear, some concerns with speed and dentition, but the diet was helping, she could feed herself, but I feel like she benefited from cues and reminders due to her diagnosis of dementia. I recommended a Modified Barium Swallow (MBS), and she had it done, I called and spoke to the speech therapist at the local hospital and they said that she did fine, had no coughing and that no aspiration was noted, the resident was not the same since a fall in her room earlier this year in which she fractured her neck and came back with a c-collar. She loves to eat and loves snacks. She confirmed that Resident #46 was not wearing a neck brace when the choking incident occurred, and it had been removed a while back. The SLP explained that she evaluated the resident on 01/25/2023 through 03/08/2023 and started again on 05/09/2023 and up to the current hospitalization. The SLP provided a copy of her evaluation, treatment, and discharge summary of these therapies for review. The record review of the SLP's evaluation notes for Resident #46, dated 05/09/2023, revealed a diagnosis of Dysphagia oropharyngeal phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing). The reason for the current referral stated, Patient is a [AGE] year old female long term care resident of this facility, patient experienced coughing/choking incident during mealtimes. Referred for MBS and ST (speech therapy) treatment to decrease deficits. Prior test-yes-05/08/2023 no aspiration noted, some penetration into airway above the vocal folds with ejection from the airway, noted shortness of breath during trials. On 05/17/2023 at 12:30 PM, an interview was conducted with the SLP to clarify what types of meat are acceptable on a Dysphagia Advanced Diet. She stated all meats should be chopped up or ground, even if ground initially they should not be re-formed into a patty. Dinner Tray Line Observation, 05/17/2023 Prior to dinner, on 05/17/2023 at 1:00 PM, an interview was conducted with District DM F, who is currently the on-site Dietary Manager, who stated that there was no policy regarding the tray assembly line but the process of the tray assembly line starts with a starter who puts the ticket on the tray and calls out to the cook a specific diet, request, and such. The cook then plates the food and the tray is passed by the starter, down to the drink person who places the drink on the tray, checks the tray for accuracy, covers it and places it on the cart and takes it to the dining room or hall. After the trays are delivered to the appropriate area, the duties are assigned to nursing at that point. An observation of the kitchen tray line was conducted on 05/17/2023 beginning at 5:15 PM. It was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 34 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0805 verified with District DM F that no substitutions were provided for this meal. Level of Harm - Immediate jeopardy to resident health or safety The posted menu for dinner on 05/17/2023 included the following: Residents Affected - Few Oven Browned Potatoes Breaded Fish on a Bun (side of tartar sauce) Squash Medley Vanilla Glazed Angel Food Cake The posted alternate menu was: Smothered Turkey Patty Seasoned [NAME] Whole Kernel Corn Dinner Roll/Bread (side of margarine) Missing items on the tray line comparative to the menu were: seasoned rice (regular and pureed), whole kernel corn (regular and pureed), pureed turkey patty, pureed bread, and pureed dessert. The observation of the tray line revealed there were no tray accuracy checks by food and nutrition services staff prior to the tray being placed on the meal cart for distribution to residents. The cook plated the food. The tray line starter was observed to correct some inaccurate food times plated by the cook. The drink aide placed drinks on the tray but did not compare the tray food items against the ticket for accuracy. No other food and nutrition services staff member was observed to check the accuracy of food items on the meal trays. The tray line was disorganized with multiple distractions from outside the kitchen, that required the drink server to leave her position on the tray line, exit the kitchen, then return to finish putting drinks on the tray. The surveyor left the kitchen at the conclusion of independent dining room tray prep and prior to the preparation of trays for the assisted dining room, to make observations of the tray delivery process. Resident# 278: On 05/17/2023 at approximately 6:35 PM, an observation was made of the tray cart being delivered from the kitchen to the assisted dining area. During this observation, Staff K, a Unit Manager, was observed removing resident trays from the cart and lifting plate covers while looking at the meal ticket on the tray. The trays were then passed to a Certified Nursing Assistant (CNA) to deliver to the appropriate resident. An observation of Resident #278's tray was made and compared to the resident's meal ticket. Resident #278's meal ticket revealed a diet order for Dysphagia Mechanically Altered and the items on the plate did not match the items listed on the ticket. The ticket listed ground smothered turkey patty with poultry gravy, pureed oven browned potatoes, pureed dinner roll/bread with margarine, pureed Vanilla glazed angel food cake, milk, tea, food in bowls. The plate included chopped fish served on a regular hamburger bun, bread was not pureed, and no bowls were present. (Photographic Evidence was obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 35 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 05/17/2023 at 6:38 PM, an interview was conducted with Unit Manager K in which she confirmed she looked at the tray items and ticket and agreed that the resident did not receive the correct items as listed on the ticket and that he should have received ground turkey and it should have been served in bowls. When asked if it was safe for him to consume the meal he was served based on his diet ordered, Unit Manager K stated, I would say no because it's not listed on the ticket but I'm not sure, I could've sworn I looked at his ticket, I'm not supposed to be in here right now, the other nurse was still in the independent dining room so I came in here so there would at least be one nurse in here. A review of Resident #278's medical record revealed a current diet order dated 05/10/2023 for Dysphagia Mechanically Altered texture, regular/thin liquids consistency with directions to serve food in bowls. A review of the MDS (Minimum Data Set Assessment) dated 05/14/2023 found in the section on Functional Status: Eating that Resident #278 requires supervision with physical assistance by 1 person. Section K (Swallowing/Nutritional status) indicated that Resident #278 required both a mechanically altered diet and a therapeutic diet. The care plan dated 04/10/2023 includes a care plan for nutritional problems with interventions to monitor/report/document signs and symptoms of dysphagia and malnutrition, provide and serve diet as ordered- Dysphagia Mechanical Soft texture with regular thin liquids consistency. A review of the diet descriptions within the facility's diet manual 2019 [NAME] & Associates, Inc. Diet and Nutrition Care Manual, revealed 4 types per the National Dysphagia Diet Levels. Level 2 was a Dysphagia Mechanically Altered diet (the diet ordered for resident #278) which defined foods allowed as breads should be pureed and meats must be tender, moist, ground or chopped to less than ¼ inch cubes. Foods to avoid on the Level 2 diet were listed as regular breads that are not pureed and dry, tough meat or any other whole pieces of meat such as bacon, sausage, and hotdogs. Level 3 was a Dysphagia Advanced diet (the diet ordered for resident #46) which stated meats allowed must be very tender, small pieces, thin slices, chopped or ground, and well moistened. Foods to avoid on the Level 3 included dry tough meat, fish or poultry, any other whole pieces of meat or cheese slices or cubes, and dry, tough, or crusty bread, crackers, or toast. The latest edition of the [NAME] & Associates, Inc. Diet and Nutrition Care Manual was published in 2021, which included the International Dysphagia Diet Standardization Initiative (IDDSI) framework for dysphagia diets which replaces the National Dysphagia Diet. On 05/18/2023 at approximately 10:52 AM, an interview was conducted with the SLP, who stated that a Dysphagia Mechanically Altered/Soft diet is a [NAME] area, it is heavily still a pureed diet, try to use that diet as a steppingstone away from puree, may get some softer items, but no items that you see on a regular diet or dysphagia advanced diet, it's just too hard and complex consistency. Something that requires a lot of chewing you wouldn't see that on that diet. Meats can sometimes come out as pureed and sometimes ground, as far as the specifics I would refer you to the diet manual the kitchen has, because I have to refer to it all the time, like if I'm looking for something that should or shouldn't be on a certain diet. We started using the renaming of diets a couple of years ago. A resident on a Dysphagia Advanced diet sandwich, with chopped fish would be allowed, not sure about it being on the Dysphagia Mechanically Altered diet and how it would be presented. I would have to check the diet manual and the ticket. When the SLP was shown a photograph taken on 05/17/2023 of resident #278's dinner meal with the corresponding meal ticket, she stated, I would expect the bread to be pureed, especially since the dinner roll on the ticket says pureed, however the meat is acceptable, even though it's the incorrect meat - it's fish instead of ground turkey, because they can have ground meat on the Dysphagia Mechanically Altered/Soft diet, would not expect the solid bun. This resident should not receive a solid sandwich, or a solid bun based on this ticket and picture. The SLP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 36 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated that she would still refer to the manual to be certain and that she will be glad to show me her process. She retrieved the diet and nutrition care manual binder from the kitchen and stated, this is what I used to make my little cheat sheet for the in-service that was requested by the Director of Nursing (DON). So, it says for the Dysphagia Mechanically Altered/Soft diet all meats should be tender and soft, ground or chopped to less than a quarter of an inch, and according to the manual breads should be pureed, foods to avoid include regular breads. This is what I personally go by, if I have questions, I pull this. If I were evaluating this resident and this tray was presented to him, I would have stopped him from eating it and pulled the manual. The SLP stated the reason why she would not allow this resident to eat this meal is because the bolus (round mass of chewed food at the time of swallowing) formed during the mastication process (chewing of food) would be a potential choking hazard for a resident with this severity of dysphagia. Second Tray Line Observation, Lunch on 05/19/2023 On 5/19/2023 at approximately 12:55 PM, an observation of the lunch tray line was conducted. There were 4 food and nutrition services staff working the tray line. Employee O, dietary aide, initiated each tray and called out the diet to the cook. Then Employee L (the cook during this meal) plated the food and placed the plate on the tray where Employee G, a dietary aide, would cover the plate and pass the tray to Employee H, dietary aide, who would add the drink and do a check for accuracy of the completed tray. An interview was conducted with Employee H, dietary aide, during the observation. Employee H stated that she was here from a different nursing home helping and her assignment at this time is the last check for tray accuracy and to supply the drinks. When asked how she verifies tray accuracy, Employee H stated that she is aware that a blue ticket is allergies. She was not sure what the yellow ticket (the ticket that signifies altered fluid consistency is required) meant because they do not use those in her facility but she always reads the ticket to check the correct fluid consistency. During this interview, Employee H was asked to review the tray just received from Employee G, dietary aide. Employee H reviewed the tray and ticket for resident #278 who was on a Dysphagia Mechanically Altered Diet. Employee H was asked what should not be included on a tray for residents ordered a Dysphagia Mechanically Altered Diet. Employee H stated that items listed on the ticket would be on the tray. When Employee H was asked again about this diet, Employee H responded, nothing regular, chopped meat. Employee H was asked if bread could be included in a Dysphagia Mechanically Altered diet (diet for resident #278), Employee H said that she did not know. Employee G and Employee O, both dietary aides, confirmed that they did not know if bread was allowed either on the Dysphagia Mechanically Altered diet. Employee L, the cook, stated, bread is allowed but has to be pureed on that diet. A review of the facility policy titled Therapeutic Diets (HCSG [(Health Care Services Group] Policy 008, revised 09/2017) included: All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet (e.g. sodium), or to increase specific nutrients in the diet (e.g. potassium), or to provide food that a resident is able to eat (e.g. mechanically altered diet). Mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physicians' or delegated registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 37 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0805 or licensed dietitian's order. Level of Harm - Immediate jeopardy to resident health or safety Procedures Residents Affected - Few 2. The Licensed Nurse completes and signs the Diet Requisition Form, including the full diet order, food allergies, and specific food preference requests. 1. The Licensed Nurse accepts the diet order from the authorized prescriber. 3. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 38 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, record reviews of temperature logs, maintenance logs, and policy review, the facility failed to maintain 1 of 2 ice machines and 2 of 2 nourishment room refrigerators located on A and B wing, in a sanitary and safe operating condition. The unsanitary condition of the ice machine represented a potential source of pathogen exposure to all residents served ice. Inadequate temperature control of residents' food during refrigeration indicates an unsafe food storage practice that can promote bacterial growth thereby increasing the nursing home residents' risk of food borne illness. The findings include: On 05/15/2023 at approximately 10:50 AM, an observation of the kitchen ice machine with District Dietary Manager F (District DM F) revealed an external surface that was unclean with unknown dark colored residue build-up and calcification present. The storage bin on the interior of the ice machine had the same type of residue as on the exterior surface. This residue appeared to be from an external leak, and, based on the amount of build-up, appeared to have been leaking for an extended period of time. The dark colored residue resembled biological growth (such as mold or mildew) and extended downward into the ice. District DM F agreed that the ice did not appear to be safe for use and stated, it needs to be cleaned. District DM F was asked when the last time the ice machine was cleaned, and he responded, I don't know, I will have to get with maintenance for the logs. District DM F stated that he will shut down the ice machine, discard the ice and have maintenance come clean it. (Photographic evidence obtained) On 05/15/2023 at approximately 12:15 PM, an observation was made of the B-Wing Nourishment Room with Certified Nursing Assistant W (CNA W). The temperature check logs were posted on the side of the nourishment refrigerator. A review of these logs showed multiple dates with empty or blank entries, indicating the temperature was not checked. An interview was conducted with CNA W during the observation regarding who was responsible for checking the refrigerator temperature. When asked who checks the temperature of this refrigerator daily and logs it on the sheet attached to the refrigerator, CNA W responded, I'm not really sure, I think nursing, maybe maintenance or dietary, I know it is stocked by dietary, think at night but not sure. On 05/15/2023 at approximately 12:50 PM, an observation was made of the A-Wing nourishment room with CNA X. Temperature check logs were posted on the wall adjacent to the refrigerator. A review of this log showed multiple dates with empty or blank entries. An interview with CNA X was conducted at this time. When asked about the delegated responsibility of checking the refrigerator temperatures and restocking snacks, CNA X stated, I think the cafeteria restocks it at night, but we can go ask for extra if we need it or it's out. I'm not sure who checks the temperature logs, maybe nursing, or dietary, maintenance might do it. She explained that when she restocks the portable ice cooler with ice for passing, she gets the ice from the B-wing ice maker or from the kitchen ice maker. When asked if she retrieved the ice currently in the portable cooler from the kitchen, CNA X stated, I don't remember, I think this was already stocked when I came in. When asked if she was aware not to use the ice from the kitchen, CNA X stated, no one has told me not to use the ice from the kitchen. On 05/15/2023 at approximately 4:00 PM, the Administrator stated, District DM F showed me the ice machine and I see your concerns with it. I just want to let you know, it has been taken completely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 39 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 out of service, and I've ordered a new one. I can provide you with a copy of the receipt if you want. Level of Harm - Minimal harm or potential for actual harm On 05/16/2023 at approximately 10:05 AM, an observation was made of employee Y (dietary aide) entering the B-Wing Nourishment room with a cart. Employee Y explained that she was about to stock. When asked to describe the blank entries on the refrigerator temperature check log, she explained it should have entries every day and that this is also dietary's responsibility to check it twice a day. Residents Affected - Some During an interview with District DM F on 05/17/2023 at approximately 1:00 PM, he was asked about temperature checks/blank logs. He stated The refrigerator temperature checks are dietary's responsibility and should be done twice a day. He explained that he was made aware of the empty logs by other staff prior to this interview and was instructed by the administrator to put up new logs and start over from the day it was brought to his attention. He agreed that blank entries on the log would indicate that the temperature checks were not done. On 05/17/2023 at approximately 3:45 PM, an interview was conducted with the Maintenance Director, who stated, I'm trying to get together the logs for any service of kitchen equipment and policies, just having a little trouble finding everything. He explained that he will get it as soon as possible. He also stated, I cleaned the inside and outside of the ice machine. A review of the Maintenance Logs for the kitchen ice machine reveal it was last serviced on 03/31/2023. Policy review: A review of the facility policy titled ICE (HCSG [Health Care Services Group] Policy 021, revised 09/2017) included: Ice will be prepared and distributed in a safe and sanitary manner. Procedures 1. The Dining Services Director and/or Maintenance Director will ensure that all ice machines are plumbed from a potable water source and that air gap drains are appropriately maintained. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. 3. The exterior of the ice machine will be cleaned weekly. 4. Ice bins will be cleaned monthly and as needed. 5. Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention. 6. Staff will adhere to proper utensil usage or clean gloved hands for handling. 7. In the event of a mechanical malfunction, ice will be purchased from an approved vendor and stored in manner that maintains proper temperature and prevents cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 40 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 - Some A review of the facility policy titled Equipment (HCSG policy 027, revised 09/2017) included: All food service equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly. A review of the facility policy titled Snacks (HCSG Policy 011, revised 09/2017) included: 7. All snacks will be properly stored for time and temperature control, as appropriate. A review of the facility policy titled Food: Safe Handling for Foods from Visitors (HCSG Policy 031, revised 09/2017) included: 5. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: Equipped with thermometers. Have temperature monitored daily for refrigeration < 41° F (Fahrenheit) and freezer < 0° F. o Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for > 7 days. (Storage of frozen foods and shelf stable items may be retained for 30 days.) o Cleaned weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 41 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, review of the quality assurance performance plan, and policy review, the facility failed to implement their corrective action plan for educating staff on ensuring the residents were served the correct diets as ordered for 2 of 5 residents selected for modified texture diets. (Resident #46 and #278). On 05/6/2023, Resident #46 was served the incorrect diet texture during the lunch meal that resulted in the resident choking on a meat patty, necessitating the Heimlich Maneuver (abdominal thrusts) by Registered Nurse (RN) D in order to clear the meat from the resident's airway. On 05/08/2023, the facility developed an immediate corrective action plan which included education of nursing and food and nutrition services staff on diet textures and consistency, and ensuring the correct diet was served to the residents, but review of the training documentation revealed the nursing staff was not trained on diet textures until 05/17/2023 and food and nutrition services staff was not trained until 05/18/2023. On 05/17/2023, Resident #278 did not receive the correct diet texture during the dinner meal. Resident #278 was ordered to receive pureed bread, but instead received a whole hamburger bun. At the time of survey, the facility census was 112 and there were 29 residents ordered to have a mechanically altered diet. This situation resulted in a finding of Immediate Jeopardy at the scope and severity of J, isolated. The facility Administrator was notified of the Immediate Jeopardy on 05/19/2023 at 5:00 PM. The Immediate Jeopardy was ongoing at the time of survey exit. Cross Reference F802, F803 and F805 The findings include: Resident #46 and #278: On 05/18/2023 at approximately 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that, on 05/6/2023, Resident #46 was in the independent dining room eating lunch and talking and chewing at the same time, that is kind of her normal behavior. One of the bites she took, she started talking and got a piece of food stuck. The nurse in the dining room responded and performed the Heimlich and was able to get the food dislodged. The DON further stated that during their investigation of the event, they identified that the resident was served a hamburger patty, and that she had spoken with the Speech Therapist who was following Resident #46 at the time. The Speech Therapist coordinated with us in developing education on the diets to in-service the staff. The DON confirmed that resident #46 diet, at the time of the incident, was on a Dysphagia Advanced Diet (a diet that consist of chopped/pureed meat, and pureed bread), and the resident was not served the correct texture of meat and choked. When asked if that would be considered harm, the DON responded yes. A record review found that Resident #278 had current orders for a Dysphagia Mechanically Altered Diet which included pureed bread. On 05/17/2023, an observation of the dinner meal revealed resident #278 did not receive the correct food texture for dinner meal. The meal ticket on the dinner tray noted that bread was to be pureed and that food was to be served in bowls and that the entrée was ground smothered turkey patty. Instead, Resident #278 was served a plate that contained dry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 42 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few chopped fish on a whole bun for dinner. A review conducted of the facility's diet manual, 2019 [NAME] & Associates, Inc. Dietary [NAME], found that the Dysphagia Mechanically Altered Diet requires all bread to be pureed. Quality Assessment and Performance Improvement (QAPI): On 05/8/2023, two Ad Hoc QAPI meetings were held regarding issues with food and nutrition services and diet accuracy which led to the choking incident. The first one was led by the DON related to nursing responsibilities regarding checking resident meal trays for accuracy. The second Ad Hoc QAPI meeting was led by the Executive Director regarding food and nutrition services staff. The QAPI team developed an Action Plan from each meeting (referred to by staff as a performance improvement plan, [PIP]), related to nursing and food and nutrition services . A review of the PIP for Nursing Education Re: Reading Tray Tickets and Correct Diets, dated 05/8/2023, found: -The section entitled Opportunity for Improvement identified: Nursing staff needs further education regarding tray slips and recognizing the correct diet. -The section entitled Data (Assess Current Situation-what were the results/trend) identified: When ALT (alternate) is put on a tray ticket nursing isn't able to always recognize the correct texture. -The section entitled Analysis (Root Cause Analysis) identified: Resident's diet texture is at the top of the dietary slip, when Alternate diet is ordered staff doesn't always recognize correct texture of diet. -The section entitled Plan identified 3 actions: 1. All CNA (Certified Nursing Assistant) and Nursing education re: diet textures. 2. CNA and nursing education re: how to correctly read dietary ticket 3. CNA and nursing education re: how to recognize alternate and verify with texture. - The section entitled Responsible Team Member(s) identified: Unit Managers, ADON (Assistant Director of Nursing), DON and Weekend Supervisor. Documentation of the training was requested for review, and a training sign-in sheet dated 05/17/2023 (9 days after the PIP) with a topic of Diet Textures and Allowances was provided. On 05/18/2023 at approximately 5:45 PM an interview was conducted with the DON regarding the delay in implementation of the PIP until 05/17/2023. The DON stated that when they identified the need for education on dietary textures for the staff, they got together with the speech therapist to clarify the diet orders and textures for the residents, then they interviewed the staff on the current understanding of the diets and textures to determine the level of understanding. The DON went on to state that they have been monitoring the dining and trays daily and had posted the new diets for the staff and have been educating the staff daily on this issue since 05/8/2023. The surveyor requested documentation to support the ongoing training, and the DON stated she did not have the staff sign an in-service sheet during that time and did not update the PIP with further identified needs for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 43 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few training. The DON confirmed that that there was no documentation that the PIP from 05/8/2023 was implemented prior to 05/17/2023. A review of the PIP developed subsequent to the second Ad Hoc QAPI Meeting related to food and nutrition services also dated 05/08/2023 revealed: -The section entitled Opportunity for Improvement identified: Resident Satisfaction related to food quality, presentation, and variety of food. -The section entitled Data (Assess Current Situation-what were the results/trend) identified: Practices put in place last year to correct dietary concerns not being followed -The section entitled Analysis (Root Cause Analysis) identified: Lack of buy in from current dietary manager. -The section entitled Plan identified: See attached PIP for plan -The section entitled Responsible Team Member(s) identified: ED and Dietary Manager [Dining Services Director]. A review of the corresponding, Four Point Action Plan, dated 05/08/2023 found that the Objective and Goal was identified as Improve overall dining experience for residents. Under the section for Action Steps the QAPI team identified: 1. Currently residents voiced concern, there is no variety, food appearance is not palatable, is often undercooked or overcooked, always available menu not being followed. 2. Dietary Manager/designee will complete the following: -Obtain dietary preferences on current residents -Review diet orders for current residents to ensure meals are being served per MD (Medical Doctor) Orders. -institute and follow the full always available menu for alternate meals 3. Current dietary (food and nutrition services) staff will be in-serviced on the following: -Providing diets that meet the needs of the residents -Adhering to established menus -Honoring preferences -Condiments are available -Silverware on trays -Using plate warmers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 44 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0867 -Proper delivery of trays to maintain temperature Level of Harm - Immediate jeopardy to resident health or safety -Proper transport of trays to the floor. Residents Affected - Few -Food palatability -Proper portion size 4. Dietary manager/designee will monitor tray line 1-time daily for 14 days . to ensure tray and tray ticket matches, preferences are honored, needed condiments and silverware are on tray, food temperatures are maintained, portions are correct, and meals are palatable. Food committee will meet weekly for 60 days . to ensure diets are served to meet the needs of the residents and preferences are honored. Findings of the tray monitoring and food committee meetings will be reported to the QAPI committee monthly, until committee determines substantial compliance has been met. Documentation of the in-service training and audits were requested for review from District Dietary Manager F (District DM F). In-service documentation was dated 05/18/2023. No tray line audits were provided, but the facility provided documentation for 3 days of meal audits prior to survey entrance. A review of the meal audit documentation found that audits with the indicator: Diets meet the needs of the resident were done following the PIP on 05/09/2023, 05/10/2023 and 05/11/2023. Each audit sampled 10 resident meals for a total sample of 50 meals. On 05/19/2023 at approximately 10:12 AM, an interview was conducted with District DM F regarding the delay in the food and nutrition services staff training following the 05/08/2023 PIP. District DM F stated, The (previous) Dietary Manager started the tray Accuracy in-service on the 8th, but that staff is no longer here. The Manager was removed from the building at the request of the facility due to the facility claiming they felt the Manager was ineffective. That was on Saturday (05/13/2023), I believe then the kitchen staff all quit, we had one aide that came to work and walked out while on the clock. The training on the tray accuracy is a broad training, it just entails the items on the trays and reading the tickets it was more of a broad overview. Diet textures are part of our education and on-boarding, we continue to educate the staff on textures. District DM F further stated, I believe the problem is an issue of reading the tickets there is a 3-point check in place of the accuracy of the meal for the resident during tray line of the starter who calls the ticket out to the cook and cook who plates it and then the drink aide who does the final check. The manager is to supervise the tray line. And then the nursing staff does another check prior to delivery to the resident. On 05/19/2023 at approximately 3:30 PM an interview was conducted with the Executive Director (ED), about the removal of the previous Dietary Manager. The ED stated he asked for him (the Dietary Manager) to be removed this past Friday (05/12/2023). The ED went on to state his last day was on Sunday (05/14/2023) prior to Survey entrance on Monday (05/15/2023). The ED further stated that the reason for the request was due to the Dietary Manager not being compliant with their PIP and corrective action plans concerning the issues in the kitchen and dining program. When the Dietary Manager left on Sunday (05/15/2023), 3 more staff left with him. A review was conducted of the document titled Policies and Procedures document subject: Quality Assurance Performance Improvement Program (QAPI) Document name: PI-215, Effective date: 11/30/2014, last revised 10/24/2022. Under Policy: The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Under Procedure: 1. The center's QAPI program is an on-going comprehensive review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 45 of 46 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 106028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Shoal Creek 500 Hospital Drive Crestview, FL 32539 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few of care and services provided to residents. Including but not limited to a. Medical Care, b. Clinical care, e. Dining Services j. Admissions, l. Medical Records. 2. Important functional areas may include but are not limited to b. admission process, c. Resident assessment, d. Quality of care, e. Quality of Life, f. Potential Adverse Events. 3. Review of activities may include but not limited to: b. Incident/accident reports, d. Interdisciplinary care planning, f. Environment of care/safety, i. Staff orientation, in-service and competence. Under Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a.) implementation, d.) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities. e.) Ensures corrective actions are implemented to address identified problems in systems. f.) Evaluates the effectiveness of actions. g.) Establishes expectations for safety, quality, rights and choice and respect. Under Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. 8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to a.) Direct observation tools. b.) Audit tools g.) Quality measures. 9. The center will develop a schedule for routine data collection. Under Performance indicators: The center will establish performance indicators for data collected. 10. The center will utilize performance indicator to establish goals, identify opportunities for improvement, and evaluate progress towards goals. Under Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). 16. The center may choose the method of corrective action i.e., Plan, Do, Study, Act or Performance Improvement Project. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 46 of 46