Inspection·August 29, 2024

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures for individual activities, the facility failed to provide recreational activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for one of one resident sampled for activities. (Resident #4) Residents Affected - Few The findings include: Observations: On 08/26/24 at approximately 01:23 PM, Resident #4 was seen sitting in a wheelchair at the nurses' station not engaged with any activities and with her eyes closed. On 08/27/24 at approximately 10:41 AM, Resident #4 was seen lying in bed with eyes closed. The resident does not have a TV but a radio/CD player is observed on the nightstand, but it is not on. On 08/27/24 at approximately 04:01 PM, Resident #4 was observed lying in bed with eyes closed, but the music was not on. On 08/28/24 at approximately 08:38 AM, Resident #4 was observed sitting in a reclining broda chair at the nurses station. Both hands are clenched and drawn in toward her torso. The residents' eyes are closed. Staff interviews: On 08/28/24 at approximately 12:10 PM, Staff A, a certified nursing assistant (CNA), stated that the resident does not participate in activities and does not have a TV in her room. She acknowledged that there is a radio/CD player in the resident's room, however the CNA states the resident does not have any CD's, and they do not play music for the resident. On 08/28/24 at approximately 03:16 PM, the Activities Director stated in an interview, the resident is care planned for 1 on 1 visits, the 1 on 1 visits are done several times per week if not daily. Charting on the activity provided is to be done daily by the activity's aides. The Activities Director was asked for documentation concerning Resident #4's activities. On 08/28/24 at approximately 04:01 PM the Activities Director stated, there was missed documentation for the department, we do not have any documentation for [Resident #4]'s participation in activities. Record review: A review of Resident #4's care plan revealed that she is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, disease process, blindness, immobility and physical limitations. Goals include: the resident will participate in activities of choice 2/3 times weekly by next review date. Interventions include bedside /in-room visits and activities if unable to participate in out of room events, the resident needs assistance to activities functions, the resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured, activities such as: talking to resident, playing music, massaging lotion on hands and legs. The resident prefers the following radio station: gospel music. (photographic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 2 of 4 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 08/29/2024 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 0679 evidence obtained). Level of Harm - Minimal harm or potential for actual harm A review of the quarterly minimum data set (MDS) dated [DATE], revealed that, in response to, How important is it to you to listen to music you like?, it was noted as very important. Residents Affected - Few During a review of the EMR, it was discovered that no documentation was present for Resident #4's participation in activities for the last 30 days. (photographic evidence obtained). A review of the facilities policy and procedure named, Individual Activities, CL-540, dated 11/01/2021, indicates: Preferred activities and activity times of the resident can be found on the Psychosocial Evaluation, Activity Plan of Care, and MDS. Duration and visits according to need/tolerance, with a minimum of three times per week for fifteen-minute periods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 3 of 4 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 08/29/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, staff interview, and policy review, the facility failed to ensure the provider documented a resident specific rationale for declination of a pharmacist's request for a gradual dose reduction for a psychotropic medication for 1 of 5 sampled residents reviewed for unnecessary medications. (Resident #25) The findings include: A review of Resident #25's medical record revealed a Consultant Pharmacist Medication Regimen Review dated 7/10/24. The physician recommendation stated the resident had been receiving Paxil (an anti-depressant) 40 mg, 1 tablet by mouth one time a day, starting in January 2024. This review states, If an anti-depressant is used for sleep or to manage behavior, stabilize mood, or treat a psychiatric disorder, it must be reviewed for a possible gradual dose reduction in an effort to find the lowest effective dose. If a dose reduction is deemed clinically contraindicated at this time, please state the rationale below and the risk versus benefit of continuing the drug at the current dose. The physician's response stated to continue the medication and did not include a specific rationale for continuing the medication. An interview was conducted with the Director of Nursing (DON) on 8/28/24 at 9:38 AM. The DON stated a new psychiatric group was going to be taking over the review of any gradual dose reduction requests for psychotropic medications and the facility refers to the notes from the psychiatric provider stating to continue the current medications. She was not able to provide a documented, specific rationale from the provider for continuing the Paxil. Review of the facility policy for Medication Management- Psychotropic Medications (document N-1255 revised 10/24/22) revealed on page 2, gradual dose reductions to be attempted per accepted standards of practice unless clinically contraindicated. Documentation by the prescriber includes specific risk versus benefit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106028 If continuation sheet Page 4 of 4