Inspection·September 27, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 9/24/19 at 12:41 p.m. with Resident #18 and his roommate, who assisted with verbalizing Resident 18's gestures, revealed that the staff asked him to move sometimes. He reported that it was annoying, but that he was fine. 3. Observations of the midday meal in the main dining room on 9/24/19 at 12:25 p.m. revealed that four of six burgundy table cloths were noted to have multiple bleach stains. Observations of the main dining room midday meal on 9/26/19 at 12:39 p.m. revealed that there were 8 tables being used for dining. Each of the 8 tables were noted to be covered with burgundy or blue tablecloths. Closer observations revealed that 4 of 8 tablecloths were noted to have large bleach spots on the tablecloth. An interview on 9/26/19 at 1:02 p.m. with the Housekeeping Account Manager revealed that she was a part of a contracted agency providing housekeeping services. She reported that the facility was responsible for ordering table cloths. She reported that she told the NHA two months ago about ordering new table cloths, but that he accidentally ordered napkins. She reported that when the table cloths are bleached, she would just ask for new ones, but does not request them in writing. An interview on 9/26/19 at 1:15 p.m. with the NHA revealed that he was unaware that he had ordered napkins instead of tablecloths, and that no one had mentioned it to him. He reported that he has now ordered new tablecloths, because the staff should not be using the stained ones. A request was made of the NHA for a policy related to dignity during dining. On 9/26/19 at 1:15 p.m. the NHA reported that the facility did not have a policy related to dignity during dining. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 2 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interviews the facility failed to provide dialysis services related to ensuring monitoring and ongoing assessments were conducted and documented on the Dialysis Communication Records before and after dialysis, and failed to ensure a meal was provided to a resident for dialysis treatment for one resident (#12) out of one resident who received hemodialysis. Residents Affected - Some Finding included: Review of the admission Record revealed that Resident #12 had a re-admission date of 8/3/19 and her diagnoses included end stage renal disease and Type I diabetes mellitus with ketoacidosis without coma. A review of the September 2019 physician orders for Resident #12 revealed an active physicians order dated 8/8/19 for, Dialysis [name of dialysis center] Tues (Tuesday), Thurs (Thursday) Sat (Saturday) pick up time 4:30 AM .Resident must have dialysis book and assessment before leaving and after arrival every shift for Assessment, and Fluid Restriction - 1000 cc (cubic centimeter)/day, 7-3 120ml (milliter), 3-11 120ml, 11-7 120ml every shift related to End Stage Renal Disease, with a date of 9/9/19, and Regular Diet Regular texture, Thin Liquids consistency, Regular RENAL Thin liquids, with a start date of 8/8/19, and Please make sure resident has a bagged lunch to be sent with her to Dialysis every Tues Thurs Sat @ 0430 every evening and night shift for Dialysis, with a start date of 8/8/19. On 9/25/19 at 1:14 p.m. an interview was with Staff F, Licensed Practical Nurse (LPN) related to the communication forms to be completed between the dialysis center and facility. Staff F stated Yes, we have a book, but she (Resident #12) left the book at the dialysis center. An interview with the Assistant Director of Nursing (ADON) on 9/25/19 1:29 p.m. revealed that she had not been informed that the book from Resident #12's scheduled dialysis treatment was not returned yesterday (9/24/19). At this time, she contacted the dialysis center via phone to access relevant information related to Resident #12's treatment on 9/24/19. She stated, The resident was 1.8 pounds over dry weight and will need an extra treatment. An interview at this time with Staff F revealed that she did write a nurse's note, however she did not call the dialysis center for any communication about Residents #12's treatment and stated, I wrote a note. No, I did not call the dialysis center. I guess I wouldn't know what to follow up on. An interview with the ADON, on 9/25/19 1:36 p.m. revealed that the expectation was for nurses to notify her if the communication book was left at the dialysis center, and to call for report, and document in the resident's medical record. A review of the Dialysis Communication Records for Resident #12 revealed the following: 9/26/19: The form did not include the resident's name, dialysis center name or the transport company name. The top section titled, Facility to Complete Prior to Dialysis, was not completed. It did not include information for vital signs, medications administered prior to dialysis as ordered by physician, shunt site information to include location, pain, any concerns, changes and lab information; and it was missing the nurse signature and the time that Resident #12 left for dialysis. The middle portion of the form titled, Dialysis Center to Complete for Facility, did not indicate the respirations, or time dialysis ended. It did include documentation related to an event that was checked off as No, however a note documented, Too much Fluid between TX (treatment). The middle section did indicate the resident did not have food or fluid at the time of dialysis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 3 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0698 9/24/19: The form was not available for review. Level of Harm - Minimal harm or potential for actual harm 9/21/19: The form did not include the transport company name. The middle section titled, Dialysis Center to Complete for Facility, was not completed. It did not include information for vital signs, pre or post weights, new orders received and sent with patient, time dialysis started and ended, shunt site information, lab values, events, medications given while at dialysis, recommendations, food/fluid or a signature of the representative from the dialysis center. The middle section did not indicate if the resident had food or fluid at the time of dialysis. The bottom section titled, Facility to Complete upon Return From Dialysis, was not completed. It did not include the vital signs, if the resident had pain, if the access site was checked and if the bruit/thrill was present or not, if there was bleeding, nor the signature of the facility's nurse. Residents Affected - Some 9/17/19: The form did not include the resident's name or the transport company name. The bottom section titled, Facility to Complete upon Return From Dialysis, was not completed. It did not include the vital signs, if the resident had pain, if the access site was checked and if the bruit/thrill was present or not, if there was bleeding, nor the signature of the facility's nurse. 9/7/19: The form did not include the resident's name or the dialysis center name or the transport company name. The top section titled, Facility to Complete Prior to Dialysis, was not completed. It did not include information for vital signs, medications administered prior to dialysis as ordered by physician, shunt site information to include location, pain, any concerns, changes and lab information; and it was missing the nurse signature and the time that Resident #12 left for dialysis. The middle section titled, Dialysis Center to Complete for Facility, did indicate the resident did not have food or fluid at the time of dialysis. The bottom section titled, Facility to Complete upon Return From Dialysis, was not completed. It did not include the vital signs, if the resident had pain, if the access site was checked and if the bruit/thrill was present or not, if there was bleeding, nor the signature of the facility's nurse. 9/6/19: The form did not include the transport company name. The middle section titled, Dialysis Center to Complete for Facility, section did not indicate if the resident had food or fluid at the time of dialysis. The bottom section titled, Facility to Complete upon Return From Dialysis, was not completed. It did not include the vital signs, if the resident had pain, if the access site was checked and if the bruit/thrill was present or not, if there was bleeding, nor the signature of the facility's nurse. 9/5/19: The form did not include the resident's name or the transport company name. The middle section titled, Dialysis Center to Complete for Facility, did indicate the resident did not have food or fluid at the time of dialysis. The bottom section titled, Facility to Complete upon Return From Dialysis, was not completed. It did not include the vital signs, if the resident had pain, if the access site was checked and if the bruit/thrill was present or not, if there was bleeding, nor the signature of the facility's nurse. Review of the facility policy titled, Coordination of Hemodialysis Services, Document Name N-1359, with an effective date of 11/30/14 and a revision date of 07/02/2019 revealed: a five-step procedure. The fourth and fifth steps were, 4. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center OR the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate, and 5. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 4 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 0698 Clinical record. Level of Harm - Minimal harm or potential for actual harm An interview with Resident #12 on 9/24/19 at 10:30 a.m. revealed that she leaves for dialysis at 4:30 a.m. and she did not always get a breakfast bag. She reported that she had told the nurse during night shift and the dietary staff who told her the kitchen had a list of residents that received dialysis, and that food was prepared and sent to the nurse's station during the evening shift. The resident stated, I have had to buy my own lunch, by the time I get here I'm bout to pass out and they don't get me something to eat, until lunch. Residents Affected - Some An interview with the Certified Dietary Manager (CDM) on 9/26/19 at 11:30 a.m. revealed she was aware there was one dialysis resident in the facility (Resident #12). She had prepared a ham and cheese sandwich for her. She reported that the evening staff oversees preparing the breakfast for this resident and, it was then taken to the nurse's station and kept in the refrigerator located on the unit. Confirmation of where the food was kept was conducted with the CDM and Staff H, LPN on 9/26/19 at 11:35 a.m. A clear plastic bag with a sandwich, drinks, snack and condiments were found in the nurse station refrigerator. Contents of bag were confirmed to be Resident #12's by Staff H and CDM. An interview with the Medical Records Coordinator on 9/27/19 at 1:00 p.m. revealed the facility did not have a policy for the provision of meals for residents receiving dialysis out of facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 5 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 - Many Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During record review for Resident #17 it was determined that the consultant pharmacist conducted a medication review on 1/3/19 wherein she recommended a gradual dose reduction for the drug Celexa, a recommendation to discontinue an as needed order for an enema on 5/9/19, a recommendation to correct a diagnosis for Mirtazapine on 6/12/19, and a recommendation to correct a diagnosis to support the use of the drug Risperidone on 7/9/19. There was no documentation that the attending physician had responded to the consultant pharmacist recommendations from these dates. 4. During record review for Resident #36 it was determined that the consultant pharmacist conducted a medication review on 3/6/19 with the order for Percocet listed as needed as the only medication for pain. The pharmacist requested that Acetaminophen be ordered for mild/moderate pain before ordering Percocet, a recommendation on 4/9/19 to decrease or discontinue the drug Famotidine, a recommendation on 5/8/19 to consider a gradual dose reduction for the drug Cymbalta, a recommendation on 6/12/19 to discontinue Lorazepam due to no stop date, a repeat recommendation dated 6/12/19 to use Acetaminophen before Percocet, a recommendation on 7/15/19 to discontinue Lorazepam because of no stop date, a repeat recommendation on 7/22/19 to discontinue Lorazepam, a recommendation on 7/22/19 to conduct a renal function assessment, a repeat recommendation on 8/4/19 for a renal function assessment, a recommendation on 8/16/19 to consider discontinuing Lorazepam, a third request for a renal function assessment on 8/16/19, a recommendation on 8/29/19 to discontinue Linezoloid due to risks of side effects, and a request to conduct a CBC (complete blood count) within 7 days as required for duration of drug therapy, and a fourth request to conduct a renal assessment. There was no documentation available to review that the attending physician had reviewed and responded to the pharmacy recommendations 5. During record review for Resident #40 it was determined that the consultant pharmacist conducted a medication regimen review on 1/3/19 and recommended a gradual reduction review for the drug Bupropion, a repeat recommendation dated 1/4/19 for a stop date to a PRN (as needed) order for Temazepam, a recommendation dated 3/6/19 related to clarification of a PRN order for Tramadol, a recommendation dated 5/8/19 to evaluate the continued need for Omeprazole , a repeat recommendation dated 3/6/19 for a discontinuation of Temazepam, a repeat request on 5/8/19 for a gradual dose reduction for Bupropion, a recommendation dated 7/9/19 for documentation of non-pharmacological interventions before using the drugs Ramelteon and Trazadone. There was no documentation to review that the attending physician had reviewed and responded to the recommendations. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 9/26/19 at 10:32 a.m. confirmed that there was no written response from the attending physician regarding the pharmacist recommendations for Residents #10, #17, #21, #36 and ,#40 and it was their expectation that the facility would provide the attending physician the pharmacist reports for review and comment within 30 days, but no more than 60 days if the recommendation was not urgent. The Administrator also confirmed that they were not able to locate any documentation from the previous Director of Nursing that she had reviewed the pharmacist recommendations from the last several months and had forwarded to the attending physicians for follow up. A telephone interview with the Consultant Pharmacist on 9/26/19 at 11:10 a.m. confirmed that she was new to the position , was trying to get caught up and would expect that the physician would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 6 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 - Many respond to her recommendations within 30 days, no more than 60 days from the date of her report. She also confirmed that she had received no response from the Facility Administrator, Director of Nursing or attending physicians regarding the recommendations for Residents #10, #17, #21, #36 and #40 for the last several months, and was focusing on the recent past to try and get the facility caught up. Record review of the current facility policy titled, Monthly Drug Regimen Review, revised 10/10/18, under the paragraph Consultant Reports revealed: * NON URGENT - Report provided to attending physician for timely response: Day 1-14 provide recommendation(s) to physician(s) for review and response Day 15-21 the DON/designee will contact the physician with any outstanding recommendations if no response from physician notify the Medical Director for further assistance *URGENT recommendations(s) communicated to the physician/ center at the time of the consultant pharmacist visit for a timely response. An interview with the administrator on 9/26/19 at 11:05 a.m. confirmed that the drug regimen review policy was current and should have been followed. Based on record review and interview, the facility failed to ensure that irregularities found by the pharmacist during the monthly medication regimen review were reviewed by the attending physician; with documentation in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address the recommendation for 5 residents (#21, #10, #17, #36, and #40) of 5 residents sampled. Findings included: 1. Review of Resident #21's record revealed the Consultant Pharmacist conducted medication reviews on 5/6/19, and 7/9/19. On 5/6/19 the Consultant Pharmacist made a recommendation to consider clarifying parameters for use of lisinopril. Review of the the Order Summary Report for September 2019 revealed that the current order for Lisinopril did not have any parameters in place. On 7/9/19 the Consultant Pharmacist noted that at that time the resident was taking: 1. Buspirone HCL 10mg (milligrams) BID (two times a day), 2. Ambien 5mg QHS (every bedtime), 3. Cymbalta 30mg BID, 4. Lorazepam 0.5mg Q12H (every 12 hours). The Consultant Pharmacist recommended attempt a gradual dose reduction (GDR) to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 7 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 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 1. Buspirone HCL 10mg QD (one a day), Level of Harm - Minimal harm or potential for actual harm 2. Ambien 5mg QHS, reevaluate continued use, 3. Cymbalta 30mg QD, Residents Affected - Many 4. Lorazepam 0.25mg Q12H. Review of the Order Summary Report and the Medication Administration Record for the month of September 2019 revealed that the resident had current orders and was currently receiving the following: 1. Buspirone HCI 10mg BID 2. Ambien 0.5mg QHS 3. Cymbalta 30mg QD & Cymbalta 60mg QHS 4. Lorazepam 0.5mg Q12H There was no documentation that would indicate that all the recommendations for GDR were conducted for each of the identified medications. Review of the identified consultant pharmacy recommendations revealed that there was no documentation or indication that would indicate that the attending physician had reviewed and responded to the consultant pharmacist recommendations. 2. A record review for Resident #10 indicated she was admitted on [DATE] with multiple diagnoses that included dementia and major depressive disorder. A review of the active physician orders for September 2019 indicated Donepezil HCl (Aricept) Tablet 5 MG (milligrams) to be given at one time a day for altered mental status. A continued record review for Resident #10 revealed that the Consultant Pharmacist conducted a medication review on 09/10/19. Her recommendation indicated the resident had tolerated the dosage and medication for four weeks and asked for an increase in dosage of the medication to be Donepezil HCl (Aricept) Tablet 10 MG once daily in the evening prior to bedtime, which might provide additional benefits to the resident. There was no documentation in the medical record by the facility for the dose increase, and the attending physician had not responded to the consultant pharmacist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 8 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews, and policy review, the facility failed to follow their policy to ensure controlled substances were stored in a permanently attached compartment in the refrigerator in the medication storage room and did not appropriately secure medications in two of two medication carts. Findings included: A facility provided policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date of 07/23/19, Page 01 of 03, was reviewed and revealed: 3. General Storage Procedures 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. On 9/26/19 at 8:13 a.m., an observation of one of one medication storage room for the facility was conducted. The refrigerator was locked, contained a locked black box which was observed to not be attached to the refrigerator unit. (Photographic Evidence Obtained.) The box was opened by the Assistant Director of Nursing (ADON), who confirmed the contents to be a box of Lorazepam (Ativan) 2MG (milligram)/ML(milliter) with two unopened vials in it. According to The United States Drug Enforcement Administration (DEA) drug scheduling alphabetical listing, https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf Page 10 of 17, Lorazepam (Ativan) DEA number 2885, is a Benzodiazepine, a Schedule IV medication and a considered a controlled substance. On 9/26/19 at 10:10 a.m., an observation of the medication cart located on the North Unit included, in the front of the first (top) drawer, three loose medications. Staff H, Licensed Practical Nurse (LPN) confirmed the presence of the one white tablet, one beige capsule and one brown capsule. (Photographic Evidence Obtained.) The back part of the drawer had four loose tablets. Staff H confirmed one large white tablet, a white pill, a small piece of a white tablet and a pink tablet. (Photographic Evidence Obtained.) Further observation in the second drawer revealed 1.5 loose tablets a pink and ½ of a white tablet. Staff H confirmed the presence of unsecured tablets in the drawer. (Photographic Evidence Obtained.) On 9/26/19 at 10:25 a.m., an observation of the medication cart on South Unit included, in the first top drawer, loose and unsecured tablets. Staff G, LPN confirmed the presence of three tablets, a yellow, a white and a blue tablet in the first (top) drawer. (Photographic Evidence Obtained.) An observation of the second drawer included 1.5 loose tablets. Staff G and the Assistant Director of Nursing (ADON) confirmed the presence of the unsecured tablets. Review of facility provided policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date of 07/23/19, Pzge 02 of 03, under General Storage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 9 of 10 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 105012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Sea - Pasadena 1820 Shore Dr S South Pasadena, FL 33707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reads: 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 9/26/19 at 10:40 a.m., an immediate interview with the ADON was conducted. She confirmed Staff H brought her a medication cup of 8.5 unsecured medications found in her cart. And she also confirmed through partial observation 4.5 unsecured medications in Staff G's medication cart. The ADON indicated all carts are to be cleaned weekly. She stated, My expectation is that every nurse cleans the carts on all shifts. On 9/27/19 at 9:08 a.m., a telephone interview was conducted with facility's Pharmacy Consultant. The pharmacist was informed of thirteen unsecured or loose pills that were found in both the North and South Unit medication carts. She stated, My expectation is that there are no loose pills in the medication carts, and I would expect the box to be chained to the refrigerator, as that is what I usually see. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105012 If continuation sheet Page 10 of 10