Health inspection·December 22, 2021

F 0558 was talking about. Level of Harm - Minimal harm or potential for actual harm On 12/22/21 at 9:49 a.m. an interview was conducted with the Social Services Director, she stated [Resident #11] was seen in November (2021) by [Eye Care Company] and she was not aware his glasses were broken. Residents Affected - Few An interview was conducted on 12/22/21 at 10:20 a.m. with Staff G, Registered Nurse (Resident #11's nurse for the shift) and she confirmed Resident #11's glasses have been broken for a while now. A policy related to dignity was requested and was not provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 2 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assist one resident (#43) of thirty-two sampled residents with Activities of Daily Living (ADLs) related to not assisting Resident #43 up and out from bed daily for three days (12/20/2021, 12/21/2021 and 12/22/2021) of three days observed. Residents Affected - Few Findings included: On 12/20/2021 observations at 9:45 a.m., 10:20 a.m., 11:45 a.m., 1:20 p.m. and 3:15 p.m. revealed Resident #43 in her room either lying in bed with the head of the bed at forty-five degrees, not dressed for the day, or in bed with the head of the bed at forty-five degrees with the blanket pulled over her head. Resident #43 was observed to be calling out and yelling at 9:45 a.m., 10:20 a.m., 11:45 a.m. and 1:20 p.m. and was visited by various staff members at these times and then she would stop yelling out. Resident #43's television was not observed on nor was there any type of radio on. Staff did not get Resident #43 up and out from bed during this timeframe. Resident #43 had a wheelchair that was positioned and placed near the foot of her bed. Resident #43 was observed with cognitive deficits and was not able to answer questions related to her care and services. An observation at 3:15 p.m. revealed Resident #43 in her bed playing an oversized electronic organ/piano, which was placed on her lap. She was also observed singing. It was observed that a music activity with a musician was held on 12/20/21 at 10:00 a.m. and Resident #43 was not at this activity nor was there documentation to show the resident was offered an opportunity to attend. On 12/21/2021 from first observed visit at 7:00 a.m. through to approximately last observed visit at 4:00 p.m. revealed Resident #43 was again observed in her room and lying or seated upright in bed. She was observed again at times with her head covered with a blanket. The wheelchair was placed near the foot of her bed. Resident #43 was observed at times calling out loudly and then visited by staff for a brief time. After the lunch meal, she was again observed playing her electronic organ and was singing. It was again observed that staff did not get Resident #43 up out from bed during the entire observed timeframe. On 12/21/2021 at 11:00 a.m. Resident #43's family member was interviewed via telephone. She indicated she does visit during the week and weekends. She revealed that she was allowed to visit in the facility and while Resident #43 was in her room. The family member indicated she had a couple of concerns and mentioned them during care plan meetings and to various staff members on the weekends, evening shift and day shift. She indicated that she knows Resident #43 would get up out from bed if assisted. The family member revealed Resident #43 cannot get up out from bed on her own and needs staff to get her up. She does not believe staff are offering or trying to get her up out of bed during the day. She feels Resident #43 would benefit more if she was at least up out from bed and in her wheelchair. The family member did not know if Resident #43 has ever refused getting up out of bed but when she visits, Resident #43 has told her that she would get up out of bed if helped. On 12/21/2021 at 1:30 p.m. an interview with Staff E, Licensed Practical Nurse (LPN) revealed Resident #43 loves to play her piano, and loves music. She further revealed Resident #43 was a musician at her church and played the piano there. Staff E also revealed she has seen Resident #43 at music activities and did not know why she was not present in the group music activity the day before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 3 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (12/20/2021), nor why she was not present and or offered to attend the current day's (12/21/2021) group social and music activities. She explained the certified nursing assistants and activities staff are to go to resident rooms every day and offer and assist with activities. On 12/22/2021 from first observed visit at 6:45 a.m. through to at least last observed visit at 5:00 p.m., Resident #43 was in her room and lying in bed under the covers and with the covers over her head. She had been observed yelling out at times but staff were able to redirect her after brief visits. Resident #43 was again observed playing her electronic organ/piano after lunch service for about thirty minutes. She had also been observed singing to herself while playing the organ/piano. Resident #43 was visited by this surveyor as she was playing the organ/piano and she was very excited to have a visitor and wanted to play and sing to this surveyor. She was asked if she wanted up out from bed at times and grabbed this surveyor's hand and shook her head up and down in a yes manner. It was observed that staff did not get Resident #43 up out from bed all day. Her wheelchair remained near the foot of her bed. On 12/22/2021 this surveyor was seated at the nurses' station, about ten feet from the resident's room from 7:30 a.m. through to 11:00 a.m. It was observed that staff had not offered or assisted Resident #43 up out from bed or to go to any of the day's scheduled social and music activities. There was a scheduled group activity in the main dining rooms that included Morning social with coffee at 10:00 a.m. On 12/22/2021 at 12:30 p.m. an interview with Staff C, Certified Nursing Assistant (CNA), who had Resident #43 on her work assignment, revealed she does know Resident #43 a little but did not know if she likes to go to group music or group social activities. She confirmed she did not get the resident up an out of bed this a.m. and did not offer her to go to any group activity scheduled for the day. Staff C confirmed the resident has refused to get up out of bed and that they (the aides and nurses) are to document those refusals. Staff C was unsure if there was any documentation to support the resident refusing to get up out of bed and attend activities. Staff C revealed she was an agency nurse and was not aware that she should have asked Resident #43 if she likes to go to activities. Staff C further revealed she thought it was the responsibility of the activity staff to go in the rooms and ask the residents if they want to attend activities. She further believed if the resident said yes, then the activities staff would let her know and she would then get the resident up out of bed and transferred to the activity. On 12/22/2021 at 2:00 p.m. an interview with the Director of Nursing (DON) revealed it is the responsibility of the floor direct care staff to get residents up and out of bed and offer and transfer if needed to activities. She was unaware Resident #43 had been in bed the past three days and also confirmed the resident does like music activities. The DON indicated the resident should be assisted up and out of bed to her wheelchair when tolerated but was unsure why Resident #43 had been in her room and in bed the past three days. The DON confirmed the Activities Director was on an extended leave and usually she assisted with residents transferring from room to the activities/dining room. Also, the DON revealed at this time there was only the activities assistant who was responsible for setting up group activities. The DON could not provide any documentation of Resident #43 refusals to get up and out from bed or any documented behaviors of refusals to attend activities. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] and included diagnoses of muscle weakness, difficulty in walking, unsteady on feet, cognitive communication deficit, anxiety, major depression, dementia and mood disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 4 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/18/2021, revealed: Section C Cognitive Patterns a Brief Interview for Mental Status score as not scored but indicated Short Term/Long Term memory deficit problems, with severely impaired decision making skills. Section G Functional Status indicated for the Activities of Daily Living (ADLs) of Bed Mobility, Transfers, Dressing, Toilet use, and Personal Hygiene as extensive assist with one person assist. Section D Mood showed none as documented and Section E for Behaviors showed none as documented. Review of the Resident #43's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated for the months of 11/2021 and 12/2021 did not indicate or have documented behaviors of refusing to get up from out of bed. Nurse progress notes reviewed from 8/20/2021 to 12/22/2021 did not indicate documentation of Resident #43 refusing to get up from out of bed, nor was there documentation of Resident #43 refusing to be seated in her wheelchair. Review of the Certified Nursing Assistants Activities of Daily Living (ADL) flow sheet for the 12/2021 revealed ADL assistance was documented as completed to include Bed Mobility and Transfers. However, it was determined through observations on 12/20/2021, 12/21/2021, and 12/22/2021 Resident #43 was not Transferred or assisted with Bed Mobility. Review of the current care plans with the next review date of 3/1/2022 revealed the following Focus areas: A. [Resident #43] has an ADL self-care performance deficit r/t (related to) dementia, fatigue, impaired balance, impaired vision, incontinent. [Resident #43] and is able to feed herself, initiated on 11/29/18 and revised on 9/14/21. Interventions included: TRANSFERS - Resident requires assistance by 1 staff to move between surfaces. B. [Resident #43] has a behavior problem r/t depression, periods of delusions, history of anxiety and as of 1/14 (2020) - resident has been yelling out- medication in place, initiated on 11/29/18 and revised on 1/14/2020 with interventions in place. C. [Resident #43] has impaired cognition function/dementia or impaired thought processes r/t Dementia, initiated on 11/29/18 and revised on 11/29/18, with interventions in place. D. [Resident #43] is at risk for c/o (complaint of) pain r/t dementia, depression, generalized discomfort, initiated on 11/29/18 and revised on 11/29/18. Interventions included: report to nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx (signs/symptoms) or c/o pain or discomfort. It was determined through review of the care plans, there were no care plan problem areas to include Resident #43 wanting to stay in bed, wanting to stay in her room and not wanting to attend activities. On 12/22/2021 at 4:00 p.m. the DON and Nursing Home Administrator confirmed there was no specific policy and procedure in relation to Activities of Daily Living assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 5 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review the facility failed to ensure necessary services to maintain good nutrition related to meal assistance for one resident (#324) out of 32 sampled residents. Residents Affected - Few Findings included: On 12/20/21 at 12:45 p.m. Resident #324 was observed feeding himself his lunch. He yelled to the surveyor, Can you get someone to come help me eat. On 12/20/21 at 12:46 p.m. Staff H, Licensed Practical Nurse (LPN) stated Resident #324 needs assistance eating. On 12/20/21 at 12:50 p.m. Staff I, Certified Nursing Assistant (Agency) was observed standing while providing assistance to Resident #324 with his lunch. She stated she did not need a chair to sit down because she was almost done. Review of Resident #324's admission Record revealed he was admitted on [DATE] from an acute care hospital with diagnoses that included muscle weakness, muscle wasting and atrophy. An observation and interview with Resident #324 were conducted on 12/21/21 at 8:11 a.m. The resident was observed sitting in front of his breakfast tray that contained a muffin with jelly, scrambled eggs, and an opened carton of milk with a handled sippy cup on his tray not in use. He stated the eggs are not that great and he would like ketchup for them. The resident stated he prefers to eat in his room. They do offer to take him to the dining room, but he's more comfortable in the room right now. He said he did not have anyone help him eat this morning, but he normally does need help because he has a hard time seeing his food, but he was able to pour his milk in his cereal this morning without spilling it. Review of Resident #324's Minimum Data Set assessment, dated 9/23/21, Section C - Cognitive Patterns revealed a Brief Interview for Mental Status score of 12 out of 15 indicating moderate cognitive impairment. Review of Resident #324's Nutrition Evaluation dated 12/22/21 revealed .M. chewing/swallowing concerns: Yes N. adaptive equipment: 2 handled cup with every meal O. comments: resident was alert with confusions. Noted that he had a diagnosis of legally blind. The staff provided supervision and assistance when need it. .Y. Assessment: [Resident #324] assessed at nutritional risk due to impaired vision, significant weight loss, and high needs for assistance. Noted that weight loss showed after readmission on 12/14 with status post cholecystectomy Tube for bile drainage. Weights were stable after re-admission and in overweight range. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 6 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0677 Level of Harm - Minimal harm or potential for actual harm .Z5. Plan/Recommendations: weekly weights x 4 weeks; will monitor PO [oral] intake and provide assistance when need it. Will follow with OT [occupational therapy] evaluation for additional adaptive equipment. Will follow on next available lab reports. Review of Resident #324's physician orders for December 2021 revealed: Residents Affected - Few An order start date of 12/16/21 with no end date for: Regular diet, dysphagia advanced texture, regular/thin liquids consistency. In addition a physician order start date of 12/16/21 with no end date for a 2 handled cup with all meals. Staff interview was conducted on 12/21/21 at 12:41 p.m. with Staff J, Certified Nursing Assistant (CNA) she stated she was the CNA for Resident #324 today and he does need assistance eating his meals because he has a hard time seeing his food. He can eat by himself, but he has a hard time seeing so that's why I help him. I helped him eat his lunch today. She stated it is not written down anywhere, who needs help with eating and who doesn't, they will just tell you who needs help when they are first admitted , but I just go by who I see is struggling. For agency staff to know who needs help or not, I don't know, it's not written down or in our tasks in the electronic record. To see if the person needs assistance or not you have to look back on the task list for feeding to see what assistance they need. On 12/21/21 at 12:48 p.m. Staff K, Registered Nurse (RN) stated Resident #324 needs assistance eating; it's good to let him try but he has a hard time seeing his food and objects. So, definitely someone needs to assist him. Review of the Resident #324's care plan revised on 12/1/21 revealed a focus are for [Resident #324] is at risk for a nutritional problem r/t (related to) multiple medical dx. (diagnosis) initiated on 6/30/21: triggered for the significant/planned weight loss x 3 months. PO intake continued to be good; initiated on 9/22/21: no significant changed in weights x 3 months. PO intake continued to be good; and initiated on 12/1/21: Triggered for the significant weight loss x 3 months. PO intake fluctuated. The interventions included: Registered Dietitian to evaluate and make diet change recommendations as needed, encourage use of 2 handled cup at meal times and provide and serve diet as ordered. Review of Resident #324's [NAME] dated as of 12/22/21 revealed Eating: independent-setup as needed. An interview was conducted with the Director of Nursing on 12/22/21 at 12:36 p.m. She stated, My expectation is the CNAs are using their point of care. It should be on their task list that he needs assistance. The DON confirmed he should have assistance eating; that is new for him, and she confirmed the [NAME] for the CNAs is not updated. A policy for providing meal assistance and a policy for activities of daily living (ADL) was requested. The facility confirmed they do not have any policies related to meal assistance or ADLs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 7 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 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 and resident family interviews, and medical record review, the facility failed to ensure implementation of care planned preferences of activities for one resident (#43) of thirty-two sampled residents related to failing to offer or assist Resident #43 to group music activities for three days (12/20/2021, 12/21/2021, and 12/22/2021) of three days observed. Residents Affected - Few Findings included: On 12/20/2021 at 9:45 a.m., 10:20 a.m., 11:45 a.m., 1:20 p.m. Resident #43 was observed and overheard with calling out and yelling out behaviors. She was easily redirected and stopped yelling out when staff came in the room to visit her. Each observed time revealed she was in her room and lying flat in bed, under the covers and with the head of her bed at approximately forty-five degrees. From 9:45 a.m. to 3:00 p.m. Resident #43 was not observed to be offered or assisted to get up out from bed and brought to any of the scheduled group activities. On 12/20/21 at 10:30 a.m. the main dining room/activities room was observed with a scheduled music activity called, Music with [name of performer]. This group activity was an outside of the facility sourced musician who visited the facility to play various songs with a guitar. The activity lasted roughly one hour. Resident #43 was not invited, nor assisted to this music activity. On 12/20/21 at 1:30 p.m. an interview with both Staff A, Certified Nursing Assistant (CNA) and Staff D, CNA, revealed that Resident #43 has been in bed all day and they believed that she wanted to stay in bed and not get up. Neither confirmed if they offered or assisted Resident #43 to the 10:30 a.m. live music group activity. Staff A, who had the resident on her assignment replied, I didn't know there was a music activity. Staff A and D also confirmed they know Resident #43, and that she does love music and loves to go to music activities. Staff A believed the activities staff usually go from room to room to ask the residents if they like to go to the day's activities. On 12/20/21 at 3:15 p.m. Resident #43 was observed in her room and in bed and with the head of her bed at approximately forty-five degrees. She had an oversized electronic keyboard over her lap and was playing the keyboard and was also singing. She was observed to sing and play her keyboard for about one hour. Various random interviews with over five passing direct care staff all revealed that Resident #43 loves music and used to play the piano at her church and plays her keyboard several times a day. On 12/21/2021 from continued observations from 7:10 a.m. through to 3:00 p.m. revealed Resident #43 was in her room and lying or seated upright in bed, and under the covers. At times Resident #43 was observed with the blanket pulled over her head. However, this State surveyor visited the resident several times through the day and each time she was visited, she lit up and wanted to touch this surveyor's hand and smiled. She was unable to be interviewed as she had cognitive impairments. However, when asked if she would like to go to the various group activities with either coffee and social or anything music related, she confirmed that she would have wanted to go. She was not aware of the person who played the guitar and sang the day before, on 12/20/2021. In addition, at times through the observations from 7:10 a.m. through to 3:00 p.m., Resident #43 was overheard calling and yelling out. However, when visited by staff, she would stop yelling out. On 12/21/2021 at 1:30 p.m. an interview with Staff E, Licensed Practical Nurse (LPN) revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 8 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #43 loves to play her piano, and loves music. She further revealed Resident #43 was a musician at her church and played the piano there. Staff E also revealed she has seen Resident #43 at music activities and did not know why she was not present in the group music activity the day before (12/20/2021), nor why she was not present and or offered to attend the current day's (12/21/2021) group social and music activities. She explained the certified nursing assistants and activities staff are to go to resident rooms every day and offer and assist with activities. On 12/21/2021 at 2:00 p.m. Resident #43 was observed seated upright in her bed, under the covers and with the call light placed within her reach. She was observed with her oversized electronic piano/organ over her lap and she was playing music and singing. On 12/21/2021 at 11:00 a.m. Resident #43's family member was interviewed via telephone. She indicated she does visit during the week and weekends. She revealed that she was allowed to visit in the facility and while Resident #43 was in her room. The family member indicated she had a couple of concerns and mentioned them during care plan meetings and to various staff members on the weekends, evening shift and day shift. She indicated that she knows Resident #43 would get up out from bed if assisted. The family member revealed Resident #43 cannot get up out from bed on her own and needs staff to get her up. She does not believe staff are offering or trying to get her up out of bed during the day. She feels Resident #43 would benefit more if she was at least up out from bed and in her wheelchair. The family member did not know if Resident #43 has ever refused getting up out of bed but when she visits, Resident #43 has told her that she would get up out of bed if helped. Resident #43's family member was unaware if the resident was brought to any various group activities, specifically with relation to music. She noted that Resident #43 loves music and would go to pretty much any music activity there was, especially those who have live entertainment. On 12/22/2021 at 7:00 a.m. 9:00 a.m., and 11:00 a.m. Resident #43 was observed in her room and lying in bed under the covers and with the covers pulled over her and sometimes over her head. On 12/22/2021 this surveyor was seated at the nurses' station, about ten feet from the resident's room from 7:30 a.m. through to 11:00 a.m. It was observed that staff had not offered or assisted Resident #43 up out from bed or to go to any of the day's scheduled social and music activities. There was a scheduled group activity in the main dining rooms that included Morning social with coffee at 10:00 a.m. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] and included diagnoses of muscle weakness, difficulty in walking, unsteady on feet, cognitive communication deficit, anxiety, major depression, dementia and mood disorder. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/18/2021, revealed: Section C Cognitive Patterns a Brief Interview for Mental Status score as not scored but indicated Short Term/Long Term memory deficit problems, with severely impaired decision making skills. Section G Functional Status indicated for the Activities of Daily Living (ADLs) of Bed Mobility, Transfers, Dressing, Toilet use, and Personal Hygiene as extensive assist with one person assist. Section D Mood showed none as documented and Section E for Behaviors showed none as documented. Review of the current Physician Order Sheet included behavior note orders, dated for the month 12/2021 and included types of intervention attempted as: A. Type of intervention attempted 1=1:1, 2= Activity, 3= Back rub, 4=increased falls, 5=care plan, 6=give food, 7= weakness, 8= visual disturbance, 9. Gastrointestinal dist., 10= other, see progress notes; every shift put in corresponding code from above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 9 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few B. 0-no behavior, 1-agitation, 2- combative, 3- verbally inappropriate, 4- sexually inappropriate, 5- crying, 6calling out, 7-screaming, 8 - inappropriate, 9- delusions, 10- resists care, 11- socially inappropriate, 12other see progress notes; every shift type the medication class put in corresponding code. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for month 12/2021 revealed: documented coding related to calling out on 12/3, 12/6, 12/16, 12/17, and 12/20. Review of the December 2021 MAR and TAR revealed: documented coding related to screaming on 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/16, 12/17, 12/18, 12/19, and 12/21. Nurse progress notes review from 8/20/2021 to 12/22/2021 revealed the following: 9/1/2021 11:23 (11:23 a.m.) - Community Life note - Is able to make requests for her needs and wants. She participates in some of the group activities. She loves to play the piano and she loves to listen to music. She loves coffee social and sweets. She loves it when her daughters come to visit her. She's been yelling more lately. Able to put music on for her. A continued review of Resident #43's medical record to include nurse progress notes dated from 7/1/2021 through to current notes 12/22/2021 did not indicate she had ever refused to get up out from bed, nor were there any notes that indicated the resident liked to stay in her room, in bed and does not want to attend activities. Review of the Psychosocial assessment dated [DATE] did not reveal anything related to likes/dislikes with activities. Review of the Psychosocial assessment dated [DATE] revealed Resident #43 was assessed for: Section A. 1 (Routines) - Very important to the resident Section B. 1. (Hobbies/Interests) - Day/activity room occurs Section B. 3. (Preferred time of activities) - Afternoon Section B. 14. (Cultural events) - Current with preference Section B. 15. (Current events/news) - Current with preference Section B. 23. (Movies) - Current with preference Section B. 24. (Music) - Current with preference Section B. 25. (Radio) - Current with preference Section B. 27. (Religious services) - Current with preference Section B. 31. (Sing-alongs) - Current with preference (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 10 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 Section B. 32. (Social/parties) - Current with preference Level of Harm - Minimal harm or potential for actual harm Section G. 4. (Motivation) - Needs encouragement - willing to try Residents Affected - Few Review of the Community Life Progress Review Sheet, dated 11/17/2021, revealed in a note that Resident #43 does not regularly participate in activities. However, the assessment did reveal that she does participate in daily small and large group activities. Review of the current care plans with the next review date 3/1/2022 revealed the following areas: - Resident is independent on staff for meeting emotional, intellectual, and social needs r/t (related to) cognitive deficits; likes to play her keyboard. Interventions included: Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities with known interests and preferences, adapted as needed, compatible with individual needs and abilities and age appropriate, establish and record residents prior level of activity involvement and interests by talking with the resident, caregivers, and residents representative on admission and as necessary, invite the resident to scheduled activities, provide with activities calendar, notify resident of any changes to the calendar of activities, Resident needs assistance/escort/reminders to activity functions, the resident preferred activities are playing her keyboard, coffee hour, parties, movies, music, church services, and small groups. - [Resident #43] has an ADL self-care performance deficit r/t (related to) dementia, fatigue, impaired balance, impaired vision, incontinent. [Resident #43] and is able to feed herself, initiated on 11/29/18 and revised on 9/14/21. Interventions included: TRANSFERS - Resident requires assistance by 1 staff to move between surfaces. - [Resident #43] has a behavior problem r/t depression, periods of delusions, history of anxiety and as of 1/14 (2020) - resident has been yelling out- medication in place, initiated on 11/29/18 and revised on 1/14/2020 with interventions in place. - [Resident #43] has impaired cognition function/dementia or impaired thought processes r/t Dementia, initiated on 11/29/18 and revised on 11/29/18, with interventions in place. There were no care planned focus areas or interventions that indicated Resident #43 refuses care and services and or refuses going to group activities. On 12/22/2021 at 11:45 a.m. it was determined the Activities Director was out on leave for a period of time. It was determined through interview with the Activity Assistant and the Director of Nursing that the Activity Director had been out on leave since 11/2021. An interview was obtained with the only Activities Assistant at 11:46 a.m. The Activities Assistant revealed she helped to set up the group activities or other scheduled activities during her daytime shift. She further revealed that she does not transfer all the residents from their respective spaces to the activity/dining room, and that is the responsibility of the floor aides to get the residents up and out from bed and transferred to the activities room. The Assistant revealed she is knowledgeable of Resident #43 and confirmed that she had not been attending any of the group activities this week. The Assistant confirmed they were short staffed as the Director was out on leave. She further revealed she had to rely on floor staff to offer the residents and bring the residents to scheduled activities. The Assistant further confirmed Resident #43 does like activities to include live (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 11 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few music visits, other music, coffee and groups. She also confirmed in the recent past Resident #43 had been at most of the activities. She did not know why the resident was not brought to any of the group activities the past three days to include (12/20/2021, 12/21/2021, and 12/22/2021). On 12/22/2021 at 12:30 p.m. an interview with Staff C, Certified Nursing Assistant (CNA), who had Resident #43 on her work assignment, revealed she does know Resident #43 a little but did not know if she likes to go to group music or group social activities. She confirmed she did not get the resident up an out of bed this a.m. and did not offer her to go to any group activity scheduled for the day. Staff C confirmed the resident has refused to get up out of bed and that they (the aides and nurses) are to document those refusals. Staff C was unsure if there was any documentation to support the resident refusing to get up out of bed and attend activities. Staff C revealed she was an agency nurse and was not aware that she should have asked Resident #43 if she likes to go to activities. Staff C further revealed she thought it was the responsibility of the activity staff to go in the rooms and ask the residents if they want to attend activities. She further believed if the resident said yes, then the activities staff would let her know and she would then get the resident up out of bed and transferred to the activity. Staff C did also confirm that the resident loves music and plays the piano/organ in her room. On 12/22/2021 at 2:00 p.m. an interview with the Director of Nursing (DON) revealed it is the responsibility of the floor direct care staff to get residents up and out of bed and offer and transfer if needed to activities. She was unaware Resident #43 had been in bed the past three days and also confirmed the resident does like music activities. The DON indicated the resident should be assisted up and out of bed to her wheelchair when tolerated but was unsure why Resident #43 had been in her room and in bed the past three days. The DON confirmed the Activities Director was on an extended leave and usually she assisted with residents transferring from room to the activities/dining room. Also, the DON revealed at this time there was only the activities assistant who was responsible for setting up group activities. The DON could not provide any documentation of Resident #43 refusals to get up and out from bed or any documented behaviors of refusals to attend activities. The DON did not have a specific Activities policy and procedure for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 12 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interview, and medical record review, the facility failed to ensure one resident (#15) of thirty-two sampled residents received services to maintain or promote further range of motion for a contracture related to not applying a hand splint for three (12/20/2021, 12/21/2021, and 12/22/2021) of three days. Findings included: On 12/20/2021 at 2:12 p.m. Resident #15 was observed in his room, lying in bed. Resident #15 was interviewable but had verbal difficulties. Further observation revealed Resident#15's right hand appeared contracted and was placed/positioned on his stomach area. Resident #15 was not wearing a hand splint on his right hand during the observation. However, a blue and black splint was observed placed on the left side of the bed on a dresser, out from his reach. On 12/21/2021 at 12:10 p.m. Resident #15 was observed lying in bed and under the covers. Resident #15 was noted not wearing a right-hand splint and it was observed positioned on the left side of the bed on a dresser. On 12/22/2021 at 10:13 a.m. Resident #15 was observed in his room, lying in bed with his hands positioned on top of the covers. He again was noted not to be wearing his right hand splint. He confirmed it was not on by nodding his head and lifted his head to point at the hand splint on the dresser at bedside which was placed out of his reach. On 12/22/2021 at 12:15 p.m. Resident #15 was observed in his room and was eating his lunch meal. He was using his left hand to eat, by using built up adaptive eating utensils. He was asked about his right hand but he had some verbal communication deficit. However, he was able to shake his head yes and no to questions about his splint. He was able to confirm that he needs help putting on his right hand splint, and it had been left in the same place on his dresser for over one week without receiving assistance to put it on. He was able to confirm he would wear it if staff would help him put it on. He confirmed that no staff has helped him with putting it on during the day or night. Resident #15 also confirmed, by nodding his head up and down, that his right hand does feel better when the splint was on. Review of Resident #15's admission Record revealed he was admitted initially on 05/26/20 and the most recent readmission on [DATE] with diagnoses to include contracture right hand, muscle wasting and atrophy, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side and cerebral infarction. Review of the current Minimum Data Set (MDS) assessment, Section G: Functional Status, dated 12/09/21, revealed Resident #15 required at minimum, extensive assistance of one person for activities of daily living and was impaired on one side of both upper and lower extremities. Section O - Special Treatments and Programs showed for Restorative Nursing Programs under Technique a 0 for Splint or brace assistance. Review of the current Physician Order Sheet for the month of 12/2021 revealed Resident #15 had orders for: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 13 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0688 Level of Harm - Minimal harm or potential for actual harm *Right hand splint to be placed for up to 6 hours and removed. Skin checks prior to putting splint on and following the removal of splint, ordered 06/02/21. *Restorative passive range of motion, right upper extremities all planes 10 repetitions times 3 sets, ordered 09/18/21. Residents Affected - Some On 12/22/2021 at 12:26 p.m. an interview with the Staff B, Restorative Aide revealed she was the restorative aide and normally if she has a resident on her case load, she would be the person who assisted the resident with applying (donning/doffing) of splints and braces. She confirmed Resident #15 had gone to the hospital and she felt that he was no longer on her restorative case load when he returned to the facility. She was unaware he currently had an order to receive restorative care. She was aware that Resident #15 had a right-hand splint and it was normally kept in his room. Staff B also revealed when not on her case load, direct care floor aides are supposed to help residents with donning and doffing of the splints/braces. Staff B confirmed Resident #15 had a contracture of his right hand and again confirmed he was not currently wearing the brace/splint, and confirmed it was currently placed on the dresser behind him. She again confirmed she does not currently have him on her workload. On 12/22/2201 at 1:28 p.m. an interview with the Rehabilitation Therapy Director (Director) revealed Resident #15 has been on their work load many times since his first admission back in 2018. The Director confirmed Resident #15 does have a right-hand contracture and does utilize a splint/brace on his right hand and there was an order for the use of it daily. She revealed he was currently on case load with the Restorative Aide (Staff B) and that she was responsible for the donning/doffing or applying of the splint, on a daily basis. When the Director was told that Staff B, Restorative Aide stated she no longer had Resident #15 on her workload, she didn't understand because there was still a current order for restorative services. The Director also confirmed the resident would benefit from daily use of the right-hand brace/splint. She revealed the order interpretation for six hours on and as tolerated would mean during the 7 (a.m.) -3 (p.m.) shift, as that was when the Restorative Aide (Staff B) normally works. Review of the Restorative Nursing Progress Notes revealed: *6/02/21 - Right hand splint was to be placed on for up to 6 hours and removed. Skin checks prior to putting on splint and following removal of splint. *06/28/21 - Continued order for right hand splint. *07/22/21 - Splint was to be placed to the right hand daily for comfort as tolerated per resident. Restorative was to continue until all goals were met. *08/03/21 - [Resident #15] continued with restorative services for splint placement to the right hand. Tolerated well. Continued current plan of care related to restorative services. Review of the Occupational Therapy Rehabilitation assessment dated [DATE] revealed under the section titled Long-term goals: [Resident #15] would tolerate four hours of right resting hand splint to inhibit any further contractures and caregivers would demonstrate 100 percent compliance with proper resting hand splint application and skin inspection. [Resident #15] was discharged to the Restorative Nursing program with recommended equipment to include right wrist/hand splint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 14 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0688 Level of Harm - Minimal harm or potential for actual harm Review of the current care plan initiated on 11/13/18 with the next review date of 12/27/21, revealed a focus area: [Resident #15] has an ADL self-care performance deficit r/t (related to) CVA (cerebrovascular accident [stroke]), impaired balance, hemiplegia, incontinent, not able to ambulate, he is alert and able to propel himself, feed self. Interventions included resting right hand splint to be worn daily as tolerated, and restorative nursing program as written. Residents Affected - Some On 12/22/2021 at 4:00 p.m. an interview with the Director of Nursing confirmed Resident #15 had a right-hand contracture and that he utilized a right-hand splint daily and as tolerated. She could not provide any documented evidence that Resident #15 had ever refused the use of the splint and confirmed Resident #15 was supposed to receive restorative aide services to apply the splint/brace daily. She could not provide any documentation to show for the past two months of 11/2021 and 12/2021, that Resident #15 was ever offered and or assisted with his donning or applying of the right hand splint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 15 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review the facility failed to provide scheduled pain medication refills for a Baclofen pump for one resident (#39) out of 32 sampled residents. Residents Affected - Few Findings included: Review of Resident #39's admission Record revealed she was readmitted to the facility on [DATE] from and acute care hospital. Medical diagnoses included multiple sclerosis, hereditary and idiopathic neuropathy, pain in unspecified joints, and muscle spasm. An interview was conducted with Resident #39 on 12/20/21 at 12:15 p.m. The resident stated she had a Baclofen pump (a pump that directs pain medication into the spinal fluid). In October (2021) she was supposed to get the pump refilled and they scheduled it, but that was a Wednesday and I don't like going on Wednesday's because they are so busy. They never rescheduled my appointment for me, and my pain is getting worse in my legs, shoulders and neck. My pump is in my right abdomen. I haven't reminded anyone about the appointment, but they know I'm supposed to get it, and I told them I didn't want to go on Wednesday. It still hasn't been rescheduled. Review of Resident #39's Minimum Data Set (MDS) in Section C - Cognitive Patterns the Brief interview for Mental Status, dated 11/12/21, revealed a score of 15 out 15 indicating no cognitive impairment. Review of Resident #39's physician orders for December 2021 revealed an order dated 6/15/21 with no end date for Baclofen pump refill every 3 months. Further review revealed an order dated 2/20/21 with no end date for Baclofen tablet 20 mg (milligrams) give 1 tablet by mouth every 8 hours for muscle spasm hold for sedation. Review of the Medication Administration Record for December 2021 revealed the Baclofen tablet 20 mg medication was given as ordered. An interview was conducted on 12/22/21 at 10:04 a.m. with Staff L, Medical Records and she confirmed she makes the appointments. She stated Resident #39 goes out to get her Baclofen pump refilled. She stated she doesn't remember off the top of her head when the last time she went, but she was going every three months, and now she goes every six months. She stated she thinks her next appointment is in February (2022) or March (2022). She stated when she schedules the appointments, corporate arranges transportation and the resident usually takes a stretcher transportation. Further interview with Staff L, Medical Records was conducted on 12/22/21 at 10:25 a.m. she obtained records, and she stated the last time the resident had a doctor's appointment to refill her Baclofen pump was on 6/30/21. When she came back from the appointment she had a scheduled appointment for 11/16/21. Staff L confirmed the resident did ask her to reschedule that appointment because that day is a busy day at the office, and she forgot to reschedule it. So, she just called them and scheduled an appointment for 1/6/21 because that was the soonest they could get her in. An interview was conducted on 12/22/21 at 10:17 a.m. with Staff G, Registered Nurse (RN). She stated she was Resident #39's nurse today. She confirmed she has a Baclofen pump and she goes out to get it refilled. She thinks she goes every five to six weeks. Staff G, RN looked at the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 16 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician orders in the electronic medical record and she stated there's an order for her to go out every 3 months to get her Baclofen pump refilled. She then stated, You see I didn't know that it was every 3 months. They just let us know when she has an appointment. There's usually a physician's order for the appointment and they come and tell us when it is as well. Review of Resident #39's physician's office documentation where her Baclofen pump gets refilled was undated and revealed low reservoir alarm date 11/17/2021, next to that a handwritten note revealed next apt. (appointment) 11/16/21. On 12/22/21 at 10:28 a.m. an interview with Resident #39 was conducted and she stated her Baclofen pump has not alarmed and she has never heard it alarm. She confirmed her last appointment was June 30, 2021. An interview was conducted with the Director of Nursing on 12/22/21 at 12:26 p.m. She said Resident #39 has a Baclofen pump; it's an internal pump. We just monitor the skin with skin checks. It is my expectation that she receives her refills when she is scheduled, and if she wants the appointment changed then that should be scheduled and arranged. Review of the facility's Physician Orders policy, with a revision date of 3/3/21, revealed, Policy: The center will ensure that physician orders are appropriately and timely documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 17 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review one resident (#9) out of 5 residents reviewed for unnecessary medications. Resident #9's anxiolytic medication was ordered as needed with no stop date and administered for longer than 14 days. Findings included: Review of Resident #9's admission Record revealed she was admitted on [DATE] from an acute care hospital, and her diagnoses included anxiety disorder. Review of Resident #9's active physician orders as of 12/22/21 revealed an order for Clonazepam tablet 0.5mg (milligrams) give 1 tablet by mouth every 12 hours as needed for anxiety. Start date 7/17/21 with no end date. Review of the December 2021 Medication Administration Record for Resident #9 revealed the resident received the medication every day from December 1st thru December 21st except on December 2nd the medication was not administered. An interview was conducted with the Director of Nursing on 12/22/21 at 3:15 p.m. She stated the last gradual dose reduction attempt was in June, 2021 and the doctor wanted her on the medication. A gradual dose reduction was attempted for the medication in June, but the doctor did not want to change the order. A review of the medical record revealed the physician declined the recommendation on 6/3/21. The facility was unable to provide a physician rationale in the medical record related to the resident's as needed Clonazepam ordered on July 17th, 2021, without a stop date. A phone interview was conducted with the facility's pharmacist on 12/22/21 at 5:21 p.m. She confirmed PRN (as needed) antipsychotics should have a 14 day stop date or if the physician wants to continue the medications psych needs to see the resident regularly and make note that they want to continue the medication on an as needed basis. PRN antipsychotics are something she reviews when reviewing medications and will make recommendations on. Review of the facility's policies and procedure titled, Medication Management-Psychotropic Medications, revised on 3/23/2018 revealed, Policy: .the center implements gradual dose reductions unless clinically contraindicated and a PRN [as needed] order for psychotropic medication is limited. .Procedure: .7. PRN physician order(s) for psychotropic medications are limited to 14 days. Except, if the physician or prescribing practitioner believes that it is appropriate to extend beyond 14 days and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 18 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 0758 documents the rationale in the medical record. Level of Harm - Minimal harm or potential for actual harm 8. PRN physician order(s) for anti-psychotic medications are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents in the medical record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 19 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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.

F812 Based on observations, record reviews, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety related to male staff members not wearing hair restraints to cover beards, expired and undated food in the walk-in cooler, and black build up and condensation leaking from vents above the serving line and food prep table in one of one kitchen, and undated food and spillage in the nourishment refrigerator on one wing (East), and an uncovered ice scoop stored in one nourishment room on one wing (West) out of a total of two nourishment rooms. Findings included: On 12/20/21 at 9:04 a.m., an initial tour of the kitchen was conducted. The Certified Dietary Manager (CDM) was observed wearing a surgical mask and no beard guard to cover facial hair. Facial hair was exposed at the bottom of the surgical mask and on both sides of the mask. Two containers of Fresh Salsa were observed in the walk-in cooler with an expiration date of 08/26/21 and 09/05/21 (photographic evidence obtained). A peanut butter and jelly sandwich was observed in the walk-in cooler on a tray without a date. The CDM was asked when the sandwich was made, he stated he did not know, and immediately removed the sandwich from the tray. Following the initial tour of the kitchen an observation of the nourishment room on the East Wing revealed: the lid to the ice cooler was open and stored next to a bedside commode, a tray with five bowls of fruit was observed in the homestyle nourishment refrigerator without a date, spillage was observed in the top and bottom of the refrigerator, and strands of hair were observed in the top of the refrigerator. Following this observation an observation of the nourishment room on the [NAME] Wing revealed an uncovered ice scoop was observed on the shelf above the ice cooler (photographic evidence obtained). On 12/21/21 at 11:25 a.m., the vents above the serving table and food preparation table were observed with black buildup and condensation leaking from the vents (photographic evidence obtained). The Account Manager stated, It's condensation and it leaks every once in a while. She stated they had not submitted a work order for the vents. One male staff member assisting with plating the trays for lunch was observed wearing a surgical mask and no beard guard to cover exposed facial hair. On 12/21/21 at 11:29 a.m., the CDM reported he and the Account Manager were responsible for ensuring there were no expired foods in the walk-in cooler and that all foods were labeled and dated in the walk-in cooler. He reported that housekeeping was responsible for cleaning the nourishment refrigerators once per month and kitchen staff was responsible for cleaning the refrigerator as needed. The CDM stated he only wears a beard guard while he is prepping food. Surveyor pointed out the male staff member assisting with plating the trays for lunch and the CDM stated he would get him a beard guard. A policy was requested at this time related to beard guards and was not provided. The policy provided by the facility titled, Equipment, dated May 2014 revealed the following: Policy Statement It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 20 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 Action Steps Level of Harm - Minimal harm or potential for actual harm 1. The Food Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials. Residents Affected - Some 2. The Food Service Direction will ensure that all staff members are properly trained in the cleaning and maintenance of all equipment. 3. The Food Services Director ensures that all food contact equipment is cleaned and sanitized after every use. 4. The Food Services Director ensures that all non-food contact equipment is clean. 5. The Food Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Food Services Director will notify the administrator when repairs are complete. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly. The policy provided by the facility titled, Food Storage: Cold, dated May 2014, revealed the following: Policy Statement It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the USDA [United States Department of Agriculture) Food Code. Action Steps 5. The Food Services Director/ [NAME] ensures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the FDA Food Code - 2017 revealed, Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. A general cleaning schedule was requested and not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 21 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 - Minimal harm or potential for actual harm Residents Affected - Some 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, record reviews, and interviews, the facility failed to ensure that its Quality Assurance plan was effective related to 1. Failure to prepare, distribute, and serve food in accordance with professional standards for food service safety related to a staff member not wearing hair restraints, condensation leaking from vents above the serving line and food prep table in one of one kitchen, and an uncovered ice scoop stored in one of two nourishment rooms (West Wing); and 2. Failure to provide one (Resident #4) of four sampled residents with timely narcotic pain medication related to not submitting a prescribed narcotic prescription to the pharmacy timely. Findings included: 1. The facility developed a plan of correction that included the following: - On 12/21/21, the Dietary manager completed a kitchen sanitation and food storage audit in the kitchen. On 12/20/21, the Dietary manager completed a sanitation and food storage in the facilities nutrition rooms. Any concerns identified were addressed at that time and actions taken/systems put into place to reduce the risk of future occurrence. On 12/21/21 and 12/22/21, the Dietary manager and/or designee educated the Dietary staff on sanitation, hair and beard coverings, food storage and spillage. How the corrective action(s) will be monitored to ensure the practice will not recur: Dietary Manager and/or designee will conduct a daily quality review of sanitation weekly x 4 weeks and then 2 x a month x 2 months to ensure equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials, staff members are properly trained in the cleaning and maintenance of all equipment, food contact equipment is cleaned and sanitized after every use, non-food contact equipment is clean, and submit any repairs, The findings of these quality reviews will be reported to Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Services when completing their systems review. Inspection of the facility's kitchen on 2/23/22 at 9:23 a.m., revealed that the Registered Dietician (RD) entered the kitchen and proceeded to the office located in the kitchen. An interview with the RD at this time, revealed that she visited the facility one time a week and knew she should have her hair covered but just came in to talk to the Accounts Manager. Continued observations during the tour of the kitchen revealed that there were two air vents mounted to the ceiling, one located over the prep table and the other located over the steam table. Both units were noted to have condensation on them dripping on both the prep table and the tray-line table. The Accounts Manager confirmed that the two vents had condensation and was dripping on the prep table and the tray-line table. The Accounts Manager proceeded to use her body to move the prep table and the tray-line table from under the vents. She reported she was not aware of anything being done regarding the condensation dripping on the tables. Continued inspection at this time, revealed the [NAME] wing nutrition room was noted to have an ice scoop sitting on the top of a cloth located on the ice cart. The ice scoop was not in an appropriate container to prevent contamination. The Accounts Manager reported that the ice scoop was not appropriately stored and she would send it back to the kitchen to be cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 22 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 - Minimal harm or potential for actual harm Residents Affected - Some In an interview with the Maintenance Director on 2/23/22 at 11:20 a.m., he said they cleaned the vents, but did not realize that condensation was still dripping onto the prep table and the tray-line. He reported that the tables had been moved and would stay where they were until the vents could be fixed. Review of the facility policy titled Staff Attire with an original date of 5/2014 and a Revised date of 9/2017 revealed the following: -1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. 2. The facility developed a plan of correction that included: 1. On 12/29/21, the ADCS and/or designee re-educated the licensed nursing staff on pain management and providing ordered pain medication in a timely manner. 2. Any newly hired licensed nursing staff or any agency licensed nursing staff will be educated on pain management and providing ordered pain medication in a timely manner. 2. On 2/23/22 at 8:55 a.m., Resident #4 was overheard from the surveyor conference room to be in her room yelling out oh I need help, no one ever comes in this room, I'm in pain, I need help, I need to go to the hospital. The resident continued to moan and call out in pain and call out for help. One staff member came into the resident's room and the resident stated she did not want her breakfast she only wanted a cup of ice water. On 2/23/22 at 9:30 a.m., Resident #4 was overheard from the surveyor conference room continuing to call out for help, she stated, I need my pills, no one ever comes down here, I haven't even gotten my water yet. She moaned in pain and stated, I want to go back to the hospital. Review of Resident #4's admission record revealed she was admitted on [DATE] from an acute care hospital with diagnoses that included but were not limited to chronic obstructive pulmonary disease, anxiety disorder, idiopathic peripheral autonomic neuropathy, major depressive disorder, chronic pain syndrome, and pain. On 2/23/22 at 11:23 a.m., the paramedics were observed to be outside of Resident #4's room. The resident indicated she felt like she could not breathe and her chest hurt. The paramedics were heard telling the resident you have oxygen on, we are going to take you to the hospital. The resident stated okay good. The resident started to complain her back was hurting and the paramedics wheeled her out of the facility on a gurney. Review of Resident #4's physicians order revealed an order for Oxycodone 5 mg give 1 tablet by mouth every 6 hours as needed for chronic pain to start on 2/22/22 with no end date. Further physician order review revealed an order for Oxycodone 5 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 5-10 related to pain to start on 2/23/22 with no end date. Further review revealed a physician's order to start on 2/23/22 with no end date for Acetaminophen 325 mg give 3 tablets by mouth every 8 hours as needed for mild pain 1-4 related to pain. Another physician's order was reviewed to start on 2/22/22 with no end date for Acetaminophen 325 mg give 3 tablets by mouth every 8 hours as needed for pain/fever. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 23 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 - Minimal harm or potential for actual harm Review of Resident #4's medication administration record revealed neither Acetaminophen nor Oxycodone were administered to Resident #4 on 2/22/22 or 2/23/22. Review of Resident #4's nurses progress notes revealed a note dated 2/23/22 at 11:20 a.m., Resident called 911 stating she had chest pain. Transferred via medics to [NAME] Dunedin Hospital. Residents Affected - Some An interview was conducted with Resident #4's nurse Staff A, Registered Nurse (RN) on 2/23/22 at 2:20 p.m. She said Resident #4 called the paramedics herself because she was in pain, and she could not wait. I guess the pharmacy did not receive any of the narcotics faxes that were sent over yesterday so someone had to go down there and give them the prescriptions. Staff A, RN stated she could not access the emergency drug kit (EDK) for pain medication for the resident because this was her first time working with the resident and the pharmacy did not have her narcotic prescriptions. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) Unit Manager on 2/23/22 at 3:ppm. She said, The nurse overnight said the fax was not working, I guess it kept kicking back her prescription and saying error. So, this morning I tried to refax the narcotic prescriptions on all the other fax machines and none of them were working. I also called the pharmacy, and they were going to call a carrier to pick up all the prescriptions but that was going to take an hour and I did not want to have to wait that long. There were nine prescriptions that did not go through to the pharmacy yesterday. The pain management physician came yesterday, and the prescriptions were for narcotic refills, so residents did not run out of their narcotics. [Resident #4] was our only new admission with a narcotic yesterday. I explained the situation to Resident #4 and told her it would be about an hour before I could get the authorization code from pharmacy to get her pain medication and she was fine with that. But, after I went across the street to fax the prescriptions, I was on the phone with the pharmacy getting the authorization code to get her narcotic, she called the paramedics, so I canceled her authorization code. Earlier in the morning [Resident #4] was telling me she was having neck pain, that is why I was trying to get her narcotics. When the paramedics came, she was saying she had chest pain. She did look worse than she did when I first saw her this morning. The hospital actually admitted her for congestive heart failure which was not a diagnosis she came in with. An interview was conducted with the Director of Nursing (DON) on 2/23/22 at 3:17 p.m. She said, [Resident #4] was having chest pain, initially said she was having shoulder and neck pain. She just got here last night, and the pharmacy had a problem with our fax machine. So, we went over next door to use their fax machine. We couldn't pull from the EDK (Emergency Drug Kit) without a faxed authorization. The pharmacy wouldn't give us a code without the script. While the unit manager was trying to get the scripts faxed, the resident called the paramedics herself. Some of our faxes give a confirmation and some don't. I would have to check the west wing fax because that is where her prescription was faxed from to see if it gives a confirmation or not. I don't know the full details of Resident #4 yet. She was the only one that it effected. I did not see if there were any other problems with the other fax machines or new admissions, but no one was complaining. An interview was conducted with the DON and Nursing Home Administrator (NHA) on 2/23/22 at 4:30 p.m., they indicated they thought their plan of correction went fine they went over all the citations and provided education and conducted audits. They indicated their QAPI (Quality Assurance and Performance Improvement) team met December 23, 2021, to discuss the citations they received and created a plan to correct each citation. The team met again on January 21, 2022 to review audits and the team continued to meet again on February 17, 2022 to further discuss their audits. The DON indicated she was having trouble with staff attendance at the meetings to educate them so she held a virtual meeting hoping she would have a better turn out because of the convenience factor. The virtual meeting had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 24 of 25 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 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 - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete some technical difficulties and did not have a good turn out, so she had been coming into the facility to educate the nursing staff on medication administration individually. The DON also indicated Resident #4's nurse was a newly hired nurse and she had not attended the virtual meeting related to medication administration and the DON had not had time to do an individual education with her the morning of the survey. The NHA stated that new hires met with the Assistant Director of Nursing (ADON) to go over their new hire paperwork and at that time they were also introduced to the facility's education portal that had all their education that was needed. Event ID: Facility ID: 105132 If continuation sheet Page 25 of 25