Inspection·December 10, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A follow up interview was conducted with Staff E and the Director of Operations on 12/10/21 11:45 a.m. Staff E confirmed observations and said, I walked through hall 100 and noticed that some of the units were bad, they may have been missed occasionally. Staff E said he did not have records showing A/C maintenance was being conducted. Review of an undated facility policy titled HVAC system revealed that it was the facility's policy to maintain (heating ventilation and air conditioning) HVAC system in a manner that protects resident health and safety from fire and extreme temperatures. The policy states: #7. HVAC units' preventative maintenance (PM) shall be done by maintenance personnel in accordance with the manufacturer's specifications. #9. HVAC filters shall be changed monthly and a date of install clearly printed on new filter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 2 of 7 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 105373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Sand Key 1980 Sunset Point Rd Clearwater, FL 33765 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review, the facility failed to ensure a care plan intervention was implemented for one (Resident #9) of thirty-four residents in the sample group. Findings Included: An initial observation was conducted on 12/07/2021 at 9:47 a.m. of Resident #9 lying in bed, not wearing the physician-ordered splint to her right hand. A later observation was made on 12/08/2021 at 12:47 p.m. During the observation, Resident #9's hand splint was not applied to her right hand for a contracture. An observation was made later in the day on 12/08/2021 at 3:35 p.m. During the observation, an interview was conducted with Resident #9's mother who was at bedside. Resident #9's mother revealed the resident wore a right-hand splint for her right-hand contracture. The resident's mother also confirmed that Resident #9 did not have the splint on at the time. She walked over to the resident's dresser top drawer and opened it up. An observation was made of a blue hand splint in the drawer; photographic evidence was obtained. The resident's mother stated, I have not seen it on her [Resident #9], and I visit regularly. A record review for Resident #9 indicated she was admitted on [DATE] with multiple diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of the active physician orders dated 11/11/2021 read, Apply right hand splint on in AM [morning] and off in PM [evening]. Wear Resting hand splint for eight hours during daytime. Review of the Care Plan for Resident #9 revealed a focus area for extensive ADL (Activities of Daily Living) assistance, with a goal of maintaining the highest level of ADL ability to perform ADLs with the least level of support from facility staff, dated 01/19/2021 and revised 11/09/2021. Under interventions it read, Apply right hand splint on in am and off in pm as resident tolerates. An interview was conducted on 12/08/2021 at 5:00 p.m. with the Director of Rehabilitation. She indicated the Certified Nursing Assistant's (CNA's) apply the restorative devices and are trained by therapy staff on the application of devices such as hand splints. During an interview with the Director of Nursing (DON) on 12/09/2021 at 12:55 p.m., he confirmed the CNA's applied all splints which were located on their [NAME] Report during shift change, and as part of their assignment under Restorative Area, which read, Apply the splint device to the right hand on in am and off in pm. The DON stated, It should have been on, I was the one who care-planned the resident for the right-hand splint device. During a subsequent interview conducted with the DON on 12/10/2021 at 9:44 a.m., he stated, When there is an order for residents to have a splint, the splint should be applied as the order states and is followed by my staff. A facility provided policy titled, Comprehensive Care Plans, revision date December 2021, Pages 01 and 02, reads under Policy , consistent with resident rights, that include measurable It is the policy of this facility to develop, implement and follow a comprehensive person centered care plan for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 3 of 7 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 105373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Sand Key 1980 Sunset Point Rd Clearwater, FL 33765 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 0656 Level of Harm - Minimal harm or potential for actual harm each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: Residents Affected - Few 8. The Facility will follow the comprehensive care plan interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 4 of 7 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 105373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Sand Key 1980 Sunset Point Rd Clearwater, FL 33765 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure two (Resident #19 and #33) of two sampled residents were free from potential accident hazards related to unsafe smoking in undesignated smoking areas. Findings included: On 12/08/21 at 8:40 a.m., the Nursing Home Administrator (NHA) reported the facility had two residents who smoked. Both residents smoked independently and were allowed to sign out for a leave of absence (LOA) to smoke on the facility grounds. She reported they had a designated smoking area underneath the covered patio area. On 12/08/21 at 8:15 a.m., Resident #19 was observed wheeling her wheelchair out of the main entrance of the facility with an unlit cigarette in her mouth. She wheeled out to the sidewalk near a trash can underneath the tree in the front of the main entrance (photographic evidence obtained). Resident #19 pulled a lighter from her pocket, lit the cigarette, and began smoking. The resident was observed dumping the ashes on the ground. There was no signage which indicated the area was the designated smoking area. On 12/08/21 at 9:30 a.m. in an interview, Resident #19 reported she had lived in the facility for about six months, and she liked to go outside to feed squirrels and to smoke underneath the tree in the front of the main entrance. On 12/09/21 at 8:39 a.m., Resident #19 was observed sitting in her wheelchair underneath the tree near the main entrance. The resident pulled a cigarette out, lit it, and started smoking. At 8:45 a.m., Resident #19 was observed dropping ashes on the ground as she opened the lid on the top of the trash can to put the cigarette out. At 8:51 a.m., she wheeled herself back into the facility. A review of the admission Record revealed that Resident #19 was initially admitted into the facility on [DATE] with a diagnosis that included but was not limited to nicotine dependence. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. A review of the OC Smoking Evaluation with an effective date of 11/17/21 revealed that Resident #19 currently smoked. The form also indicated the resident was able to acknowledge understanding of the smoking policy. The policy was signed by Resident #19 on 12/07/21. The care plan related to smoking initiated on 11/16/21 revealed the resident may smoke independently per the smoking assessment. The goal reflected Resident #19 would smoke safely through the next review period. Interventions included but were not limited to inform and remind the resident of location of smoking area/times. A review of an admission record information sheet showed Resident #33 admitted to the facility on [DATE] with diagnoses to include complete traumatic amputation, cellulitis left of lower limb, type 2 diabetes, unspecified dementia without behavioral disturbance, and blindness one eye unspecified. Review of the admission MDS dated [DATE] showed that Resident #33 had a brief interview for mental status (BIMS) score of 14, indicating intact cognition. Review of a smoking evaluation for Resident #33 conducted on 11/01/21 showed Resident #33 was a smoker who smoked about 5-9 times per day and was deemed a safe smoker. A Care Plan initiated on 11/02/21 showed Resident #33 was a safe smoker, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 5 of 7 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 105373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Sand Key 1980 Sunset Point Rd Clearwater, FL 33765 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some able to smoke off property. The goal indicated Resident #33 would smoke safely at a designated area off property through the next review. During the facility's entrance conference on 12/07/21 at 9:27 a.m., the NHA reported the facility was a non-smoking facility. The NHA stated that there were two residents who could sign out and go out of the facility to smoke. On 12/07/21 at 2:26 p.m., Resident #33 was observed smoking on the facility grounds in front of the building. Resident #33 was observed dropping his ashes on the ground as he smoked his cigarette. An ash tray or cigarette butt receptacle was not observed, and the area did not have a designated smoking sign. On 12/08/21 at 11:19 a.m., an interview was conducted with Resident #33. The resident stated he smoked by the gazebo, per policy, and pointed to a policy on the bed side table. Resident #33 said, They reviewed this with me, made me sign it yesterday. When asked what he signed, Resident #33 stated it was to make sure cigarette butts go into the receptacle. Resident #33 stated that no one had spoken to him about smoking before yesterday (12/07/21). Resident #33 said he had been a resident of the facility since the end of October, and he did not follow a smoking schedule and could smoke anytime. Resident #33 stated that his smokes and lighter were kept at the nurse's station. On 12/08/21 at 5:35 p.m., Resident #33 was observed smoking at the same spot in front of the facility. The resident stated, there used to be a gazebo, but not anymore. The resident was noted without an ash tray or receptacle for cigarette butts and was observed dropping his ashes on the ground as he smoked. The resident stated, I sometimes put them [cigarette butts] in my wheelchair bag and throw them in a trash can inside. An interview was conducted with the NHA on 12/09/21 at 12:30 p.m. The NHA stated, We used to be a smoking facility before Covid. When Covid came and no one could go out, we became a non- smoking facility unofficially. We did not notify the ombudsman or families. The NHA said they had two smokers who were independent and were allowed to sign out and go out front to smoke. The NHA confirmed this was not a designated smoking area, stating, we don't want them on the streets. We want them in the front area where we can all view them. The NHA said if there was inclement weather, the residents could go to the Gazebo in the courtyard. She confirmed the Gazebo area was the designated smoking area that had all the necessary smoking supplies. The NHA stated, The two are independent smokers. I ask them not to go to the road, as long they are on the premises and are safe, they are okay. They can use the trash can in the middle of the front yard, the top of the trash can is metal. She said she would like the facility to be non-smoking, but it was their [resident's] right to smoke. A facility-provided smoking policy was reviewed with the NHA during the interview. The policy, dated with an October 2021 revision date, revealed smoking was prohibited except in the smoking area. The NHA confirmed the designated smoking area was the Gazebo and said she would not consider the front yard as a designated smoking area. The NHA stated, The two residents know not to smoke in the front but prefer and choose where they want to be. Regarding the cigarette butts, the NHA stated, I think they save them and bring them to the red container. I don't know. It has not been an issue. On 12/10/21 at 11:34 a.m., a follow -up interview was conducted with the NHA. The NHA said they reviewed the smoking policy and confirmed the facility would now follow their own procedures. A review of the policy provided by the facility Resident Smoking revised October 2021 indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 6 of 7 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 105373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Sand Key 1980 Sunset Point Rd Clearwater, FL 33765 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 0689 -Policy: Level of Harm - Minimal harm or potential for actual harm This facility provides a safe environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents Affected - Some -Policy Explanation and Compliance Guidelines: 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. 2. Safety measures for the designated smoking area will include, but not limited to: a. Protection from weather conditions (i.e., covered). b. Provision of ashtrays made of noncombustible material and safe design. c. Accessible metal containers with self-closing covers into which ashtrays can be emptied. d. Accessible fire extinguisher. e. Prohibition of oxygen use in the smoking area. F. A Smoking blanket will be available in the designated area. g. Smoking aprons will be available in the designated area. 5. All residents and family members will be notified of this policy during the admission process, and as needed. 8. All residents will be supervised while smoking. 11. If a resident or family member does not abide by the smoking policy or care plan (e.g., smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional measures such as room searches, prohibited smoking, or even discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 7 of 7