Health inspection·June 27, 2023

F 0759 staff member that indicated she was in the dining room. Level of Harm - Minimal harm or potential for actual harm At 8:40 a.m. Resident #7 returned to her bedroom and confirmed she had eaten breakfast. Staff B provided the oral medications followed by one puff of Incruse Elipta inhaler. After twenty-five seconds the second inhaler Fluticasone- Salmeterol was administered. Residents Affected - Few Medication reconciliation revealed the following Physician orders: -Metformin HCL 500 mg tablet. Give one tablet by mouth before meals for diabetes mellitus (DM) dated [DATE]; the medication was administered after breakfast. -Fluticasone -salmeterol 500/50 mcg/act Aerosol Powder, breathe activated. Give 1 puff by mouth two times a day related to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (RINSE MOUTH AFTER USE) dated [DATE]. Resident #7 was not directed to rinse mouth after use. -Polysaccharide Iron complex oral tablet 150 mg (polysaccharide iron complex). Give 1 table by mouth one times a day for anemia dated [DATE]. The medication was omitted. 2. On [DATE] at 8:50 a.m. Staff B LPN was observed as she prepared and administered the following medications to Resident #8. -Eliquis 2.5 mg tablet -Metoprolol 25 mg tablet -Sertraline 50 mg tablet -Potassium Chloride ER 10 [NAME] (milliequivalents) tablet -Bumex 1 mg tablet Staff B confirmed a total of five medications were due at that time. Medical reconciliation revealed the following Physician orders: -NU-IRON 150 mg cap give 1 capsule orally in the morning for anemia dated [DATE]. The medication was omitted. 3.On [DATE] at 11:45 a.m. Staff B LPN was observed as she prepared Resident #9 insulin pen -Lispro for administration. Staff B turned the dose knob on the pen to 2 units, pointed the pen side ways and expelled the insulin. She stated, I primed the pen. Staff B then attached the needle to the pen and turned the dose knob to 20 units. The cartridge on the pen was observed with an air bubble. Staff B then entered the Resident #9 bedroom when she was asked to stop. The Director of Nursing (DON) was in the hallway at the time when Staff B stated, I primed the pen. The DON was present and confirmed he heard staff B state she had primed the pen. The DON was informed during the observation the pen was primed without a needle in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 2 of 5 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 06/27/2023 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 0759 Review of the Manufacture's Instructions for Use: HUMALOG KwikPen® insulin lispro injection revealed: Level of Harm - Minimal harm or potential for actual harm -Priming your Pen -Prime before each injection. Residents Affected - Few -Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. -If you do not prime before each injection, you may get too much or too little insulin. -Step 6: -To prime your Pen, turn the Dose Knob to select 2 units. -Step 7: -Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. -Step 8: -Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. -You should see insulin at the tip of the Needle. Accessed on [DATE] at https://uspl.lilly.com/lispro/lispro.html#ug1. On [DATE] at 2:15 p.m. Staff B removed the Elpt inhaler from the medication cart and confirmed she administered it to Resident #7. The Director of Nursing was present when Staff B confirmed the package contained an open on date [DATE]. The package manufacture's instructions read to discard after 42 days, that indicated the discard date on [DATE]. The DON confirmed the medication was expired and should not have been administered. During the interview, Staff B indicated she was unaware on how much time to wait in-between inhalers. The DON stated, the normal time to wait between inhalers is to two to three minutes. Staff B confirmed after the second inhaler was administered (Fluticasone) she failed to instruct Resident #7 to rinse her mouth after use. On [DATE] at 10:35 a.m. a phone interview was conducted with the facility's Pharmacist. The Pharmacist stated the normal time to wait in between two different inhalers is a minute. We follow manufactures recommendations. She confirmed if the inhaler has directions to rinse mouth after use it needs to be followed. The Pharmacist stated, we follow manufacture's recommendation. She confirmed if the manufacture indicates to discard an inhaler after 42 days it should be discarded and reordered. The Pharmacist indicated manufacture's directions need to be followed when priming an insulin pen. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 3 of 5 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 06/27/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed if the pen is not primed as directed the resident will not receive the correct insulin dose. The Pharmacist confirmed all Physician ordered medications should be administered and not omitted. Review of policy titled Medication Administration revised date [DATE]. Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 11. Compare medication source (bubble pack, vial, ect.) with MAR to verify resident name, medication name, form, dose, route, and time. b. Administer with 60 minutes prior to or after scheduled time unless otherwise ordered by physician. C. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye ear, rectal, ect.) 12. Identify expiration date. If expired, notify nurse manager. 14. Administer medications as ordered in accordance with manufacture specifications. Example guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive. Medication requiring a wait time period between inhalations or drops: Metered dose inhalers-follow manufactures product information for administration instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 4 of 5 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 06/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure and maintain water pitchers in a clean manner for two (100 cart and 200 cart ) out of four pitchers used on medication carts as evidenced by a build up of pink and dark tan colored residual biogrowth. Findings Included: 1.On 06/26/223 at 8:50 a.m. the 100-medication cart contained a clear colored water pitcher dated 6/21. The water pitcher cover was observed with a dark tan colored residual surrounding the inside edge. Staff B, Licensed Practical Nurse stated, I just washed it this morning. She confirmed she had used the same water pitcher when she administered the morning medications to the residents. She removed the cover off the pitcher and with a tissue wiped the inside of it. The tissue reflected a moderate amount of pink to brown colored residual. Staff B stated I'm going to take it the kitchen. 2. On 06/26/2023 at 9:01 a.m. the 300-medication cart was observed with a clear colored water pitcher. The pitcher did not contain a date. Staff D, Registered Nurse Minimum Data Sheet Coordinator confirmed the water pitcher should contain a date that would indicate it was clean that day. 3. On 9:15 a.m. the 200-med cart water pitcher was dated 6/26 Staff C, Licensed Practical Nurse was present and stated, I cleaned it this morning when I got here. She confirmed she had used the same water pitcher during the morning medication administration. Staff C removed the cover from the pitcher and wiped the inside. The wipe contained a pink to tan colored debris (photographic evidence was obtained). On 06/26/2023 at 9:44 a.m. an interview was conducted with the Staff E, Registered Nurse Assistant Director of Nursing (ADON) who stated, all the water pictures are being cleaned. He said he would look to see if a process was in place. On 06/27/2023 at 11:45 a.m. an interview was conducted with the Director of Nurse (DON) who indicated he was not unaware of a process for cleaning water pitchers. The DON said the nurses in the evening send the pitchers to the kitchen for cleaning and them pick them up. He indicated he was unaware nurses wash the water pitchers. The DON stated yes, like we have a bottle of [company name] detergent in each medication room, we don't. The nurses should not be washing them. At 2:00 p.m. on 06/27/2023 an interview was conducted with the Staff F Kitchen Manager who stated there is no process in place, for the cleaning of the water pitchers. Staff F reviewed the photographic evidence and stated that could be from not being washed for a few days or a week. He confirmed the residual had resembled what is found in the ice maker if not routinely cleaned. The DON was present and stated, the water pitchers should be sent to the kitchen in the evening to get washed. He confirmed his agency staff members would not know this unless something was posted. He confirmed he did not have anything posted and it was his expectation the pitches were washed daily by the kitchen staff. At 2:15 p.m. on 06/27/2023 Staff K stated I looked and cannot find any type of process about cleaning the water pitchers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 5 of 5