Inspection·October 31, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of admission records showed Resident #1 was admitted on [DATE] with diagnoses including Acute and Chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), atrial fibrillation, speech and language deficits following cerebral infarction (CI,) hemiplegia and hemiparesis following CI, focal symptomatic epilepsy and epileptic syndromes. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], Section C, Cognition, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section E, Behaviors, did not indicate the resident had any behaviors. Section G, Functional Status, showed the resident needed one-person physical assist with bed mobility, transfers, and toileting. Review of Resident #1's Order Summary Report, printed on [DATE] showed the following orders: Full Code. (Meaning all resuscitation efforts should be made to keep the resident alive) Date [DATE] Record pain level every shift using numerical scale or pain scale for cognitively impaired. Every shift. Date [DATE]. Atorvastatin Calcium Oral Tablet 20 milligram (mg). Give 20 Mg by mouth at bedtime for cholesterol. Date. [DATE]. Allopurinol Oral Tablet 100 mg. Give 100 mg by mouth two times a day for gout. Date [DATE]. Clonazepam Oral Tablet 0.5 mg. Give 1.5 tablets by mouth two times a day for anxiety. Date [DATE]. Cholecalciferol Oral Tablet. Give 25 microgram (mcg) by mouth one time a day for supplement. Date [DATE]. Debrox Otic Solution. Instill 5 drops in both ears at bedtime for ears. Date [DATE]. Diltiazem HCL (hydrocholoride) ER (extended release) Oral Tablet. Give 120 mg by mouth in the morning for hbp (high blood pressure). Date [DATE]. Advair Diskus Inhalation Aerosol Power Breath Activated 500-50 mcg/act (actuation.) 1 puff orally two times a day for SOB (shortness of breath). Date [DATE]. Ferrous Sulfate Tablet 325 mg. Give 1 tablet by mouth two times a day for low hgb (hemoglobin). Date [DATE]. Guaifenesin Oral Tablet. Give 600 mg by mouth two times a day for mucus. Date [DATE]. Furosemide Oral Tablet 20 mg. Give 20 mg by mouth one time a day for edema. Date [DATE]. Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. Date [DATE]. Magnesium Oxide Oral Tablet 400 mg. Give 400 mg by mouth one time a day for antacid. Date [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 2 of 24 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 10/31/2023 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 0600 Nicotine Patch 24 hour 14 mg/24 hour. Apply to arm topically in the morning for Nicotine for 14 days for less than 10 cigarettes a daily. Date [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Olanzapine Oral Tablet 5 mg. Give 5 mg by mouth in the morning for bipolar. Date [DATE]. Residents Affected - Few Omeprazole Oral Capsule Delayed Release 30 mg. Give 20 mg by mouth in the morning for GERD (Gastroesophageal reflux disease). Date [DATE]. Potassium Chloride ER (extended release) Tablet 20 milliequivalents (meq). Give two tablets by mouth one time a day for hypoxia. Date [DATE]. Pregabalin Oral Capsule 75 mg. Give 75 mg by mouth at bedtime for muscle pain. Date [DATE]. Levetiracetam oral tablet 1000 mg. Give 1000 mg by mouth two times a day for seizure. Date [DATE]. Albuterol Sulfate HFA 108 mcg/act Aerosol, solution 2 puff inhale orally every 6 hours as needed for SOB. Date [DATE]. Ipratropium-Albuterol solution 0.5-2.5 mg/3 ml [milliliter] inhale orally via nebulizer every 6 hours as needed for SOB. Date [DATE]. Norco Oral tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for Moderate to severe pain 5-10. Date [DATE]. Ondansetron HCL Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. Date [DATE]. Complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night for 10 days. Date [DATE]. Isolation Droplet Precautions due to COVID-19 and/or possible exposure. Every shift for 10 days. Date [DATE]. Review of Resident #1's Treatment Administration Record (TAR) dated [DATE] - [DATE] revealed: Oxygen at 2 liters/ min [minute] via Nasal Cannula, Humidification: [specify] No. every shift, Start date [DATE] 1500, D/C [discontinue] date [DATE] 0829. The oxygen was signed off as provided for 2 shifts on [DATE] and one shift for [DATE]. Review of Resident #1's Order Summary Report, printed on [DATE], and Resident #1's Medication Administration Record (MAR) and TAR dated [DATE] - [DATE] revealed no active order for oxygen administration. Review of Resident #1's MAR showed the resident was administered Cholecalciferol, Diltiazem HCL, Furosemide, Magnesium oxide, a nicotine patch, Olanzapine, Omeprazole, Potassium Chloride, Advair Diskus, Allopurinol, Clonazepam, Ferrous Sulfate, Guaifenesin, Levetiracetam on the morning of [DATE]. These were all scheduled medications. Review of Resident #1's medical records showed a care plan in place for Risk for respiratory complications related to dx [diagnosis] of COPD, Acute and Chronic hypoxia, respiratory failure, tobacco (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 3 of 24 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 10/31/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety dependance, Asthma, CHF [Congestive heart failure], initiated [DATE]. The Interventions included: Administer oxygen as ordered (Refer to MAR for current order), Check and report O2 Sat (oxygen saturation) levels via pulse oximetry as ordered and report prn, Encourage to express feelings of fear and anxiety and provide verbal and non-verbal support, Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects, Report to MD (Medical doctor) as indicated, Observe for increased wheezing and or lower activity tolerance and report to MD as indicated. Residents Affected - Few Review of an article titled Pulse Oximetry, accessed on [DATE], showed the following: Oxygen saturation is a crucial measure of how well the lungs are working A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person.Note that for people with known lung disorders such as COPD, resting oxygen saturation levels below the normal range are usually considered acceptable. (https://www.yalemedicine.org/conditions/pulse-oximetry) Review of Resident #1's medical records showed a care plan in place for Risk for cardiovascular complications related to: A-fib, H/O [history of] Arrhythmias, HTN [hypertension,] Pacemaker, CHF, HLD [Hyperlipidemia], initiated [DATE]. The interventions included administer medication as ordered, administer oxygen as ordered, diet as ordered and meal consumption monitored, monitor for SOB, chest pains, bradycardia, hypotension, dizziness, tachycardia, HTN, increased edema, weight gain-report abnormalities to nurse, and monitor for vitals. Review of a progress note dated [DATE] at 6:12 a.m. showed the following: LATE ENTRY Resident c/o (complained of) SOB. Full assessment of resident showed decreased O2 SATs 88%. Call placed to MD. Orders to send out to (hospital name) for observation. Review of progress notes showed the following: [DATE] at 7:12 a.m. Change in Condition: Shortness of Breath. The VS documented in the progress note were dated [DATE] 6:29 a.m.: Blood pressure (BP) 127/72 Pulse (P) 80, Respiratory rate (RR) 18, Temperature (T) 98.0, Pulse Oximetry (O2 Sat) 93% Method: Oxygen via Nasal Cannula. Primary care provider responded to send resident out to the hospital. Review of Resident #1's Medical Certification for Medicaid Long-Term Care [NAME] and Patient Transfer From (AHCA Form 5000-3008,) dated [DATE], showed the resident returned to the facility from the hospital. At the time of transfer Resident #1 was on 2 Liters of continuous oxygen, could ambulate independently with assistance, could feed herself, was continent of bowel and bladder, was alert and oriented, followed instructions, and was capable of making healthcare decisions. Review of a progress note dated [DATE] at 4:00 a.m. showed the following: Awake in bed complaining she was incontinent of urine and she could not breathe to go to the bathroom. SATS 90% with O2 @2L/m via nasal cannula. Inhale provided without good effect. Nebulizer treatment provided with good relief and O2 SAT up to 96% with O2 @2L/m via nasal cannula. Requested and provided pain medication for back pain. Peri care provided. Had another episode of urinary incontinence and peri care provided with new brief. Will continue to monitor. Review of a progress note dated [DATE] at 6:30 a.m. showed the following: Resting quietly in bed at present. SATs 96% with O2 @3L/M via nasal cannula. Requested to be given smoke patches to help her stop smoking as she was very upset with her SOB. Will pass on to oncoming nurse to obtain orders for same. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 4 of 24 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 10/31/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of a Progress Note written by an APRN (Advanced Practice Registered Nurse) dated [DATE] revealed the following: History of Present Illness: This is a complicated patient who was recently discharged from the hospital under the care of multiple subspecialists. Medically the patient requires continued close monitoring and follow up in the skilled nursing arena on a proactive basis to have an impact on reduction of rehospitalization/morbidity/and mortality. The patient's respiratory status is slowly improving at this time. We will continue to monitor closely due to the patient's multiple comorbidities and high risk for decompensation. In the review of systems the resident was negative for reduced appetite, negative for dyspnea (feeling short of breath) on exertion. Review of a progress note dated [DATE] at 6:59 p.m. showed the following: Pt (patient) reported to NP(Nurse practitioner name) she was having severe pain in her abdomen. NP (name) gave orders to write to order a KUB (kidney, ureter, and bladder x-ray). Review of a Radiology Results Report, dated [DATE], showed the KUB conclusion was: Unremarkable abdomen exam. Consider more sensitive imaging evaluation with CT (computerized Tomography Scan, sometimes called a CAT scan) as clinically directed. This result was reviewed by Staff G, LPN/UM on [DATE] at 9:40 a.m. Review of a progress note dated [DATE] at 11:21 a.m. showed the following: During care plan meeting resident verbalized that she would like to stay at facility for long term care as she feels this is the level of care she needs. Explained that she will need to speak to the BOM (Business office manager) regarding the Medicaid process and she did state she has spoken to her about this as well as the owner of the previous home she was in. A Nutrition/Dietary Note, dated [DATE] at 11:50 a.m. showed the following: Resident came in dining room today and spoke to this clinician regarding her teeth. Resident c/o tooth pain d/t (due to) cracked/broken upper teeth. Resident states that she thinks that all of her upper teeth need to be pulled. Resident states that she has lower dentures but that they may to be readjusted. Resident on regular textures and agreed to downgrade to mech (mechanical) soft at this time for easier chewing. Resident had concerns regarding her hearing and needing glasses. Notified unit manager as social services was not available. Will continue to monitor and f/u (follow-up) prn. The resident had an active order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml. 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Start date: [DATE]. The MAR shows this medication was last administered on [DATE] and was not administered on [DATE]. The MAR showed Resident #1 was administered PRN Norco 5-325 mg at 8:18 a.m. on [DATE] with a pain level documented as 0 out of 10 and again at 3:02 p.m. with a pain level documented as 0 out of 10. The resident received Norco 2 to 3 times daily from [DATE] to [DATE]. Resident #1 had an order to complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night shift for 10 days. Start date [DATE]. This was signed off on the Treatment Administration Record (TAR) as being completed 10/5 and [DATE]. There was no documentation related to the assessments in the medical record. Review of Resident #1's electronic medical record weights and vitals summary pages and progress notes showed the VS documented for her stay of [DATE] to [DATE] and [DATE] to [DATE] were the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 5 of 24 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 10/31/2023 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 0600 [DATE] Level of Harm - Immediate jeopardy to resident health or safety admitted , no VS documented Residents Affected - Few BP 127/72, P 80, RR 18, T 98.0, O2 Sat 93% Method: Oxygen via Nasal Cannula. [DATE] 6:29 a.m. [DATE] 6:12 a.m. O2 Sat 88%, no other VS documented [DATE] Resident in the hospital [DATE] Resident in the hospital [DATE] readmitted , no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] 4:00 a.m. O2 Sat 90% with oxygen at 2L/m, no other VS documented [DATE] 4:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 6 of 24 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 10/31/2023 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 0600 O2 Sat 96% with oxygen at 2L/m after breathing treatment Level of Harm - Immediate jeopardy to resident health or safety [DATE] 6:30 a.m. Residents Affected - Few [DATE] O2 Sat 96% with oxygen at 2L/m, no other VS documented no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 7 of 24 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 10/31/2023 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 0600 [DATE] Level of Harm - Immediate jeopardy to resident health or safety no VS documented Residents Affected - Few no VS documented [DATE] [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] 8:00 p.m. BP 0/0, P 0, RR 0, T 98°, O2 Sat 90% [DATE] 8:30 p.m. BP 90/60 [DATE] 8:39 p.m. BP 0/0 An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN/UM said the documentation of blood pressure (of 90/60) on [DATE] at 8:30 p.m. and O2 Saturation (at 90%) on [DATE] at 8:00 p.m. were an error. Staff G, LPN/UM said Staff D, RN had called her that evening to let her know she had problems with documenting VS at the time. During an interview on [DATE] at 9:35 a.m. Staff F, RN said the VS were documented in the weights and vitals tab of the electronic medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 8 of 24 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 10/31/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on [DATE] at 10:05 a.m. Staff C, RN said VS were documented on the MAR/TAR if it asks for them and if vital signs are being taken because of a concern they are documented directly under the VS tab or sometimes in the progress notes (in the electronic record). During an interview on [DATE] at 11:51 a.m. Staff B, LPN/UM said VS are documented in the electronic record in the progress notes and she does not know the Policy and Procedure for monitoring VS. She said there was usually an O2 sat order along with the oxygen order. She agreed there was no evidence in the medical record of the resident being stable because assessments and VS were not documented. She said that she did not notify the physician about the resident wanting to go to the hospital and she said I know, I didn't document . An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN said regarding vitals for Resident #1 being documented throughout her stay at the facility she said, that would have been nice, especially her. Staff G, LPN said for a resident with a distended abdomen she would listen for bowel sounds, call the doctor, and see if they wanted to order an x-ray or anything else. Staff G, LPN/UM reviewed Resident #1's KUB results from [DATE] and confirmed there had been no follow-up. An interview was conducted on [DATE] at 1:05 p.m. with Resident #1's primary care physician. He said he would not have expected Resident #1's oxygen orders to have stopped. He said he would expect a patient that came to the facility with a history of respiratory failure to have oxygen saturation monitoring and I would be surprised if they were not. He said for the chest x-ray results on [DATE], the results would not have been overly concerning assuming the resident did not have a fever, but the facility should have notified the provider of all abnormal labs. An interview was conducted on [DATE] at 2:18 p.m. with Staff H, RN. Staff H, RN said Resident #1 was pleasant, alert, and oriented. He said she would sometimes take her oxygen off when she was in the hall and staff would tell her to put it back on due to her having shortness of breath. He said she was out of her room [ROOM NUMBER]% of the time. Staff H, RN said the resident didn't ever complain, say she wanted to go to the hospital and didn't have any behaviors besides occasionally refusing something. An interview was conducted on [DATE] at 2:22 p.m. with Staff J, CNA. Staff J, CNA said Resident #1 mostly took care of herself. Staff J, CNA said the resident would ask for ice or help with little things. She said the resident did get short of breath getting out of bed or doing simple tasks. Staff J, CNA said the resident never gave anybody a hard time and didn't complain unless it was something small. She said Resident #1 would normally eat and if she didn't like the meal, she would ask for snacks or order something to be delivered. Staff J, CNA said the resident never complained of stomach pain or said she wanted to go to the hospital. She said the resident would often have conversations with other residents. An interview was conducted on [DATE] at 2:48 p.m. with Staff I, CNA. Staff I, CNA said Resident #1 was a sweet lady and a good eater. Staff I, CNA said she doesn't remember the resident complaining or having any behaviors. An interview was conducted on [DATE] at 10:34 a.m. with Staff B, LPN. Staff B, LPN said the day Resident #1 went to the hospital ([DATE]) she had cared for the resident on the day shift, from 7:00 a.m. to 7:00 p.m. Staff B, LPN said Resident #1 was not feeling well that day. She confirmed Staff A, PCA came to her three to four times during her shift and told her the resident wasn't feeling good (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 9 of 24 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 10/31/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and wanted to go to the hospital. Staff B, LPN said while she was at lunch, Staff A, PCA came and said he didn't feel like Resident #1 was acting right. Staff C, RN went down and was getting a set of VS when Staff B, LPN said she joined him. Staff B, LPN said Resident #1 was saying she was having a hard time breathing. She said the resident was scooted down in the bed and Staff B, LPN told the resident she could breathe better if staff pulled her up in bed and got her lungs straight. Staff B, LPN said she thinks that was around 3:00-4:00p.m. She said when Staff A, PCA told her what the resident said, she did an assessment of what the resident needed and she basically just wanted her pain medication. Staff B, LPN said she gave Resident #1 a pain pill when she went down there and she was much more pleasant. A follow-up interview was conducted on [DATE] at 11:51 a.m. with Staff B, LPN. Staff B, LPN said for Resident #1 she noticed her abdomen was distended earlier in the day on [DATE]. She said when she went back around 3:00 p.m. the resident had just had a bowel movement. She said she thinks the resident's abdomen was down some compared to what it was. Staff B, LPN said she thinks the bowel movement could have possibly been the cause of her distended abdomen. Staff B, LPN confirmed the resident was complaining of breathing issues on [DATE]. She said she did not administer the resident's PRN breathing treatment because her oxygen saturation was ok. She said we just sat her up in bed. Staff B, LPN said at that time no she did not ask the resident if she wanted her breathing treatment. Staff B, LPN confirmed she did not document any assessments or VS she did during the day of [DATE]. Staff B, LPN said on [DATE] she did not consider the resident was having a change in condition. She said the resident had taken her oxygen off before and was short of breath. She said that day the resident was slumped in bed, so we straightened her up and put her oxygen back on. Staff B, LPN was asked if a resident is alert and oriented and requested to go to the hospital does she have the right to go. Staff B, LPN responded, yes ma'am! She said, I wasn't trying to rebuke her rights, I checked on her and like I said, she was stable. Staff B, LPN confirmed she did not notify the physician about the resident's condition or request to go to the hospital. She said at the time I assessed her. I didn't feel at the time she needed to go to the hospital. An interview was conducted on [DATE] at 11:43 a.m. with Staff C, Registered Nurse (RN.) Staff C, RN said on [DATE] from 7:00 a.m. to 7:00 p.m. he worked on the unit with Staff B, LPN. Staff C, RN said Staff A, PCA said Resident #1 was feeling bad and needed assistance. He said he and Staff B, LPN went to the room and Resident #1 said she wasn't feeling ok and wanted to go to the hospital. Staff C, RN said the resident's stomach was distended and he believes her oxygen saturation was normal for her. He said Staff B, LPN was the nurse assigned to the resident and the one that would have assessed her. A follow-up interview was conducted on [DATE] at 10:05 a.m. with Staff C, RN. He said the PCA came to him because Staff B, LPN was on her lunch break. He said as he walked to the resident's room, Staff B, LPN came in. He said vitals were done and the resident's abdomen was distended. Staff C, RN said the resident was saying she was in a lot of pain and wanted to go to the hospital. Since Staff B, LPN was the assigned nurse, she took over and he went back to his residents. An interview was conducted on [DATE] at 4:03 p.m. with Staff D, RN. Staff D, RN said she worked [DATE] from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #1. She said she got report at 7:00 p.m. from Staff B, LPN and does not recall anything being said about Resident #1 not feeling well, having a distended abdomen, or wanting to go to the hospital. She said she was only told about the room being on precautions due to Resident #1's roommate having COVID. Staff D, RN said she had not seen Resident #1 yet that shift until the Certified Nursing Assistant (CNA) came down the hall around 8:00 p.m. and said the resident needed help. Staff D, RN said she went to assess the resident and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 10 of 24 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 10/31/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident did not have a pulse and was not breathing. She said she started CPR on the resident and attached the AED (Automated External Defibrillator) and allowed it to analyze. Staff D, RN said she continued compressions until EMS arrived. An interview was conducted on [DATE] at 4:32 p.m. with Staff E, CNA. Staff E, CNA said she took over care for Resident #1 at 7:00 p.m. on [DATE]. She said in report she was told Resident #1 had been different that day and not her usual self. She said it was not like the resident to soil her bed, but when she went to check on her the resident had her brief off and had urinated all over the bed. Staff E, CNA said she thought Resident #1 was asleep. She said she grabbed supplies and asked another CNA to assist her. She said when she went to the resident to wake her up and roll her to her side, she noticed the resident was limp. She said the other CNA ran and got the nurse, the nurse came right away and started CPR. An interview was conducted on [DATE] at 11:46 a.m. with the facility's Medical Director. The Medical Director said he doesn't know the specifics of Resident #1, but it sounded like she had a pretty sudden change in condition. He said usually with COPD you see a slow decline in oxygen saturation. The Medical Director said if a patient with that history said she isn't feeling well and needs to go to the hospital, the nurse should call the provider. He said if a resident had a change in condition the process should be for the nurse to first assess the resident, hopefully properly and completely, then contact the provider for orders. He said that could be medication or going to the hospital. The Medical Director said, no matter how self-inflicted things may be a change in condition warrants an assessment. An interview was conducted on [DATE] at 1:20 p.m. with the interim DON and Registered Nurse Consultant (RNC). The RNC said if Resident #1 came from the hospital with oxygen orders, they should have been put in the computer. The interim DON said staff should have been monitoring Resident #1's O2 saturation and documenting. He said they have identified the facility is lacking in the area of documentation and have started education. Regarding the stat x-ray for Resident #1 on [DATE], the RNC said she could not attest to what happened or why there was no documented response. She said, Regardless, the nurse who received the results should have notified the physician and documented. The RNC stated regarding Resident #1 complaining she did not feel well on [DATE], she spoke with the nurse (Staff B) who said once the resident had a bowel movement, she was okay and did not have further complaints. She stated the nurse reported the resident had a bowel movement sometime after 3 p.m. She said, I would expect if a resident was requesting to go to the hospital, that their right to seek medical care was honored. The RNC stated she would have expected the nurse (Staff B) to document vitals and all assessments completed on Resident #1 when she verbalized not feeling well. Review of hospital records showed the patient presented in cardiac arrest. Allegedly had been in cardiac arrest for 30 minutes prior to arrival. She was immediately intubated in the prehospital airway was swapped out for an endotracheal tube. After initial dose of epinephrine in the emergency department she did have return of spontaneous circulation. Pulses were palpable. The record added the prognosis is extremely guarded considering she was allegedly in cardiac arrest for approximately 30 to 45 minutes prior to the return of spontaneous circulation. Of note, EMS reported her bloog [sic] glucose was 26 on arrival. They administered d10 and her glucose went up to 126 prior to arrival. A normal blood glucose level is between 70-100 milligrams(mg)/deciliter(dL.) The Emergency Department history of present illness showed Patient is a [AGE] year old Female presenting in cardiac arrest. Patient allegedly was found around 8 PM this evening approximately an hour prior to arrival unresponsive and allegedly in cardiac arrest. Unknown when she was last normal per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 11 of 24 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 10/31/2023 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 0600 the rehab Level of Harm - Immediate jeopardy to resident health or safety facility. EMS reports that she was in PEA (Pulseless Electrical Activity) cardiac arrest through the entire transport. She underwent multiple rounds of ACLS (Advanced Cardiac Life Support) guidelines and epinephrine prior to arrival. However other than this the history is extremely limited from what was provided to me via EMS from the rehab facility. Residents Affected - Few Hospital records showed the resident was admitted to the ICU (Intensive Care Unit) and died on [DATE] at 10:35 a.m. The hospital record Death Summary showed Resident #1's individual problem list as follows: Cardiac arrest, Patient found down at facility for unknown amount of time. Underwent CPR for more than 30 minutes prior to return of circulation. Patient placed on Arctic sun protocol [A non-invasive temperature management system used to induce hypothermia in comatose patients that ha[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 12 of 24 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 10/31/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure nursing staff were competent to recognize and respond to a change in condition for one resident (#1) out of three residents reviewed for change in condition. On [DATE] Resident #1 complained of shortness of breath and not feeling well, was unable to perform her normal daily activities, exhibited unusual behaviors and was begging to go to the hospital. The aide assigned to the resident notified the nurses on duty of the resident's condition and complaints multiple times during a 12-hour shift. There were no documented assessments, vital signs (VS) or notifications to a physician or family member. There were no PRN (as needed) medications provided to the resident except pain medication. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) was begun by facility staff. EMS (Emergency Medical Services) transported the resident to a hospital where she was admitted to intensive care and died 2 days later. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: An interview was conducted on [DATE] at 11:20 a.m. with Staff A, Personal Care Attendant. (Personal Care Attendant or PCA means a person who meets the training requirement in this rule and Section 400.141(1)(w), F.S., and provides care to and assists residents with tasks related to the activities of daily living. According to Florida Administrative Code 59A-4.1081 Personal Care Attendant Training Program Requirements). Staff A, PCA said the day Resident #1 went to the hospital, [DATE], she looked really bloated and hadn't been able to go to the bathroom. Staff A, PCA said the resident was really out of it. He said Resident #1 didn't go out of her room, didn't eat all day and she took her clothes on and off. He said he had never seen the resident act that way before. He said Resident #1 said she wasn't feeling good and was begging to go to the hospital. Staff A, PCA said he told Staff B, Licensed Practical Nurse (LPN) what the resident said and Staff B, LPN told him [Resident #1] tends to exaggerate. Staff A, PCA said when the LPN made that comment he reminded her the resident wanted to go to the hospital. He said another time he went to Staff B, LPN and told her the resident was bloated and not feeling good, Staff B, LPN said she would give Resident #1 a suppository. He said he went to Staff B, LPN three to four times during his shift and told her the resident wasn't feeling good and wanted to go to the hospital. An interview was conducted on [DATE] at 10:34 a.m. with Staff B, LPN. Staff B, LPN said the day Resident #1 went to the hospital ([DATE]) she had cared for the resident on the day shift, from 7:00 a.m. to 7:00 p.m. Staff B, LPN said Resident #1 was not feeling well that day. She confirmed Staff A, PCA came to her three to four times during her shift and told her the resident wasn't feeling good and wanted to go to the hospital. Staff B, LPN said while she was at lunch, Staff A, PCA came and said he didn't feel like Resident #1 was acting right. Staff C, RN went down and was getting a set of VS when Staff B, LPN said she joined him. Staff B, LPN said Resident #1 was saying she was having a hard time breathing. She said the resident was scooted down in the bed and Staff B, LPN told the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 13 of 24 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 10/31/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident she could breathe better if staff pulled her up in bed and got her lungs straight. Staff B, LPN said she thinks that was around 3:00-4:00p.m. She said when Staff A, PCA told her what the resident said, she did an assessment of what the resident needed and she basically just wanted her pain medication. Staff B, LPN said she gave Resident #1 a pain pill when she went down there and she was much more pleasant. A follow-up interview was conducted on [DATE] at 11:51 a.m. with Staff B, LPN. Staff B, LPN said for Resident #1 she noticed her abdomen was distended earlier in the day on [DATE]. She said when she went back around 3:00 p.m. the resident had just had a bowel movement. She said she thinks the resident's abdomen was down some compared to what it was. Staff B, LPN said she thinks the bowel movement could have possibly been the cause of her distended abdomen. Staff B, LPN confirmed the resident was complaining of breathing issues on [DATE]. She said she did not administer the resident's PRN breathing treatment because her oxygen saturation was ok. She said we just sat her up in bed. Staff B, LPN said at that time no she did not ask the resident if she wanted her breathing treatment. Staff B, LPN confirmed she did not document any assessments or VS she did during the day of [DATE]. Staff B, LPN said on [DATE] she did not consider the resident was having a change in condition. She said the resident had taken her oxygen off before and was short of breath. She said that day the resident was slumped in bed, so we straightened her up and put her oxygen back on. Staff B, LPN was asked if a resident is alert and oriented and requested to go to the hospital does she have the right to go. Staff B, LPN responded, yes ma'am! She said, I wasn't trying to rebuke her rights, I checked on her and like I said, she was stable. Staff B, LPN confirmed she did not notify the physician about the resident's condition or request to go to the hospital. She said at the time I assessed her. I didn't feel at the time she needed to go to the hospital. An interview was conducted on [DATE] at 11:43 a.m. with Staff C, Registered Nurse (RN.) Staff C, RN said on [DATE] from 7:00 a.m. to 7:00 p.m. he worked on the unit with Staff B, LPN. Staff C, RN said Staff A, PCA said Resident #1 was feeling bad and needed assistance. He said he and Staff B, LPN went to the room and Resident #1 said she wasn't feeling ok and wanted to go to the hospital. Staff C, RN said the resident's stomach was distended and he believes her oxygen saturation was normal for her. He said Staff B, LPN was the nurse assigned to the resident and the one that would have assessed her. A follow-up interview was conducted on [DATE] at 10:05 a.m. with Staff C, RN. He said the PCA came to him because Staff B, LPN was on her lunch break. He said as he walked to the resident's room, Staff B, LPN came in. He said vitals were done and the resident's abdomen was distended. Staff C, RN said the resident was saying she was in a lot of pain and wanted to go to the hospital. Since Staff B, LPN was the assigned nurse, she took over and he went back to his residents. An interview was conducted on [DATE] at 4:03 p.m. with Staff D, RN. Staff D, RN said she worked [DATE] from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #1. She said she got report at 7:00 p.m. from Staff B, LPN and does not recall anything being said about Resident #1 not feeling well, having a distended abdomen, or wanting to go to the hospital. She said she was only told about the room being on precautions due to Resident #1's roommate having COVID. Staff D, RN said she had not seen Resident #1 yet that shift until the Certified Nursing Assistant (CNA) came down the hall around 8:00 p.m. and said the resident needed help. Staff D, RN said she went to assess the resident and the resident did not have a pulse and was not breathing. She said she started CPR on the resident and attached the AED (Automated External Defibrillator) and allowed it to analyze. Staff D, RN said she continued compressions until EMS arrived. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 14 of 24 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 10/31/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An interview was conducted on [DATE] at 4:32 p.m. with Staff E, CNA. Staff E, CNA said she took over care for Resident #1 at 7:00 p.m. on [DATE]. She said in report she was told Resident #1 had been different that day and not her usual self. She said it was not like the resident to soil her bed, but when she went to check on her the resident had her brief off and had urinated all over the bed. Staff E, CNA said she thought Resident #1 was asleep. She said she grabbed supplies and asked another CNA to assist her. She said when she went to the resident to wake her up and roll her to her side, she noticed the resident was limp. She said the other CNA ran and got the nurse, the nurse came right away and started CPR. Review of admission records showed Resident #1 was admitted on [DATE] with diagnoses including Acute and Chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), atrial fibrillation, speech and language deficits following cerebral infarction (CI,) hemiplegia and hemiparesis following CI, focal symptomatic epilepsy and epileptic syndromes. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], Section C, Cognition, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section E, Behaviors, did not indicate the resident had any behaviors. Section G, Functional Status, showed the resident needed one-person physical assist with bed mobility, transfers, and toileting. Review of Resident #1's Order Summary Report, printed on and dated [DATE] showed the following orders: Full Code. (Meaning all resuscitation efforts should be made to keep the resident alive) Date [DATE] Record pain level every shift using numerical scale or pain scale for cognitively impaired. Every shift. Date [DATE]. Atorvastatin Calcium Oral Tablet 20 milligram (mg). Give 20 Mg by mouth at bedtime for cholesterol. Date. [DATE]. Allopurinol Oral Tablet 100 mg. Give 100 mg by mouth two times a day for gout. Date [DATE]. Clonazepam Oral Tablet 0.5 mg. Give 1.5 tablets by mouth two times a day for anxiety. Date [DATE]. Cholecalciferol Oral Tablet. Give 25 microgram (mcg) by mouth one time a day for supplement. Date [DATE]. Debrox Otic Solution. Instill 5 drops in both ears at bedtime for ears. Date [DATE]. Diltiazem HCL (hydrocholoride) ER (extended release) Oral Tablet. Give 120 mg by mouth in the morning for hbp (high blood pressure). Date [DATE]. Advair Diskus Inhalation Aerosol Power Breath Activated 500-50 mcg/act (actuation.) 1 puff orally two times a day for SOB (shortness of breath). Date [DATE]. Ferrous Sulfate Tablet 325 mg. Give 1 tablet by mouth two times a day for low hgb (hemoglobin). Date [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 15 of 24 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 10/31/2023 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 0726 Guaifenesin Oral Tablet. Give 600 mg by mouth two times a day for mucus. Date [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Furosemide Oral Tablet 20 mg. Give 20 mg by mouth one time a day for edema. Date [DATE]. Residents Affected - Few Magnesium Oxide Oral Tablet 400 mg. Give 400 mg by mouth one time a day for antacid. Date [DATE]. Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. Date [DATE]. Nicotine Patch 24 hour 14 mg/24 hour. Apply to arm topically in the morning for Nicotine for 14 days for less than 10 cigarettes a daily. Date [DATE]. Olanzapine Oral Tablet 5 mg. Give 5 mg by mouth in the morning for bipolar. Date [DATE]. Omeprazole Oral Capsule Delayed Release 30 mg. Give 20 mg by mouth in the morning for GERD (Gastroesophageal reflux disease). Date [DATE]. Potassium Chloride ER (extended release) Tablet 20 milliequivalents (meq). Give two tablets by mouth one time a day for hypoxia. Date [DATE]. Pregabalin Oral Capsule 75 mg. Give 75 mg by mouth at bedtime for muscle pain. Date [DATE]. Levetiracetam oral tablet 1000 mg. Give 1000 mg by mouth two times a day for seizure. Date [DATE]. Albuterol Sulfate HFA 108 mcg/act Aerosol, solution 2 puff inhale orally every 6 hours as needed for SOB. Date [DATE]. Ipratropium-Albuterol solution 0.5-2.5 mg/3 ml [milliliter] inhale orally via nebulizer every 6 hours as needed for SOB. Date [DATE]. Norco Oral tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for Moderate to severe pain 5-10. Date [DATE]. Ondansetron HCL Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. Date [DATE]. Complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night for 10 days. Date [DATE]. Isolation Droplet Precautions due to COVID-19 and/or possible exposure. Every shift for 10 days. Date [DATE]. Review of Resident #1's Treatment Administration Record (TAR) dated [DATE] - [DATE] revealed: Oxygen at 2 liters/ min [minute] via Nasal Cannula, Humidification: [specify] No. every shift, Start date [DATE] 1500, D/C [discontinue] date [DATE] 0829. The oxygen was signed off as provided for 2 shifts on [DATE] and one shift for [DATE]. Review of Resident #1's Order Summary Report, printed on and dated [DATE], and Resident #1's Medication Administration Record (MAR) and TAR dated [DATE] - [DATE] revealed no active order for oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 16 of 24 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 10/31/2023 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 0726 administration. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's MAR showed the resident was administered Cholecalciferol, Diltiazem HCL, Furosemide, Magnesium oxide, a nicotine patch, Olanzapine, Omeprazole, Potassium Chloride, Advair Diskus, Allopurinol, Clonazepam, Ferrous Sulfate, Guaifenesin, Levetiracetam on the morning of [DATE]. These were all scheduled medications. Residents Affected - Few Review of Resident #1's medical records showed a care plan in place for Risk for respiratory complications related to dx [diagnosis] of COPD, Acute and Chronic hypoxia, respiratory failure, tobacco dependance, Asthma, CHF [Congestive heart failure], initiated [DATE]. The Interventions included: Administer oxygen as ordered (Refer to MAR for current order), Check and report O2 Sat (oxygen saturation) levels via pulse oximetry as ordered and report prn, Encourage to express feelings of fear and anxiety and provide verbal and non-verbal support, Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects, Report to MD (Medical doctor) as indicated, Observe for increased wheezing and or lower activity tolerance and report to MD as indicated. Review of an article titled Pulse Oximetry, accessed on [DATE], showed the following: Oxygen saturation is a crucial measure of how well the lungs are working A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person.Note that for people with known lung disorders such as COPD, resting oxygen saturation levels below the normal range are usually considered acceptable. (https://www.yalemedicine.org/conditions/pulse-oximetry) Review of Resident #1's medical records showed a care plan in place for Risk for cardiovascular complications related to: A-fib, H/O [history of] Arrhythmias, HTN [hypertension,] Pacemaker, CHF, HLD [Hyperlipidemia], initiated [DATE]. The interventions included administer medication as ordered, administer oxygen as ordered, diet as ordered and meal consumption monitored, monitor for SOB, chest pains, bradycardia, hypotension, dizziness, tachycardia, HTN, increased edema, weight gain-report abnormalities to nurse, and monitor for vitals. Review of a progress note dated [DATE] at 6:12 a.m. showed the following: LATE ENTRY Resident c/o (complained of) SOB. Full assessment of resident showed decreased O2 SATs 88%. Call placed to MD. Orders to send out to (hospital name) for observation. Review of progress notes showed the following: [DATE] at 7:12 a.m. Change in Condition: Shortness of Breath. The VS documented in the progress note were dated [DATE] 6:29 a.m.: Blood pressure (BP) 127/72 Pulse (P) 80, Respiratory rate (RR) 18, Temperature (T) 98.0, Pulse Oximetry (O2 Sat) 93% Method: Oxygen via Nasal Cannula. Primary care provider responded to send resident out to the hospital. Review of Resident #1's Medical Certification for Medicaid Long-Term Care [NAME] and Patient Transfer From (AHCA Form 5000-3008,) dated [DATE], showed the resident returned to the facility from the hospital. At the time of transfer Resident #1 was on 2 Liters of continuous oxygen, could ambulate independently with assistance, could feed herself, was continent of bowel and bladder, was alert and oriented, followed instructions, and was capable of making healthcare decisions. Review of a progress note dated [DATE] at 4:00 a.m. showed the following: Awake in bed complaining she was incontinent of urine and she could not breathe to go to the bathroom. SATS 90% with O2 @2L/m via nasal cannula. Inhale provided without good effect. Nebulizer treatment provided with good (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 17 of 24 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 10/31/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few relief and O2 SAT up to 96% with O2 @2L/m via nasal cannula. Requested and provided pain medication for back pain. Peri care provided. Had another episode of urinary incontinence and peri care provided with new brief. Will continue to monitor. Review of a progress note dated [DATE] at 6:30 a.m. showed the following: Resting quietly in bed at present. SATs 96% with O2 @3L/M via nasal cannula. Requested to be given smoke patches to help her stop smoking as she was very upset with her SOB. Will pass on to oncoming nurse to obtain orders for same. Review of a Progress Note written by an APRN (Advanced Practice Registered Nurse) dated [DATE] revealed the following: History of Present Illness: This is a complicated patient who was recently discharged from the hospital under the care of multiple subspecialists. Medically the patient requires continued close monitoring and follow up in the skilled nursing arena on a proactive basis to have an impact on reduction of rehospitalization/morbidity/and mortality. The patient's respiratory status is slowly improving at this time. We will continue to monitor closely due to the patient's multiple comorbidities and high risk for decompensation. In the review of systems the resident was negative for reduced appetite, negative for dyspnea (feeling short of breath) on exertion. Review of a progress note dated [DATE] at 6:59 p.m. showed the following: Pt (patient) reported to NP([Nurse practitioner name) she was having severe pain in her abdomen. NP (name) gave orders to write to order a KUB (kidney, ureter, and bladder x-ray). Review of a Radiology Results Report, dated [DATE], showed the KUB conclusion was: Unremarkable abdomen exam. Consider more sensitive imaging evaluation with CT (Computerized Tomography Scan, sometimes called a CAT scan) as clinically directed. This result was reviewed by Staff G, LPN/UM on [DATE] at 9:40 a.m. Review of a progress note dated [DATE] at 11:21 a.m. showed the following: During care plan meeting resident verbalized that she would like to stay at facility for long term care as she feels this is the level of care she needs. Explained that she will need to speak to the BOM (Business office manager) regarding the Medicaid process and she did state she has spoken to her about this as well as the owner of the previous home she was in. A Nutrition/Dietary Note, dated [DATE] at 11:50 a.m. showed the following: Resident came in dining room today and spoke to this clinician regarding her teeth. Resident c/o tooth pain d/t (due to) cracked/broken upper teeth. Resident states that she thinks that all of her upper teeth need to be pulled. Resident states that she has lower dentures but that they may to be readjusted. Resident on regular textures and agreed to downgrade to mech (mechanical) soft at this time for easier chewing. Resident also had concerns regarding her hearing and needing glasses. Notified unit manager as social services was not available. Will continue to monitor and f/u (follow-up) prn. Resident #1 had an order for a stat chest x-ray PA/Lateral one time only for hypoxia on [DATE]. The results, reported on [DATE] at 6:36 p.m. showed the following: Findings: The heart is modestly enlarged. Mediastinum is normal. There is a right lower lobe atelectasis. Pulmonary vascularity is normal. There is a pacemaker in position. Conclusion: Right lower lobe atelectasis and modest cardiomegaly, no infiltrate or congestion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 18 of 24 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 10/31/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few There was no progress note, VS, or assessment to show why the Stat Chest x-ray was ordered. The results, however, do not show they were reviewed until [DATE] by Staff G, LPN/Unit Manager (UM,) after the resident left the facility. There is no note indicating a provider had been notified of the results. The resident had an active order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml. 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Start date: [DATE]. The MAR shows this medication was last administered on [DATE] and was not administered on [DATE]. The MAR showed Resident #1 was administered PRN Norco 5-325 mg at 8:18 a.m. on [DATE] with a pain level documented as 0 out of 10 and again at 3:02 p.m. with a pain level documented as 0 out of 10. The resident received Norco 2 to 3 times daily from [DATE] to [DATE]. Resident #1 had an order to complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night shift for 10 days. Start date [DATE]. This was signed off on the Treatment Administration Record (TAR) as being completed 10/5 and [DATE]. There was no documentation related to the assessments in the medical record. Review of Resident #1's electronic medical record weights and vitals summary pages and progress notes showed the VS documented for her stay of [DATE] to [DATE] and [DATE] to [DATE] were the following: [DATE] admitted , no VS documented [DATE] 6:29 a.m. BP 127/72, P 80, RR 18, T 98.0, O2 Sat 93% Method: Oxygen via Nasal Cannula. [DATE] 6:12 a.m. O2 Sat 88%, no other VS documented [DATE] Resident in the hospital [DATE] Resident in the hospital [DATE] readmitted , no VS documented [DATE] no VS documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 19 of 24 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 10/31/2023 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 0726 [DATE] Level of Harm - Immediate jeopardy to resident health or safety no VS documented Residents Affected - Few no VS documented [DATE] [DATE] no VS documented [DATE] no VS documented [DATE] 4:00 a.m. O2 Sat 90% with oxygen at 2L/m, no other VS documented [DATE] 4:00 a.m. O2 Sat 96% with oxygen at 2L/m after breathing treatment [DATE] 6:30 a.m. O2 Sat 96% with oxygen at 2L/m, no other VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 20 of 24 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 10/31/2023 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 0726 no VS documented Level of Harm - Immediate jeopardy to resident health or safety [DATE] Residents Affected - Few [DATE] no VS documented no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 21 of 24 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 10/31/2023 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 0726 [DATE] Level of Harm - Immediate jeopardy to resident health or safety no VS documented Residents Affected - Few BP 0/0, P 0, RR 0, T 98°, O2 Sat 90% [DATE] 8:00 p.m. [DATE] 8:30 p.m. BP 90/60 [DATE] 8:39 p.m. BP 0/0 An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN/UM said the documentation of blood pressure (of 90/60) on [DATE] at 8:30 p.m. and O2 Saturation (at 90%) on [DATE] at 8:00 p.m. were an error. Staff G, LPN/UM said Staff D, RN had called her that evening to let her know she had problems with documenting VS at the time. During an interview on [DATE] at 9:35 a.m. Staff F, RN said the VS were documented in the weights and vitals tab of the electronic medical record. During an interview on [DATE] at 10:05 a.m. Staff C, RN said VS were documented on the MAR/TAR if it asks for them and if vital signs are being taken because of a concern they are documented directly under the VS tab or sometimes in the progress notes (in the electronic record). During an interview on [DATE] at 11:51 a.m. Staff B, LPN/UM said VS are documented in the electronic record in the progress notes and she does not know the Policy and Procedure for monitoring VS. She said there was usually an O2 sat order along with the oxygen order. She agreed there was no evidence in the medical record of the resident being stable because assessments and VS were not documented. She said that she did not notify the physician about the resident wanting to go to the hospital and she said I know, I didn't document . An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN said lab and x-ray results go into a portal and have to be reviewed. The nurses, Director of Nursing (DON,) UM, and Advanced Practice Registered Nurse (APRN) had access to view. The reviewed by on the report is the first person to review the results. Staff G, LPN said nurses can view the results without clicking reviewed. She confirmed the results for the stat chest x-ray for Resident #1 on [DATE] were not reviewed until [DATE]. Staff G, LPN also confirmed there is no documentation showing a provider was notified of the results. Regarding vitals for Resident #1 being documented throughout her stay at the facility she said, that would have been nice, especially her. Staff G, LPN said for a resident with a distended abdomen she would listen for bowel sounds, call the doctor, and see if they wanted to order an x-ray or anything else. Staff G, LPN/UM reviewed Resident #1's KUB results from [DATE] and confirmed there had been no follow-up. An interview was conducted on [DATE] at 1:05 p.m. with Resident #1's primary care physician. He said he would not have expected Resident #1's oxygen orders to have stopped. He said he would expect a patient that came to the facility with a history of respiratory failure to have oxygen saturation monitoring and I would be surprised if they were not. He said for the chest x-ray results on [DATE], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 22 of 24 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 10/31/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the results would not have been overly concerning assuming the resident did not have a fever, but the facility should have notified the provider of all abnormal labs. An interview was conducted on [DATE] at 1:57 p.m. with the Social Services Director (SSD.) The SSD said Resident #1 was alert and was trying to decide if she was going to stay long term care or move back home with her husband. The SSD said Resident #1 was a smoker and understood the issues with smoking. She said the week prior to going to the hospital, the resident said she was going to try to stop smoking. The SSD said Resident #1 was active with therapy, would eat normally and was out of her room often interacting with people. She said the resident got close with the group of smokers. The SSD said Resident #1 wasn't difficult to work with and if the resident had concerns, she would go to social services. An interview was conducted on [DATE] at 2:05 p.m. with the Activities Director. The Activities Director said Resident #1 was alert, oriented, and aware. She said the resident was boisterous and would get into discussions with other residents. The Activities Director said Resident #1 would come out to smoke and got along with most of the people out there. She said Resident #1 had started a smoking patch and wanted to stop smoking. The Activities Director said she never heard Resident #1 complain about being sick or wanting to go to the hospital. An interview was conducted on [DATE] at 2:18 p.m. with Staff H, RN. Staff H, RN said Resident #1 was pleasant, alert, and oriented. He said she would sometimes take her oxygen off when she was in the hall and staff would tell her to put it back on due to her having shortness of breath. He said she was out of her room [ROOM NUMBER]% of the time. Staff H, RN said the resident didn't ever complain, say she wanted to go to the hospital and didn't have any behaviors besides occasionally refusing something. An interview was conducted on [DATE] at 2:22 p.m. with Staff J, CNA. Staff J, CNA said Resident #1 mostly took care of herself. Staff J, CNA said the resident would ask for ice or help with little things. She said the resident did get short of breath getting out of bed or doing simple tasks. Staff J, CNA said the resident never gave anybody a hard time and didn't complain unless it was something small. She said Resident #1 would normally eat and if she didn't like the meal, she would ask for snacks or order something to be delivered. Staff J, CNA said the resident never complained of stomach pain or said she wanted to go to the hospital. She said the resident would often have conversations with other residents. An interview was conducted on [DATE] at 2:48 p.m. with Staff I, CNA. Staff I, CNA said Resident #1 was a sweet lady and a good eater. Staff I, CNA said she doesn't remember the resident complaining or having any behaviors. An interview was conducted on [DATE] at 11:46 a.m. with the facility's Medical Director. The Medical Director said he doesn't know the specifics of Resident #1, but it sounded like she had a pretty sudden change in condition. He said usually with COPD you see a slow decline in oxygen saturation. The Medical Director said if a patient with that history said she isn't feeling well and needs to go to the hospital, the nurse should call the provider. He said if a resident had a change in condition the process should be for the nurse to first assess the resident, hopefully properly and completely, then contact the provider for orders. He said that could be medication or going to the hospital. The Medical Director said, no matter how self-inflicted things may be a change in condition warrants an assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 23 of 24 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 10/31/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted on [DATE] at 1:20 p.m. with the interim DON and Registered Nurse Consultant (RNC.) The RNC said if Resident #1 came from the hospital with oxygen orders, they should have been put in the computer. The interim DON said staff should have been monitoring Resident #1's O2 saturation and documenting. He said they have identified the facility is lacking in the area of documentation and have started education. Regarding the stat x-ray for Resident #1 on [DATE], the RNC said she could not attest to what happened or why there was no documented response. She Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 24 of 24