Health inspection·September 5, 2024

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She said, the staff were taking an hour and sometimes more to answer the light. The aid would come in, the resident would ask for something, and an hour later, the resident was still waiting. She said the worst was the 11 pm-7 am shift. An interview was conducted on 09/05/2024 at 1:57 p.m. with the Director of Nursing (DON). She stated she had started her position at the end of July 2024. She stated for call lights, timeliness, or un-timeliness, I have not done audits. I do not know if others have done call bell light issues. On 09/05/2024 at 2:36 p.m., the DON stated, back in June, the ADON (Assistant Director of Nursing) gave an in-service, there has been nothing since. 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 09/05/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe and sanitary environment for residents as evidenced by discoloration on ceiling tiles in one of two resident day rooms; discoloration on ceiling tile in room [ROOM NUMBER] with evidence of water by the air conditioning wall unit; ceiling damage from rain in room [ROOM NUMBER]; discoloration on ceiling air vents above one of two nursing stations; and a fallen tree limb in one of one resident courtyard. Findings included: During the tour of the facility conducted on 09/05/2024 initiated at 9:30 a.m., the following physical plant observations were conducted. Photographic evidence obtained. At 9:30 a.m., an observation on the 300 hall, the resident day room, revealed three of the ceiling panels next to the fan had brownish, black, pinkish discoloration present. The discoloration was approximately 10 inches by 10 inches in size each, with one of the marks having grayish growth like material on top of the pinkish black. At 9:40 a.m., an observation on the 400 hall, resident room [ROOM NUMBER]. Three ceiling panels had brownish discoloration covering 25-50% of the panels located next to the window which had a room air conditioner (a/c) unit present. Under the a/c unit was a blanket on the floor. At 9:50 a.m., an observation of the south wing (100 and 200 hall) showed the A/C return vent, approximate 18 inches by 18 inches in size in the ceiling outside of the south wing resident day room had an accumulation of dust debris hanging on the slats. Five air vents, approximate 12 inches by 12 inches in size, in the ceiling around the nurses' station and in the halls had noticeable black discolored material present. The ceiling panels and the seams had dust hanging down in the ceiling panels above the nursing station by the ceiling fan. A corner of the ceiling across from the nursing station had ceiling panels with brownish beige discoloration. At 10:10 a.m., an observation was conducted of resident room [ROOM NUMBER]. The ceiling panels above the resident in bed A had been removed. The Maintenance Assistant was present and was interviewed. He stated when the wind blew, and it was raining, the water would come in through the vent in the roof. He was replacing the ceiling tiles above the bed due to water damage. An attempt to interview the resident in 121A was conducted at this time. He was not able to be interviewed. He would talk about other subjects that the questions posed. Observed his bed had a blanket over it to protect it. The ceiling tiles above his bed had been removed. The resident was sitting at bedside, dressed in seasonally appropriate clothing. On 09/05/2024 at 11:40 a.m., an interview was conducted with the Maintenance Director. He stated the facility had been cited before for unclean air vents. It was corrected back in March 2024. When asked how often the vents were cleaned, he stated probably not since March. He stated the building had no insulation, there was condensation, the panels were discolored continuously. He stated a vendor for roof repairs had been out to the facility approximately one month ago. He stated, this company used one vendor for the repairs, and he had not heard any updates since the vendor had come out. He stated for room [ROOM NUMBER], the discoloration in the ceiling tiles was from the roof leaking. He stated the blanket on the floor was because the water would pool outside the building, and it would (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 09/05/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few come in through the frame of the wall a/c (air conditioning) unit. He stated, that was not the only room with that issue. He stated he had gone around the building and raked the leaves away in order to facilitate better drainage. He stated, really, there should be rocks out there and the trees cut back. He stated, there were downed branches from Tropical Storm [NAME], August 4-5, 2024, there was a big one in the courtyard. He stated, I had three tree trimmers come out within the last two weeks. The Administrator just sent the bids up to corporate yesterday. He stated, for the roof repair there was a process. He provided the process, roof repair procedure. He said, from the e-mail date, the request was sent up on 08/15/2024, because they asked for a facility map. An observation was conducted on 09/05/2024 at approximately 12:05 p.m. of the middle courtyard of the building with the Maintenance Director. An observation of the resident smoker's gazebo revealed the sidewalk, leading away from the gazebo to a fence with a gate, had a large portion of a tree laying across it. The tree limb was observed to be approximately 30 feet in length, the main branch approximately 12-14 inches diameter. The branches smothered the sidewalk. The Maintenance director stated at this time, the tree limb had come down during the tropical storm. He stated he had gotten two bids for the tree issue; the bids must go through corporate for approval. He stated one guy wanted to remove the trees because they look like they are dying; and he pointed to the tree that had lost the large section, which was hollow in the center. The Maintenance Director subsequently provided two documents which he stated were proposals. Review of one Proposal, invoice 1198 by (name of company, for $5400. Dated 10/03/24, which the Maintenance director stated, at approximately 12:15 p.m., the date was wrong, he thought the estimate was given approximately 1 month ago. Review of the proposal documented the labor description: Trim trees over roof throughout complex & remove 1 large limb laying on ground. Review of the second Proposal, quote 08/13/2024, from (name of company), dated 08/13/2024, for $6,200.00, documented the labor description: 4 Laurel Oak Trees (courtyard) Remove all large limbs over units & remove large deadwood 360 degrees. Remove all hanging limbs. Strongly suggested for removal all four trees are in decline. 2 Laurel Oak Trees (right rear) elevate & reduce, remove all large deadwood over structure. 2-3 large limbs. Remove. 2 Laurel Oak trees (left rear) elevate & reduce, remove all large deadwood over structure. 4 large limbs remove. 1 dead queen Palm (front) remove. All the Laurel Oaks on this property are approaching the end of their life cycle and are in decline. No further documentation of a commitment to remove the tree downed in the courtyard was provided. Subsequently, the Maintenance Director provided an e-mail document: Review of the e-mail dated 08/15/2024, to [Email address of tree company], documented a facility map with tree pictures had been provided to the e-mail address. (continued on next page) 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 09/05/2024 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 0921 No further documentation of a commitment to repair the roof was provided to the survey team. Level of Harm - Minimal harm or potential for actual harm On 09/05/2024 at 12:25 p.m. an interview was conducted with the Activities Director. When asked if he conducted activities out in the courtyard with the residents, he stated yes. He stated, mainly at this time it was supervised smoking. But we have done tea parties, corn hole games, or other games. Yes, the branch had been laying there since the tropical storm, it had been a while. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105373 If continuation sheet Page 5 of 5