Health inspection·February 18, 2021

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that their policy related to identifying and arranging an appropriate representative to make health care decisions was implemented for one Resident (#231) of forty-four residents sampled. Findings included: A review of the facility policy titled Resident Rights Regarding Treatment and Advance Directives, with implementation date of 11/21/2021 revealed: Policy Explanation and Compliance Guidelines: 5. The facility will identify or arrange for an appropriate representative for the resident to serve primary decision maker if the resident is assessed as unable to make relevant health care decisions. A record review for Resident #231 indicated she was originally admitted on [DATE] and re-admitted on [DATE] with multiple diagnoses that included Cerebral Infarction, Traumatic Subarachnoid Hemorrhage with loss of consciousness of unspecified duration, Gastrostomy, and Tracheostomy. A continued record review revealed no advance care planning with no advance directive. Active physician orders dated 02/16/2021 listed the resident as a Full Code. A review of care plan dated 01/28/2021 denotes under Focus area dependent on staff for all her daily care needs secondary to vegetative state. The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 231 did not have a Brief Interview For Mental Status (BIMS) score and was listed as comatose, could not be aroused. The most recent updated MDS made on 02/09/2021 was requested, but not provided by the facility. On 02/16/2021 at 11:04 a.m. a telephone interview was conducted with the Responsible Party/Emergency contact listed on Resident #231's facility profile sheet. During the family interview the party revealed that he was the resident's ex-husband, and he is listed because he is trying to help her out since her children were living in another country and has not been able to find or contact them in the past five (5) years. During the interview he indicated he did not know where Resident #231 was at the present time, and had not spoken to anyone regarding where she was. He further indicated that when the resident was recently hospitalized , he was called by the hospital to provide her Medicaid number and social security number. He said he did not have that information, and did not know where to get it, since he was not officially made the resident's guardian or official health care decision maker. During an interview conducted on 02/17/2021 at 09:30 a.m., with the Social Services Director (SSD), he was asked if the facility is trying to obtain a guardian for Resident #231. The SSD could not provide any documentation or progress notes in the clinical medical record to show that he attempted to contact the resident's ex-husband. He stated I tried to call him to do a Health Care Proxy last week, he does not answer the phone, I left a voice mail. I promise that I spoke to him when she first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 2 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few arrived for first 72 hours, I will print it out for you to see. We only do the 72 hour the first time, and she has been out to the hospital more than once, and her last re-admit was 2/9/2021 An observation was conducted on 02/17/21 at 08:20 a.m. of Resident #231 sleeping with the Head of the bed up at 45 Degrees. The G-Tube (GT) was observed to be running, and the enteral feed pump transfusing at 60 ml/hr. On 02/19/21 at 08:50 a.m. an interview was conducted with the Resident #231's Advance Practice Nurse (ARNP) who was aware of the resident not having a health care decision maker/guardian. She stated, She will call and have the advance care-plan discussion with the ex-husband who will be the designated surrogate once he signs and returns the paperwork. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 3 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record review and facility policy review, the facility failed to ensure that a resident centered care plan was developed and implemented related to wearing a Wander Guard Device/Bracelet for one (Resident #24) of forty-four residents in the sample group. Findings included: On 02/18/2021 at 3:00 p.m., Resident #24 was observed to be walking with an unidentified Certified Nursing Assistant, (CNA) into his resident room, and as he lifted his leg up to step forward his pants moved slightly, showing a white Wander Guard Device/Bracelet on his ankle. A medical record review for Resident #24 indicated he was admitted on [DATE] with multiple diagnoses that included Cerebral Infarction, Aphasia, Atrial Fibrillation and Cognitive Communication Deficit. A record review of active Physician Orders revealed that Resident #24 did not have an order to wear a Wander Guard Device/Bracelet. Record review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident #24's Brief Interview for Mental Status (BIMS) score was 09, (indicating moderate cognitive impairment). Further record review of Resident #24's care-plan dated 02/15/2021, with several revisions since admission did not include a Focus area for a Wander Guard Device/Bracelet care and monitoring with goals and intervention/tasks to be followed by facility staff. On 02/19/2021 at 09:00 a.m. an interview was conducted with the Director of Nursing (DON). The DON was informed of the observation made of Resident #24 wearing an ankle Wander Guard Device/Bracelet and that there were no active orders, or a Care Plan area developed or implemented to wear one if the facility considered Resident #24 to be an Elopement Risk. The DON indicated she would investigate the matter and get back to the surveyor. At 9:09 a.m. a physician order was observed to be placed in Resident #24's medical record and written by the Regional Clinical Nurse. On 02/19/2021 at 10:00 a.m., the DON approached the survey team with three Elopement Binders containing Resident #24's picture and information regarding the Wander Guard Device/Bracelet. She revealed that she has performed a visual inspection of the resident's information in all the books, and also checked Resident #24's Wander Guard Device/Bracelet with a Secure Care Tester Box, which showed that it was functioning. She said her staff will be checking placement for Resident #24's Wander Guard Device/Bracelet on the 11-7 shift. The DON further indicated information from Resident #24's medical record dropped off when new ownership took over operational control of the facility. The DON was asked what her expectation was for her staff related to development and implementation of care plans, and she stated I would expect the resident to be care-planned if he has an order for a wander-guard bracelet. On 02/19/2021 at 10:19 a.m., an interview was conducted with the Regional Clinical Reimbursement Nurse, filling in as MDS(Minimum Data Set)/Care Plan Coordinator, who confirmed that Resident #24 was not care-planned to wear a Wander Guard. Device/Bracelet. She stated I saw the order put in today for the Wander Guard, and I confirm the resident did not have a Wander Guard area in his care plan. I did the update to the care plan today from the quarterly care plan that was originally completed on 02/15/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 4 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility policy titled Comprehensive Care Plans, with incorrect implementation date and reviewed/revised date of 11/21/2021, Pages 02 of 02 revealed: Policy Explanation and Compliance Guidelines: 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Event ID: Facility ID: 105394 If continuation sheet Page 5 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to perform full body skin assessment weekly for one resident (Resident #72) out of the sampled forty-four residents. Residents Affected - Few Findings included: A review of the admission Record revealed that Resident #72 was originally admitted into the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, pressure ulcer of sacral region, and pressure ulcer of right ankle. A review of Section C of the Nursing Home Comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section M of the MDS revealed that Resident #72 was at risk for pressure ulcers/injuries. A review of the Order Summary Report with active orders as of 02/18/2021 revealed that there was not an order for skin assessments. A review of the Medication Administration Record and Treatment Administration Record dated February 2021 revealed that there was no documentation related to skin assessments. A review of the Progress Notes for February 2021 revealed that no skin assessments were documented. A review of the assessments tab for weekly skin checks revealed that no skin assessments had been completed (photographic evidence obtained). The care plan related to skin with an initiation date of 02/09/2021 revealed that Resident #72 was at risk for skin breakdown due to impaired mobility related to diagnosis of quadriplegia and malnutrition, incontinence of bowel, indwelling catheter, and current area to left lateral thigh. Interventions included but were not limited to complete weekly skin assessments, monitor skin during bathing and daily, and monitor skin for signs and symptoms of skin breakdown. On 02/18/21 at 2:31 p.m., Staff A, Licensed Practical Nurse (LPN), reported that skin checks are done on second shift. Skin checks are done as needed with a shower. Skin checks are completed under assessments. On 02/18/21 at 3:40 p.m., the Director of Nursing (DON) stated that skin checks are done weekly and that it was a standard. They are documented in the assessment section of the medical record. The DON confirmed that no skin assessments had been completed for Resident #72. The policy provided by the facility Skin Assessments revised on 11/21/2021 revealed the following: Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. Policy Explanation and Compliance Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 6 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 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 0684 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 7 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to ensure a resident's fall on 2/6/21 was investigated to ensure effective interventions were in place after a previous fall on 2/3/21 for one (Resident #65) of two sampled residents. Findings included: Review of Resident #65's medical record showed their diagnoses included Repeated falls. Review of the nursing progress notes dated 2/6/21 at 10:46 p.m. revealed the resident fell. The nursing observations, evaluation, and recommendations were: Resident confused and tries to walk unassisted. Review of the resident's care plan reflected the a focus area of at risk for fall related injury created on 2/8/21 to include interventions: anticipate needs, provide prompt assistance, follow facility fall protocol, and report falls to physician and responsible party. Review of the fall risk evaluation dated 2/6/21 at 10:32 p.m. reflected a score of 14 for at risk for falls. During an interview with the Director of Nursing (DON) on 2/18/21 at 02:54 PM the DON confirmed the resident had a change in condition on 2/6/21 but did not see a fall on 2/6/21. After review of the record the DON stated she would have to call the nurse that completed the documentation as she was not aware of the fall. During an interview with the DON on 2/18/21 at 3:31 p.m. she stated the resident should have a change of condition and progress note related to the falls. The DON confirmed an investigation for the fall on 2/6/21 was never started or completed. During an interview with the Advanced Practice Nurse Practitioner (ARNP) on 2/19/21 at 9:28 a.m. she stated she reduced Resident #65's blood pressure medicine on 2/4/21 after a fall the day before due to a vasovagal response. The ARNP confirmed she was notified on the 2/7/21, the day after the fall but did not document in her notes. Review of the facility policy for fall prevention program dated 11/21/20, 2 pages, from the compliance store revealed: 9. When any resident experiences a fall, the facility will: a. assess the resident, b. complete a post fall assessment, c. complete an incident report, d. notify the physician and family, e. review the resident's care plan and update as indicated, f. document all assessments and actions, g. obtain witness statements in the case of injury. Review of the facility policy for documentation in the medical record dated 11/19/20, one page from the compliance store, revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of the facility policy for notification of changes dated 11/21/21, two pages, revealed: The purpose of this policy is to ensure the facility promptly informs the resident, consults the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 8 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 9 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record reviews, and interviews, the facility failed to ensure food was dated and labeled in two of two nourishment refrigerators. Residents Affected - Few Findings included: On 02/15/21 at 10:15 a.m., the nourishment room on the 100 hall was observed. Temperatures were missing from the Refrigerator Temperature Log for 02/11, 02/12, 02/13, and 02/14. Inside the refrigerator were the following foods with no label or date: an opened bottle of Gatorade, an opened orange juice, a brown bag that held a plastic bag of unknown food, a container of opened ice cream, a frozen to go fast food cup, an opened bag of pizza rolls, 3 sandwiches in plastic bags, and an open carton of French vanilla with an expiration date of 02/04/21. On the counter was an uneaten breakfast tray with eggs and toast. The Certified Dietary Manager (CDM) reported that breakfast was at 7:30 a.m. The nourishment room on the 300 hall was observed. Inside the refrigerator were the following foods with no label or date: two frozen to go fast food cups, an opened package of sausage, and a plastic container of carrots. At 10:25 a.m., the CDM reported that he thinks the nurses are responsible for taking the temperatures. The CDM stated that his expectation is that everything in the refrigerator should be dated and labeled. The policy provided by the facility Date Marking for Food Safety revised on 11/21/2021 revealed the following: Policy The facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 10 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to schedule outside appointments in a timely manner for one resident (Resident #13) out of the one sampled resident. Findings included: On 02/15/21 at 12:30 p.m., Resident #13 reported that he had been trying to get an appointment scheduled for months with a urologist. The resident reported that he spoke to the Social Services Director (SSD) about scheduling the appointment and he reported that there were issues with his Medicaid. The admission Record revealed that Resident #13 was admitted into the facility on [DATE] with a primary diagnosis of multiple sclerosis (MS). Section C of the Quarterly Minimum Data Set (MDS) revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. On 11/18/20, a physician's note revealed that Resident #13 wanted to see a urologist. The resident's levels of testosterone needed to be checked before a referral to the urologist. There were no notes that indicated that the resident had a scheduled urologist appointment. On 02/17/21 at 1:42 p.m., the Social Services Director reported that Resident #13 had reported to him that he wanted to see a urologist last week. The SSD stated that he reported this information to the Nurse Practitioner, and she stated that she would reach out to a urologist. Nurses usually work with the residents to get appointments scheduled. He stated that he had not had any luck with getting the appointments scheduled and he had no documentation that indicated that he had attempted to get the appointments scheduled. On 02/18/21 at 2:37 p.m., the Director of Nursing (DON) reported that nurses are responsible for scheduling outside appointments and setting up transportation. On 02/18/21 at 4:29 p.m., the DON reported that they did not have a policy on scheduling outside appointments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 11 of 12 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 105394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Palms 2600 Highlands Blvd N Palm Harbor, FL 34684 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and policy review, the facility failed to follow their policy and procedure related to providing education, and obtaining consent for the influenza vaccination, for one resident (#39), of five sampled residents that were reviewed for of immunization documentation. Residents Affected - Few Findings included: Record review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 39's Brief Interview For mental Status (BIMS) score was 15, (indicating cognitively intact); and Section O, listed under Influenza Vaccine as not receiving one, with no choice selected for the area of reason not given. A record review of Resident #39's Immunization report revealed that the resident consented to receive the Influenza Vaccination, in the right Deltoid on 10/10/2020. A further record review of the Electronic Medical Record (EMAR) was conducted and read Fluzone Quadrivalent Suspension filled Syringe 0.5 ml (influenza Vac Quad. Inject 0.5 ml intramuscularly) on 11/20/2020, with the nurse's initials who administered the vaccination Further record review of the EMAR and Resident #39's paper chart revealed that there was no current (Year 2020) consent, and education documented in the resident's record. The last consent signed by Resident #39 for an Influenza vaccination was on 10/17/2018. During an interview conducted with the Director of Nurses on 02/18/2021 at 2:42 p.m. she confirmed that appropriate documentation of education and recent consent were not found in Resident #39's record. She indicated that Resident #39 should have written proof of consent and education in his medical record. A facility provided policy titled, Influenza Vaccination, dated 11/15/2021 was reviewed Page 01 of 02, revealed: 7. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed signed and dated record will be filed in the individual's medical record. 9. The resident's medical record will include documentation that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contradiction or refusal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 12 of 12