Health inspection·April 22, 2022

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (SNF/NF) to Hospital Transfer Form, dated 02/25/22, that identified the resident was sent to an acute facility for the reason of other. The form identified the resident was capable of making decisions and the proxy was notified of the transfer. The Acute Care Transfer Documentation Checklist did not identify any documents were sent with the resident. The review of Resident #25's medical record included a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 04/18/22, an identified the resident was sent to an acute care facility for other. Review of a progress note indicated on 04/18/22 the resident was observed with plus 4 pitting edema, jerking, and slow to respond. The Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form indicated the medical proxy was notified of the resident's transfer and clinical situation. The Agency for Healthcare Administration Nursing Home Transfer and Discharge Notice (AHCA Form 3120), given to the resident on 04/18/22, did not include the address or phone number of the resident's proxy, effective date, location to which the resident was transferred or discharged , or a brief explanation for the transfer. The form identified the location in which the resident was transferred or discharged was a required section. The resident's AHCA Form 3120, dated 04/18/22, did not indicate a date the notice was given to the Resident, Legal Guardian or Representative, or the Local Long Term Care Ombudsman Council, and placed in the Resident Clinical Record, or included the attachments of the requests for Ombudsman Review and Fair Hearing. 3. A review of the admission Record for Resident #30 revealed the resident was initially admitted on [DATE], recently discharged on 04/06/22, and readmitted on [DATE]. The admission Record included diagnoses of cause unspecified cardiac arrest, chronic respiratory failure with hypoxia, anoxic brain damage not elsewhere classified, and persistent vegetative state. The admission Record identified three family members as the emergency contacts for Resident #30. The AHCA Form 3120, identified the notice was given to the resident representative on 04/06/22. The form did not include the location to which the resident was transferred or discharged , or a brief explanation of why the needs were not met by the facility. The notice identified the resident or representative was notified by phone and did not indicate the notice was given to Resident, Legal Guardian, or Representative, Local Long Term Care Ombudsman Council or Resident's Clinical Record. On 04/20/22 at 4:50 p.m., Staff N, Unit Manager/Licensed Practical Nurse (UM/LPN) stated a copy was to be made of the AHCA Form (3120) and to be kept in the chart. The Interim Director of Nursing (DON) identified, on 04/21/22 at 11:31 a.m., the facility does not have an AHCA Form 3120 for Resident #30's recent (04/10/22) hospitalization. She stated staff were recently educated on the bed hold notice and the AHCA transfer forms. She stated the facility sends a red folder to the hospital with the resident's information including the bed hold and the AHCA transfer. She stated she did not know if the nurses sent the forms to the hospital and confirmed they had not made copies for the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 2 of 31 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 04/22/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and review of the facility policy, the facility failed to ensure three residents (#47, #128, and #25) or their representatives were provided a notice of bed hold policy when the residents were transferred to the hospital of four residents reviewed for hospital transfers. Findings included; 1. Review of the admission Record revealed Resident #47 was initially admitted to the facility on [DATE] with a readmission date of 03/12/22. Resident #47 had multiple diagnoses to include quadriplegia, chronic osteomyelitis, acquired absence of right leg above the knee and neuromuscular dysfunction of the bladder. Further review revealed Resident #47 was his own responsible party and had one emergency contact noted. On 04/21/22 at 9:30 a.m. Resident #47 confirmed he was transferred to the hospital on [DATE] and returned on 03/12/22. Resident #47 reported he wasn't able to return to his same room immediately. He reported he had to be in another part of the facility for a certain number of days. Review of the medical record revealed Resident #47 was transferred to the hospital on [DATE] through 03/12/22 to treat a wound on the resident's right lower leg. Further review of the resident's medical record revealed, upon transfer, he did not receive the notice of bed hold policy indicating the length of time the facility would hold his bed during the hospital stay. 2. A review of the admission Record for Resident #128 showed the resident was admitted to the facility on [DATE] with multiple diagnoses to include paraplegia and neuromuscular dysfunction of bladder. Resident #128 was identified as his own responsible party. A closed medical record review revealed on 05/07/21 the resident was transferred to a local hospital to be evaluated and treated and returned to the facility on [DATE]. Further review of the resident's medical record revealed, upon transfer, he did not receive the notice of bed hold policy indicating the length of time the facility would hold his bed during the hospital stay. On 04/21/22 at 9:51 a.m. an interview with Staff O, Medical Records revealed she was unable to locate the bed hold notice forms in Resident #47's and #128's paper or electronic records. Staff O confirmed the bed hold notice was to be completed by the nursing staff upon transferring or discharging a resident. On 04/21/22 at 11:17 a.m. Staff O indicated Resident #47 was not provided with the required documentation and the medical record was silent in this respect. 3. A review of the admission Record revealed Resident #25 was admitted to the facility initially on 02/01/22 and readmitted on [DATE]. The admission Record included diagnoses not limited to end stage renal disease, dependence on renal dialysis, and unspecified chronic obstructive pulmonary disease (COPD). The medical record identified the resident's attending physician deemed the resident incapacitated on 02/11/22 and a family member was appointed as the medical proxy on 02/14/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 3 of 31 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 04/22/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm A review of Resident #25's medical record included a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 02/25/22, that identified the resident was sent to an acute facility for the reason of other. The form identified the resident was capable of making decisions and the proxy was notified of the transfer. The Acute Care Transfer Documentation Checklist did not identify any documents were sent with the resident. Residents Affected - Some A closed medical record review of Resident #25's information from 02/2022 revealed a blank bed hold notice. The review of Resident #25's medical record included a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 04/18/22, an identified the resident was sent to an acute care facility for other. Review of a progress note indicated on 04/18/22 the resident was observed with plus 4 pitting edema, jerking, and slow to respond. The Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form indicated the medical proxy was notified of the resident's transfer and clinical situation. The Bed Hold Notice, dated 04/18/22, for Resident #25 did not identify the reason for the notice and indicated the resident was unable to sign and did not indicate the medical proxy for the resident was notified. On 04/20/22 at 4:50 p.m., Staff N, Unit Manager/Licensed Practical Nurse (UM/LPN) stated there should be a bed hold (notice) in the front of every chart so that it was easy to find. The Staff N stated if the resident was unable to sign, the facility was to call the family member, make a copy, and send the original with the patient and keep a copy in the chart. The Interim Director of Nursing (DON) stated, on 04/21/22 at 11:31 a.m., the staff were recently educated on the bed hold notice and the AHCA transfer forms. She stated the facility sends a red folder to the hospital with the resident's information including the bed hold and the AHCA transfer. She stated she did not know if the nurses sent the forms to the hospital and confirmed they had not made copies for the clinical record. The policy titled, Bed Hold Notice Upon Transfer, implemented 11/2021 and revised 03/10/22, indicated, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. The policy identified the facility would keep a signed and dated copy of the Bed Hold Notice given to the resident and/or representative in the resident's file. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 4 of 31 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 04/22/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility policy and record reviews, the facility failed to ensure the interventions on the resident centered care plan were revised, related to wearing a left-hand soft orthosis for contracture management for one resident (#15) of thirty-eight residents sampled. Findings included: On 04/18/22 at 10:04 a.m. Resident #15 was observed with a left hand contracture, not wearing a soft hand orthosis device. A second observation on 04/18/22 at 12:59 a.m. of Resident #15 was conducted. Resident #15 was sleeping in a (medical recliner chair) and not wearing a left hand soft hand orthosis device. On 04/19/22 at 9:19 a.m. Resident #15 was observed to be lying in bed, not wearing a soft hand orthosis device, and a certified nursing assistant (CNA) was in the room. A second observation on 04/19/22 at 10:02 a.m. of Resident #15 was conducted. Resident #15 was seated in the (medical recliner chair) in the activities room, and not wearing a left hand soft hand orthosis device. On 04/20/22 at 8:01 a.m. an observation of Resident #15 revealed the resident sleeping in bed, dressed, and not wearing a left hand soft hand orthosis device. A second observation of Resident #15 conducted on 04/20/22 at 10:11 a.m. revealed that she was lying in bed sleeping, and not wearing a left hand soft hand orthosis device. A review of the admission Record for Resident #15 indicated she was originally admitted on [DATE] and re-admitted on [DATE], with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and contracture. A review of the Order Summary Report, dated 04/20/22, for Resident #15 revealed an active physician order dated and started on 05/05/21 for a Left soft wrist hand orthosis for contracture management, on after AM (morning) meal, off prior to evening meal. May be removed for meals, self-care tasks, activities and per patient request, every day and evening shift. On 04/20/22 a review of the active care plans for Resident #15 was conducted and revealed the care plan with a focus area as: (Resident #15) has decreased ability to perform ADL (activities of daily living) self-care tasks in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, wheelchair locomotion and toileting related to advanced age and dementia, CVA (Cerebrovascular Accident) with left hemiparesis and left hand contracture, impaired cognition, initiated on 12/31/21 and revised on 02/14/22. The care plan also included a focus area as (Resident #15) is at risk for pain/discomfort secondary to immobility, contracture left UE (upper extremity), left knee pain, bruising. (Resident #15) has dementia and may have difficulty verbalizing her discomfort. A review of the active care plan revealed it was silent of an intervention for a left hand soft ortho device for contracture to be worn by Resident #15 as ordered by the physician on 05/05/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 5 of 31 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 04/22/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/20/22 at 1:53 p.m. an interview was conducted with the Director of Occupational Therapy and Rehabilitation (DOR). During the interview, the DOR confirmed Resident #15 needed to wear the left-hand soft orthosis for contracture management, and therapy was applying it at this time. The DOR stated, She tolerates one hour to one and a half hours. We are training her contracture right now; and after three weeks restorative program, the CNAs will do range of motion (ROM) and apply the device. The staff were not putting the device on her contracture, and it got worse. In an interview conducted with the Assistant Director of Nursing (ADON) on 04/20/22 at 2:02 p.m., she confirmed Resident #15 should be care planned to wear the left hand soft ortho device for contracture and did not know why it was omitted as an intervention on the care plan. An interview was conducted on 04/20/22 at 2:11 p.m., with the Minimum Data Set (MDS) Coordinator, who is responsible for updating care plans. During the interview she confirmed the intervention was not on the current care plan. She further indicated if there is an active physician order in the medical record, then it must be on the care plan too. Immediately after the interview, the MDS Coordinator revised Resident #15's care plan focus area related to ADLs by adding the intervention. The intervention, initiated on 4/20/22, read: Place-left soft wrist hand orthosis for contracture management after morning meal and remove prior to evening meal. May be removed for meals, self-tasks, activities, and per patient request. A review of the facility policy titled, Comprehensive Care Plans, revised on 4/15/22, read as follows: POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and compliance guidelines: 2. The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR (Preadmission Screening and Resident Review) recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 6 of 31 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 04/22/2022 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 0657 e. Discharge plans, as appropriate. Level of Harm - Minimal harm or potential for actual harm 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Residents Affected - Few 8. Staff personnel responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 7 of 31 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 04/22/2022 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined the facility failed to arrange a physician ordered appointment for eye surgery in a timely manner for one resident (#38) out of a sample of thirty eight residents. Residents Affected - Few Findings included: An interview with Resident #38 on 04/18/2022 at 11:50 a.m. revealed the resident lying in bed with the lights off. He stated a couple of months ago, he had a concern and asked his nurse if she could schedule an appointment due to his vision becoming cloudy and experiencing blurriness. Resident #38 was still concerned at this time, and explained the blurriness is getting worse. A review of the admission Record revealed Resident #38 was readmitted to the facility on [DATE] and initially admitted on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia and unspecified severe protein-calorie malnutrition. A review of the Order Summary Report, dated 04/20/2022, for the dates of 01/01/2022 - 01/31/2022 revealed a physician order for: Refer to YAG laser (laser used to clear the frosting from the back surface of an intraocular lens) treatment to both eyes (physician name) due to secondary cataracts, order date was 01/10/2022. A review of the electronic medical record under the Orders tab showed this order was entered on 01/10/2022 at 17:20 (5:20 p.m.) by Staff G, Licensed Practical Nurse (LPN). A review of Resident #38's care plan, initiated on 01/11/2022, revealed: Focus - (Resident #38) has vision impairment related to Cataracts. Goals - (Resident #38) will maintain baseline level of visual acuity through the review date as evidenced by no complaints of decreased vision. Interventions/Tasks included: Arrange for appts (appointments)/follow-ups with eye care provider as ordered. On 04/19/2022 at 3:30 p.m. an interview was conducted with Staff S, LPN. Staff S said, Once the nurse gets the physician order, they input it into the system, under the tab labeled Orders for that resident medical record. They would then check the resident's insurance to find a provider that would take it for the specific appointment. The nurse would then call that provider and schedule the appointment. Once that is completed, it would then be entered into the resident's electronic medical record. This sends an alert to staff that the resident has an upcoming appointment with date and time and name of provider. They would also inform the resident that an appointment was made. Staff S continued with, If they are unable to find a suitable provider, they would then contact the social services department, who would then look for a provider that takes the resident's insurance. Once completed they would then call the provider and schedule the appointment, which then would be added to the resident's MAR (medication administration record). The information would be shared with the resident and notification to any family if applicable. On 4/20/2022 at 12:50 p.m. the Assistant Director of Nursing (ADON) provided a policy titled, Process for scheduling and Making Follow-up Appointments. The steps were documented as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 8 of 31 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 04/22/2022 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 0685 1. During morning meeting orders are reviewed for all residents for any appointment needs. Level of Harm - Minimal harm or potential for actual harm 2. All orders for appointments are discussed. The medical records representative will take notes regarding appointment details in order to make appointment. Residents Affected - Few 3. Once appointment has been scheduled, it is added to notification in Electronic Medical Record (EMR) Software. 4. At same time the appointment is made transportation is also arranged. The ADON stated during the interview on 04/20/2022 at 12:50 p.m. they do not have a current policy or procedure from the new company in regard to the arranging of medical appointments for the residents. The ADON stated they had to create a policy this morning. On 04/20/2022 at 3:30 p.m. an interview with Staff G, LPN (nurse who entered the physician order on 01/10/2022) accessed the EMR to review the physician order record for Resident #38. After review, she confirmed she did not finish filling in the order. Staff G confirmed the order entered on 1/10/2022 was never sent. An interview with Staff N, LPN was conducted on 04/20/2022 at 4:30 p.m. Staff N stated, No, the order needs to be completely processed, which then gives enough information to create a complete care plan. If the staff had witnessed an order that was not processed, they should have notified me immediately and we could have processed the resident's order for the medical appointment. On 04/20/2022 at 4:45 p.m. an interview was conducted with the ADON. The ADON stated it was her expectation that all orders are followed through on, from receiving the PO (physician order), to inputting the order in the EMR. She said it should then be discussed in morning meeting the next day during new orders review. Transportation should be arranged for the appointment, and this allows all disciplines, who need to be involved, are notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 9 of 31 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 04/22/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure a Stage IV pressure ulcer was treated in a manner to promote healing and prevent infections for one resident (#45) out of 14 facility residents with pressure injuries. Residents Affected - Few Findings included: Resident #45 was admitted to the facility on [DATE] with a diagnoses, including Type 2 Diabetes Mellitus with foot ulcer (onset 12/22/21), morbid (severe) obesity due to excess calories, and unspecified complication of skin graft (onset 1/9/22). An observation was conducted, on 4/20/22 at 2:19 p.m., with Staff M (Agency Licensed Practical Nurse/LPN) of the wound care for Resident #45. The resident was observed lying on the bed as the staff member removed the gray non-slip sock from the resident's left foot. The staff member did not place a barrier under the resident's foot as she removed the elastic bandage from the area and exposed the rolled gauze underneath. Staff M began pulling at the tape holding the rolled gauze and tearing at the rolled gauze as she removed it. Staff M did not use scissors to cut away the rolled gauze. An area of tan and red discoloration was observed on the rolled gauze at the heel area. The staff member used wound cleanser to loosen the gauze sponge and blue Hydrofera pad from the wound. She cleansed the wound by spraying wound cleanser and using a 4x4 gauze sponge which had been sitting on the resident's dresser without a barrier to pat the wound dry. Staff M opened a package of 4x4 Hydrogel, a prism of Collagen and Silver, and a 4x4 drain sponge. She stated the Hydrogel was an off brand of the ordered Hydrofera sponge dressing. Resident #45 informed Staff M she was missing the purple one. Staff M reported to the resident she was not missing anything, she had written everything down. A review of what the staff member had written down identified Hydrofera. The resident informed the nurse the purple dressing was on the left side of the top drawer of the dresser. Staff M removed an opened package of Hydrofera blue, then removed the sponge dressing with bare hands and placed the packaging on top of the bedspread with the sponge. Staff M left the resident room, went to the treatment cart, and removed a pair of scissors, then began to return to the resident's room. The staff member confirmed she had contaminated the Hydrofera sponge by removing it from the packaging with bare hands. She stated, I took my gloves off. The staff member went into the unit's pantry, looked around and then reported to Staff E, Minimum Data Set (MDS) Coordinator, she needed another Hydrofera, because it got contaminated. After several minutes Staff E returned to the unit and had produced an unopened package of Hydrofera. Staff M placed the scissors onto the resident's bedspread, applied a pair of gloves (without performing hand hygiene), sprayed wound cleanser into the wound and used a 4x4 gauze pad to pat dry the wound. She picked up the scissors from the bedspread and cut off a piece of the Hydrofera, then placed the remaining piece on top of the packaging. She placed a drain sponge on top of the blue sponge, applied a large abdominal pad, then began to wrap rolled gauze around the dressings and the resident's foot. Prior to adhering the rolled gauze, she removed the rolled gauze, the abdominal pad, drain sponge, and the blue sponge. The LPN applied the prism to the wound bed, used scissors (that had been lying on the bedspread) to cut another piece of the Hydrofera before applying it, then she placed the previous 4x4 drain sponge, the previously applied abdominal pad, and then used the previously applied rolled gauze to secure the dressing to the left heel before wrapping the area with an elastic bandage. The staff member applied the previously removed gray sock, threw away all the trash, removed gloves, and washed hands for approximately 10 seconds. Immediately following the observation, an interview was conducted with Staff M. She stated hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 10 of 31 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 04/22/2022 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hygiene was to be done before and after care. She acknowledged hand hygiene should be done between dirty and clean applications, and the scissors were contaminated from lying on the bedspread. Staff M stated she was assured the scissors removed from the treatment cart were clean. A review of Resident #45's April 2022 Order Summary Report identified the resident had the following orders: -Continue dressing change 3 times (x) per week, use Prisma Promogram followed by Hydrofera Blue, 4x4, Abdominal (AND), wrap with rolled gauze ([NAME]) every day shift every Monday, Wednesday, and Friday for treatment. Start date: 3/9/22 with no discontinuation date. - Continue dressing changes 3 x/week to left heel using Hydrofera Blue, 4x4, AND, [NAME], Ace wrap any questions every day shift every Monday, Wednesday, Friday for open area. Start date: 4/18/22 with no discontinuation date. A review of the April 2022 Treatment Administration Record (TAR) for Resident #45 identified Staff M had documented she completed both of the wound care treatments listed above for the resident on 4/20/22. A review of the Weekly Pressure Wound Evaluation dated 2/22/22 identified Resident #45 had acquired a left heel stage II pressure ulcer on 11/29/21. A review of the Encounter note from the physician dated 4/3/22 indicated Resident #45 had a left heel ulcer with continuing wound care. A review of the Skin/Wound note dated 4/11/22 at 9:59 a.m., indicated Resident #45 had a Stage IV pressure ulcer to (the) left heel. The Care Plan for Resident #45 identified the following: - (Resident) had actual skin breakdown: 11/15/21 trauma/scratching to Right buttock, 11/29/21 chronic slow-healing left heel surgical wound - history of infected diabetic foot ulcer (surgically closed with graft at readmission since debrided) 1/9/22 rash. Revised 3/25/22. The goal was to remain free from signs and symptoms of infection related to actual skin issues. The interventions included treatments as ordered. A review of the policy entitled Clean Dressing Change, undated as to implementation and revision dates, indicated the following: Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Policy Explanation and Compliance Guidelines: - 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: -- a. if the table is soiled, wipe clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 11 of 31 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 04/22/2022 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 0686 -- B. Place a disposable cloth or linen over on the overbed table. Level of Harm - Minimal harm or potential for actual harm -- c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide, and pen/pencil, skin protestant products as indicated, dressings, tape). Residents Affected - Few - 6. Establish area for soiled products to be placed (chux or plastic bag). - 7. Wash hands and put on clean gloves. - 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. - 9. Lose the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution, or use adhesive remover to remove tape. - 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. - 11. Wash hands and put on clean gloves. - 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze. - 13. Measure wound using disposable measuring guide. - 14. Wash hands and put on clean gloves. - 15. Apply topical ointments or crams and dress the wound as ordered. - 16. Secure dressing. [NAME] with initials and date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 12 of 31 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 04/22/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observations, record review, and interviews, the facility failed to ensure one (#31) of two sampled residents reviewed for enteral feedings received nutritional support as ordered. Residents Affected - Few Findings included: Resident #31 was admitted on to the facility in 2018 with diagnoses to include unspecified protein-calorie malnutrition, subsequent encounter for diffuse traumatic brain injury without loss of consciousness, persistent vegetative state, and gastrostomy status. An observation on 4/18/22 at 10:39 a.m., identified an opened (spiked) bottle of Jevity 1.5 calorie connected to a nutrition pump. The manufacturer label identified the enteral nutrition bottle held approximately 1000 milliliters (ml)/ 33.8 fluid ounces/1 liter of liquid. The label indicated the bottle was hung at 12:00 PM on 04/17/22 with a run rate of 55 ml per hour (hr). The observation revealed the bottle contained approximately 700 ml, indicating the resident had received approximately 300 ml since the bottle was hung, approximately 22 hours and 39 minutes prior to the observation. The observation on 4/18/22 at 2:01 p.m. indicated the resident was receiving nutrition at 55 ml/hr and the bottle of nutrition continued to appear to contain approximately 700 ml. On 4/18/22 at 2:58 p.m. and 3:16 p.m., an observation identified the nutrition pump was not running, the same bottle dated 4/17/22 at 12 p.m. was hanging and contained slightly less than 700 ml. Photographic evidence was obtained. A review of Resident #31's April 2022 Order Summary Report indicated the following orders related to the resident's nutrition: - Nothing by mouth (NPO) diet, NPO texture for Enteral Feeding, start 4/8/22. - Enteral Feed Order every shift. Flush feeding tube with 30 ml of water before and after medication administration and 5-15 ml between each individual medication. - Enteral Feed Order four times a day. Flush tube with 150 cubic centimeters (cc) of water. - Enteral Feed Order one time a day for nutrition. Restart Jevity 1.5 at (@) 55 ml/hr., ordered 4/10/22. - Shut down Jevity 1.5 for 4 hours daily, down @ 6 a.m., up @ 10 a.m. A review of Resident #31's April 2022 Medication Administration Record (MAR) indicated the following: - Enteral Feed Order one time a day for nutrition. Restart Jevity 1.5 at (@) 55 ml/hr., ordered 4/10/22. Scheduled at 10:00 a.m. - Enteral Feed Order four times a day. Flush tube with 150 cubic centimeters (cc) of water. Scheduled at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. A review of the medical record identified Resident #31 should have received enteral nutrition and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 13 of 31 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 04/22/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few water flushes for 18 hours from 4/17 at 12 p.m. to 4/18/22 at 6 a.m. (scheduled time for nutrition to come down). The resident should have received water flushing four times during the time period, including a flushing scheduled at 9 a.m. The orders reflected the resident was to receive 14 hours of enteral nutrition and 4 hours of water supplement during the time period. The amount of enteral nutrition would equal 770 ml (14 hours x 55 ml/hr.). The bottle was observed hanging from the pole, on 4/18/22 at 10:39 a.m., next to the resident with only 300 ml's of enteral nutrition delivered between 4/17 at 12 p.m. and 10:39 a.m. on 4/18/22, totaling a deficit of enteral nutrition of approximately 470 ml in the time period. On 4/18/22 at 3:10 p.m., Staff Member T (Licensed Practical Nurse, LPN) stated Resident #31 had been re-admitted to the unit yesterday after being on the south hall. The LPN observed the residents' nutrition was not running and confirmed it should be running at 55 ml/hr. She stated the nutrition was good for 24 hours and should have been changed at 12 p.m. on 4/18/22. The staff member stated she had not restarted the nutrition until 12 p.m. because she was behind. The nurse stated when she hooked the nutrition up to the resident (at 12 p.m.) she had not looked at the bottle. Staff T was unable to calculate the amount of nutrition the resident had received in the approximate 25-hour period between the time the bottle was hung and interview, stating I'm tired, I can't calculate, I can't figure it out. The staff member confirmed the resident should have received more nutrition and it was obvious the resident had not gotten enough. She stated, I don't know what happened. The Director of Nursing (DON) observed Resident #31's enteral nutrition feeding, on 4/18/22 at 3:20 p.m., and stated she knew it was not running and it should be. The DON confirmed the resident had not gotten enough nutrition and 300 ml of nutrition from 12 p.m. on 4/17/22 was not acceptable. She stated her expectation was to follow the physician orders for enteral feeding. A review of the policy titled Assisted Nutrition and Hydration, undated, indicated the Residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. The Explanation and Compliance guidelines indicated the facility would provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment and to provide a therapeutic diet taking into account the resident's clinical condition and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 14 of 31 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 04/22/2022 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and medical record review, the facility failed to arrange transportation to a medical appointment, which resulted in a delay of care and treatment, for one resident (#43) of 38 sampled residents. Residents Affected - Few Findings included; During an interview conducted with Resident #43 on 4/18/22 at 1:12 p.m., he reported he had an appointment for a follow up with his orthopedic surgeon in (City) approximately ten days ago and wanted to see him again because he was having a high amount of pain. Resident #43 stated he had a follow up appointment with his orthopedic surgeon in (City) scheduled for 4/19/22 at 1:30 p.m. The facility was to arrange the transportation. Review of the admission Record revealed Resident #43 was admitted to the facility on [DATE] with multiple diagnoses to include orthopedic after care, fracture of left femur, fracture of shaft of left tibia, fracture of left fibula and foot drop. Resident #43 was identified as his own responsible party. A review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns Resident #43's Brief Interview for Mental Status (BIMS) score was a 15, indicating he was cognitively intact. A review of a progress note dated 4/14/22 at 12:17 p.m. revealed: Received called from orthopedics Dr. office in (City), office stated that the pt (patient) had called them stating that he had twisted his left leg and was in pain, has been seen here and evaled (evaluated) in past days placed on Medrol-dose pack for what he stated was a gout flare-up which is why the increased pain. Orthopedics office wants to see pt in (City) on Tuesday (4/19/22) at 1:45 (p.m.). Spoke to nurse practitioner getting x-rays of left leg from hip and tib/fib (tibula/fibula) 2 view r/t (related to) pain. Transport being arranged for Tuesday appt. Pt did not state to facility or during therapy that he twisted his leg will continue to monitor. On 4/20/22 at 10:30 a.m. during an additional interview with Resident #43, to follow up with the outcome to his appointment scheduled on 4/19/22 with his surgeon, he confirmed he was not picked up and his appointment had to be rescheduled for 4/21/22. On 4/20/22 at 11:00 a.m. an interview was conducted with Staff N, Licensed Practical Nurse (LPN)/Unit Manager in regard to the reason the resident did not get taken to his appointment on 4/19/22. She reviewed the electronic medical record (EMR) and was unable to answer the question. Staff N called Staff O, Medical Records, who is responsible to arrange medical transportation. Staff N was informed there was no authorization (insurance) for transportation, but they were able to obtain one for Thursday 4/21/22. At this time, Staff O, Medical Records was asked to provide any documentation showing an effort was made to accommodate the resident's medical transportation needs. Staff O reported she began making efforts on 4/14/22 to obtain an insurance authorization, she was on leave on Friday 4/15/22, and Staff N, LPN/Unit Manager and Staff D, Registered Nurse (RN)/MDS were going to follow up with Resident #43's transportation needs for his appointment with his surgeon. During an interview with Staff N, LPN/Unit Manager and Staff D, RN/MDS on 4/20/2022 at 2:00 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 15 of 31 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 04/22/2022 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed they worked on trying to make transportation arrangements but had not documented in the medical record. Staff O, Medical Records reported on 4/20/2022 at 2:16 p.m. the facility needs need to obtain an authorization from the insurance company due to the travel time being more than an hour long. She confirmed Resident #43 had an emergency follow up appointment with his orthopedic surgeon scheduled for 4/19/2022. The Assistant Director of Nursing confirmed on 04/20/2022 at 3:18 p.m. the facility did not have a policy on transportation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 16 of 31 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 04/22/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure medications were monitored for behaviors related to the administration of psychotropic medication(s) and failed to clarify a dosage for Acetaminophen for one (Resident #178) of five residents sampled for unnecessary medications. Findings included: Resident #178 was admitted to the facility on [DATE] with diagnoses which included metabolic Encephalopathy, alcoholic cirrhosis of liver without ascites, delirium due to known physiological condition, unspecified hallucinations, unspecified anxiety disorder, and unspecified recurrent major depressive disorder. An observation on 4/18/22 at 11:41 a.m., was conducted with Resident #178. The resident was observed sitting on the side of the bed. On 4/20/22 at 11:05 a.m., the resident was observed lying in bed covered with a blanket. A review of Resident #178's April 2022 Order Summary Report as of 4/20/22 at 1:56 p.m. included the following: - Acetaminophen Tablet - Give 2 tablet by mouth every 4 hours as needed for mild pain, started 4/15/22. - Acetaminophen Tablet - Give 2 tablet by mouth every 4 hours as needed for Temperature above 101.3 Fahrenheit, started 4/15/22. - Fluoxetine Hydrochloride 10 milligram (mg) capsule - Give 1 capsule by mouth one time a day for depression, start 4/15/22. - Restoril Capsule 30 mg - Give 1 capsule by mouth at bedtime for insomnia, start 4/17/22. - Risperidone Tablet 0.5 mg - Give 1 tablet by mouth every 12 hours for psychosis, start 4/15/22. The Order Summary Report did not include orders for monitoring the behaviors or the side effects of the psychotropic medications and the Acetaminophen orders for the resident did not include a dosage. On 4/20/22 at 1:56 p.m., Staff N, Unit Manager/Licensed Practical Nurse (UM/LPN), confirmed Resident #178 should be monitored for behaviors and side effects. She stated staff had to go into the order set and select types of monitoring based on resident needs and this should be done at admission. Staff N stated, at 4:40 p.m. on 4/20/22, the facility had 325 and 500 mg tablets of Acetaminophen available. She reviewed the orders for Resident #178 and stated, that's a problem. A review of Resident #178's April 2022 Medication Administration Record (MAR) identified the monitoring for the behaviors and side effects related to the administration of the antidepressant, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 17 of 31 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 04/22/2022 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 0758 antipsychotic, and sedative/hypnotic medications began on the evening shift of 4/20/22. A dosage of 325 mg was added to the resident's Acetaminophen orders at 4:40 p.m. on 4/20/22. 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 18 of 31 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 04/22/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and two errors were identified for two (Residents #74 and #47) of five residents observed. These errors constituted a 7.41% medication error rate. Residents Affected - Few Findings included: 1. On 4/19/22 at 11:45 a.m., an observation of medication administration with Staff T, Registered Nurse (RN), was conducted with Resident #74. The staff member dispensed the following medications: - Novolog FlexPen - 2 units. Staff T held the pre-filled Insulin FlexPen upright without a needle and stated there was no air bubble so it was all clear. Staff T wiped the end of the syringe and dialed it to 2 units. Staff T injected the 2 units into the upper left extremity of Resident #74. Staff T stated she would have primed the Novolog pen if there was room for an air bubble. 2. On 4/20/22 at 8:36 a.m., an observation of medication administration with Staff M, Licensed Practical Nurse (LPN), was conducted with Resident #47. Staff M dispensed the following medications: - Amiodarone 200 milligram (mg) oral tablet - Buspirone 5 mg oral -2 oral tablets - Carvedilol 3.125 mg oral tablet - Eliquis 5 mg oral tablet - Omeprazole 20 mg oral tablet - Iron 325 mg oral tablet - Loratadine 10 mg oral tablet - Multi Vitamin oral tablet - Vitamin C 500 mg oral tablet - Zinc 220 mg oral tablet - Fluticasone nasal spray A review of Resident #47's April Medication Administration Record (MAR) identified the resident was scheduled at 9:00 a.m. to receive a Multi Vitamin with minerals one time a day for a supplement. The dose given to the resident did not contain minerals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 19 of 31 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 04/22/2022 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 0759 Level of Harm - Minimal harm or potential for actual harm According to the manufacturers' pharmaceutical insert, located at https://www.novo-pi.com/novolinr.pdf, instructed users to give an air shot before each injection: -- Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin: Residents Affected - Few -- Turn the dose selector to select 2 units. -- Hold your Novolin® R FlexPen® with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. -- Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. -- A drop of insulin should appear at the needle tip. If not, change the needle, and repeat the procedure no more than 6 times. -- If you do not see a drop of insulin after 6 times, do not use the Novolin® R FlexPen® and contact Novo Nordisk at [PHONE NUMBER]. -- A small air bubble may remain at the needle tip, but it will not be injected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 20 of 31 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 04/22/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure medications were stored and labeled properly in two (300-hall 1 and 300-hall 2) of four medication carts and one (south) of two medication rooms. Findings included: On 4/19/22 at 5:15 p.m., an attempt was conducted to observe medication administration with Staff U, Licensed Practical Nurse (LPN). Staff U opened the top drawer of the 300-hall 1 medication cart and removed a medication cup with medications in it and then entered Resident #40's room. When the Staff U returned to the medication cart, she stated she had administered the resident a chewable Vitamin C and the scheduled Oxycodone. Staff U then removed a blister card of Doxycycline tablets from the medication cart, dispensed a tablet into a medication cup, left the card of tablets on the top of the medication cart, and re-entered Resident #40's room. She came back out and stated she had signed out the Oxycodone and confirmed she had pre-dispensed medications due to the computer not staying charged if not plugged in. The cart was parked between rooms [ROOM NUMBERS]; an electrical outlet was observed on the other side of the door to room [ROOM NUMBER], on the wall between rooms [ROOM NUMBERS], and between the room [ROOM NUMBER] and the mechanical room. Staff U reported she had four other residents that she had pre-dispensed medications for. She removed a medication cup from the top drawer of the cart and identified the medications were for Resident #14. Staff U verified, at 5:26 p.m. on 4/19/22, she had pre-dispensed medications for the residents in room [ROOM NUMBER] who were in the Dining Room, room [ROOM NUMBER], and room [ROOM NUMBER]. Staff Member U walked away from the medication cart and stated, you planning on giving me a long vacation, I hope so. On 4/19/22 at 5:30 p.m., the 300-hall 2 medication cart was reviewed with Staff U. The observation included the following: - an insulin FlexPen prefilled syringe labeled with an illegible resident name and date. The staff member stated it could be 4/17, 4/18, or 4/19. - A container of Microdot Bleach wipes stored in the same drawer compartment with boxes of inhalation solution, HFA inhalers, and a pre-filled Admelog syringe stored in a bag labeled for Novolog. On 4/21/21 at 2:46 p.m., a review of the South medication room was conducted with Staff V, agency Registered Nurse (RN). The review of the medication room identified a drawer with 13 prefilled syringes of Heparin in it and was labeled Safe Needles. Staff V stated Heparin is patient-specific and did not know why it was stored like that. The policy - Medication Storage, implemented 11/2020 and reviewed 3/15/22, indicated it was the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The guidelines identified During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. and External Products: Disinfectants and drugs for external use are stored separately from internal and injectable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 21 of 31 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 04/22/2022 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 0761 medications. Level of Harm - Minimal harm or potential for actual harm On 4/19/22 at 5:49 p.m., the Interim Director of Nursing (DON) stated nurses are not allowed to pre-pour medications and the one stipulation was if medications are poured and the resident was indisposed at the time. She stated there was no reason for pre-dispensing 4-5 residents. On 4/20/22 at 8:45 a.m., the Interim DON stated she had spoken with Staff U and the staff member confirmed the findings. Residents Affected - Some The Consultant Pharmacist stated, on 4/22/22 at 11:07 a.m., Heparin syringes are patient specific, stored in a bag with the resident name and was also an Emergency Drug Kit item and said she had notified the DON the syringes needed to be returned and the pharmacy should make sure there was enough. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 22 of 31 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 04/22/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility's quality assurance (QA) and assessment committee failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 4/18/22 through 4/22/22 as evidenced by: 1) failure to ensure an allegation of neglect was reported to state agencies for one (#5) of three residents sampled for abuse and neglect (F609), 2) failure to ensure allegations of abuse and neglect were thoroughly investigated for two (#5 and #7) of three residents sampled for abuse and neglect (F610), 3) failure to monitor for behaviors and side effects for psychotropic medications and failure to limit as needed psychotropic medications to 14 days for two (#1, #5) of three residents reviewed for psychotropic medications (F758), and 4) failure to ensure the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and twelve errors were identified for two (#1 and #13) of 8 residents observed. These errors constituted a 42.8% medication error rate (F759). Findings included: 1. On 6/30/22 at 3:05 p.m., an interview was conducted with the Regional Director of Clinical Services (RDCS), Nursing Home Administrator (NHA), and the DON to discuss the facility's quality assurance program. The facility's administrative team reviewed everything that they had done according to the plan of correction for each deficiency cited during the survey ending on 4/22/22. They reported that the QA committee met on 5/5/22 to discuss all tags cited during the survey ending 4/22/22. They met again on 5/27/22 and 6/23/22 to address all citations and found that the corrective action plan was effective with no concerns. The facility's administrative team reported that if they had identified a problem, they would have done a Root Cause Analysis (RCA) or updated/changed their audits, but they believed the plan was effective, so no changes were made. 2. Review of the facility's Quality Assurance/Risk Management (QA/RM) and Quality Assurance/Performance Improvement (QAPI) Policy/Plan, reviewed/revised November 2021, revealed: Policy: It is the policy of this facility to develop and effective, comprehensive facility and discipline specific Quality Assurance and Risk Management Program that focuses on the indicators or outcomes of resident care and quality of life. The facility will coordinate and evaluate activities under the QAPI program, including the development of Performance Improvement Projects (PIPs) if necessary. Policy Explanation and Compliance Guidelines: d. Develop and implement appropriate PIPs to correct identified quality deficiencies. 3. The QAPI plan will address the following elements: b. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: v. Developing and implementing performance improvement plans and or activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 23 of 31 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 04/22/2022 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 0867 5. Program Systematic Analysis and Systemic Action- Level of Harm - Minimal harm or potential for actual harm a. The facility takes actions aimed at performance improvement as documented in QAA/RM Committee meeting minutes and improvement plans. Results of the PIP will be monitored and documented in subsequent QAA/RM/RM Committee. Residents Affected - Few b. To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA/RM/RM Committee meetings. 3. Review of the facility's plan of correction for the survey ending 4/22/22 with a completion date of 5/19/22 revealed the following measures would be taken to correct the deficient practice which was identified at

F609 and F610: 3. The administrator and director of nursing were educated on reporting requirements and investigation of allegations of abuse, neglect, and misappropriation by the Regional Nurse consultant on 5/10/2022. Staff educated on reporting abuse, neglect, and misappropriation was completed on 4/22/2022. Newly hired staff will be educated upon hire regarding abuse, neglect, and exploitation during orientation. 4. Director of nursing/designee will review skin assessments for 10 random residents weekly X 4 weeks, then monthly X 2 months to ensure any injuries of unknown origin have been reported and investigated per state and federal guidelines if indicated. Administrator/designee will conduct interviews with 5 random residents weekly x 4 weeks, then monthly to ensure if voiced, any allegations of abuse or neglect are reported and investigated per state and federal guidelines. Results will be presented to QAPI Committee monthly. Ongoing quality review schedule may be modified based on findings to ensure compliant practice remains in place. On 6/29/22 and 6/30/22 a revisit survey was conducted to ensure compliance with F609 and F610. The revisit survey identified the following on-going concerns with F609 and F610: Interview on 6/29/22 at 3:35 PM with Resident #5 revealed that on 6/24/22 he used his call light to call for help and the assigned (agency) Certified Nursing Assistant (CNA) came in. He told her he needed help and some wipes. He reported that the CNA did bring the wipes, and then left the room. He reported that he wiped as much as he could without help and needed more wipes. The resident stated he used the call light, waited for 2 hours, and no one came. Resident #5 reported that he eventually used his phone to call the front desk and ask for more wipes. After that, an unknown person brought the wipes and left the room. He reported that the assigned CNA never came back to assist him with personal hygiene after having a bowel movement. Review of a behavior note written by Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM) dated 6/24/22 at 14:00 (2:00 PM) revealed this writer was sitting at nurse's station as resident was self-propelling wheelchair around corner. Resident stated, That's it I am going to the Hospital I am checking out of this place. This writer asked why he needed to to to the hospital. Resident stated, My foot is [expletive] killing me, and I have been covered in [expletive] for 2 hours. Assigned nurse stated that she administered as needed pain medication to Resident. This writer asked resident if he received pain meds. Resident stated yeah, about 20 minutes ago. Resident stated, Come here I want (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 24 of 31 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 04/22/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to show you something. This writer followed, resident into his room. Resident stated, I am leaving this place; I should not have to be covered in [expletive] for 2 hours. This writer assessed resident with no visible signs of fecal matter or fecal smell emitting from resident at this time. Resident pointed to bedside commode. This writer observed bag with feces and cleaning cloths inside. Resident stated, The aide would not help him and I asked her to change the bed and she said why? At that time, the assigned aide walked into room and asked the resident if he needed anything. I asked resident, with aide present, if he asked the aide for help and she would not assist him? Resident stated, I am sitting on the toilet I shouldn't have to ask for help. This writer reiterated to resident, did he ask assigned aide to assist him and she refused? Resident stated, No, she helped me. Resident then stated, My bed is covered in [expletive], and I asked you to make it. This writer observed an approximately 4 inches by 4 inches brown colored area on bed. Assigned aide at that time stated, You asked me to make the bed. Resident then stated, Well I need you to make it again. Assigned aide left room to gather linen. This writer removed bag of soiled items from commode as well as bag from trash can next to commode . Resident is alert, oriented, able to make all needs known and possesses a BIMS score of 15. Interview on 6/29/22 at 3:25 PM with the Regional Nurse Consultant and the Nursing Home Administrator (NHA) revealed that if a resident alleged sitting in filth for 2 hours, this should be considered an allegation of neglect and should be investigated as such. Interview on 6/29/22 at 4:15 PM with Staff A, LPN/UM and the Director of Nursing (DON), who also was the facility's Risk Manager, revealed that this was not an allegation of neglect because when they entered the resident's room, the bedside commode had stool in it, the garbage can next to the commode had stool stained tissue in it, and the bed did have a brown substance on it which the resident could have caused after the bed was made by the staff. The DON reported that she did not need to do anything else about the documented incident because they interviewed the CNA at that time. The DON stated that the CNA reported that the resident had asked for wipes which she provided, and the resident requested his bed to be made, which she also did. Follow-up interview on 6/30/22 at 9:34 AM with the DON/Risk Manager reported that there was no other information regarding the incident involving Resident #5's allegation that he did not receive care. The DON/Risk Manager confirmed that only the CNA involved was interviewed, but there was no statement written and no statements or interviews were obtained from the resident or other residents and staff who may have had knowledge of the incident or experienced a similar occurrence. The DON stated that the allegation was not reported. Review of the facility's incident log for the month of June 2022 revealed an incident dated 6/10/22 indicating Other for Resident #7. Review of the incident revealed that on 6/10/22, Resident #7's roommate called the front office and reported that a CNA hit Resident #7 in the face. Review of the facility's investigation packet revealed an immediate and five-day federal report was completed. An investigation was started on 6/10/22 and the accused staff person was taken off of the schedule on 6/10/22. The facility's investigation packet included two written statements from two CNA's (one being the alleged perpetrator, Staff F). Continued review of the investigation packet revealed that there was no statement from Resident #7, no statement from the roommate, no statements from the assigned nurse, and no statement from any other resident who the accused staff member was assigned to. On 6/30/22 at 9:31 AM, Resident #7 was observed seated in the common area. Interview with the resident revealed he was waiting to take a shower. The resident reported that a staff member had hit him a few weeks ago (resident could not recall the date), and the nurse took care of it. The resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 25 of 31 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 04/22/2022 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 0867 reported that he was not hurt but fell when trying to hit the staff member back. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 6/10/22 at 17:58 (5:58 PM) revealed the DON/Risk Manager documented that the resident's roommate called up to nurses' station and made a report that the CNA in room hit patient in the face. Nurse management went to patient's room to assess situation. CNA was leaving room and patient was standing in the doorway. Patient was asked if he was hit by staff member and he stated no. He was also asked if he was harmed, touched rough or injured by staff. He again stated no. Patient started motioning and swinging his arm stating, me me. When asked, did you try to hit the staff? He stated yes. Skin assessment was completed. Small red abrasion was noted on patient's back from when he fell. Face had no redness or edema noted. Resident's roommate's curtain was pulled all the way around his bed like the resident prefers it, and roommate had his sound proof headphones on and was lying on his side toward the wall. Patient continues to deny pain and denies being hit or touched. Residents Affected - Few Interview on 6/30/22 at 10:40 AM with the DON/Risk Manager revealed that if she received allegations, she would remove the staff person, question the resident involved, question the roommate who reported the allegation, obtain statements from the staff member involved or anyone else involved, perform a skin assessment, complete all reporting and notifications to include the physician and family. She reported that for this allegation, she did not interview any other residents assigned to the accused staff person, no statements from the resident involved in the allegation or the resident's roommate who made the allegation were taken, no statements from the nurse or any other staff assigned to the unit were obtained and no statements or interviews were conducted with other residents cared for by this CNA. She reported that she was still in training for the position of Risk Management. Interview on 6/30/22 at 11:08 AM with the Regional Nurse Consultant revealed that she was told that staff and residents were interviewed so she knows that this task was done; however, the documentation was not provided. A review of the facility's Active Employee Report with a run date of 6/29/22 revealed Staff F was still listed as an active agency employee with this facility. Staff F's hire date was listed as 6/10/22. 4. Review of the facility's plan of correction for the survey ending 4/22/22 with a completion date of 5/19/22 revealed the following measures would be taken to correct the deficient practice which was identified at

F758: 2. On 5/10/2022 an quality audit was conducted by the Director of nursing on anti psychotropic medication for behavior monitoring and side effect monitoring present for each medication. 3. On 5/17/2022 the Director of nursing/designee completed education with the licensed nurses on medication monitoring and side effect monitoring for all psychotropic medication and education on medication orders including dosage and strength. New hired staff to be educated during orientation 4. Director of Nursing/Designee will complete 5 random resident audits to check for behavior monitoring and side effect monitoring for residents receiving psychotropic medication. Both audits will be done weekly X 8 weeks and monthly X 1 month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 26 of 31 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 04/22/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm The results of these audits will be presented at the monthly QA/Risk Management meeting for a minimum of 3 months or until the committee has determined substantial compliance has been achieved. On 6/29/22 and 6/30/22 a revisit survey was conducted to ensure compliance with F758. The revisit survey identified the following on-going concerns with F758: Residents Affected - Few Record review of the active physician orders revealed Resident #1 had the following orders for psychotropic medications: Citalopram Hydrobromide 20 mg (milligrams) daily for depression with an order/start date of 6/9/22 Mirtazapine 7.5 mg at bedtime for depression with an order/start date of 6/9/22 Xanax 0.25 mg every 12 hours as needed (PRN) for anxiety with an order/start date of 6/9/22 (with no 14-day end date) Record review of the care plan initiated on 6/9/22 and last reviewed on 6/27/22 revealed the resident was at risk for complications related to the use of psychotropic drugs including antidepressants, antianxiety for depression, and anxiety. The care plan goal was to have the smallest most effective dose without side effects. Interventions included: monitor for continued need of medication as related to behavior and mood; monitor for changes in mental status and functional level and report to physician as indicated; monitor for side effects and consult physician and or pharmacist as needed. Review of the June 2022 Medication Administration Record (MAR), Treatment Administration Record (TAR), and progress notes revealed no monitoring for behaviors and side effects associated with the psychotropic medications could be located. During an interview on 06/30/22 at 2:01 p.m., the DON verified the Xanax order did not have an end date and was ordered as needed. She also verified there was no behavior or side effect monitoring in place for these medications. The DON reported possible negative outcomes of not monitoring behaviors and side effects of psychotropic medications would be failure to provide a timely gradual dose reduction, not adjusting medications, and not knowing if an adverse reaction to a medication was occurring. On 07/01/22 at 3:36 p.m., the Pharmacy Manager stated that PRN psychotropics such as Xanax should have a 14-day end date. He stated that the pharmacy will not send out more than 14 days of medication. He stated that psychotropics such as antidepressants and antianxiety medications should have behavior and side effect monitoring in place. Record review of the facility's policy, Use of Psychotropic Medication, dated 01/22/22 revealed Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: .9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). 10. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: .D. in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 27 of 31 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 04/22/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident's comprehensive plan of care. 11. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. Review of Resident #5's active physician orders revealed an order dated 6/2/22 for Xanax Tablet 1 MG (ALPRAZolam) Give 1 tablet by mouth every 8 hours as needed for anxiety. Continued review of physician orders revealed that there was no end date for the use and no discontinue order for the Xanax. Interview on 06/30/22 at 2:05 PM with the DON confirmed that Resident #5's Xanax order did not have an end date and was ordered on an as needed basis. 5. Review of the facility's plan of correction for the survey ending 4/22/22 with a completion date of 5/19/22 revealed the following measures would be taken to correct the deficient practice which was identified at

F759: 3. On 5/17/2022 the Director of nursing/designee completed education with the licensed nurses on about proper insulin administration including priming insulin pens prior to administration. On 5/17/2022 the Director of nursing/designee completed education with the licensed nurses on following physician orders including all over the counter medication. 4. Director of Nursing/Designee will complete an audit on 5 random nurses during medication administration to ensure medication error rate is < 5% this medication administration will be done weekly X 8 weeks and monthly X 1 month. The results of these audits will be presented at the monthly QA/Risk Management meeting for a minimum of 3 months or until the committee has determined substantial compliance has been achieved. On 6/29/22 and 6/30/22 a revisit survey was conducted to ensure compliance with F759. The revisit survey identified the following on-going concerns with F759: Observation and interview on 06/29/2022 at 11:00 a.m. with Resident #1 revealed he was lying in bed with the head elevated and an air mattress in place. He stated he had not had any of his morning medications yet to include his insulin and pain medications. Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 06/29/22 at 11:20 a.m. stated he had an order for blood glucose monitoring due to his Humalog insulin 8 units not being given on time (due at 7:30 a.m.). According to Staff C, LPN, none of the resident's medications had been given as of 11:35 a.m. On 06/29/22 at 11:42 a.m., Staff A told Staff C the physician ordered 8 units of Novolog via a quick pen. On 06/29/22 at 11:52 a.m., Staff C, LPN entered Resident #1's room with a cup and Novolog-R and Novolog quick pens of insulin. Resident #1 asked why he was getting his insulin so late. Staff C stated she was going to give him Novolog 8 units and Novolog-R 5 units. Resident #1 asked, How could she know the sliding scale dose without doing his [blood sugar]? The LPN stated she was running late. He told Staff C he needed a pain pill before he went to therapy. Staff C performed the blood glucose measurement, and his blood sugar was 297. The LPN did not administer any insulin at this time. Interview with Staff C, LPN at the time of the observation revealed she was not giving any insulin due to the resident questioning the amount of insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 28 of 31 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 04/22/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Staff C, LPN went back to the nursing station to speak to Staff A, LPN/UM again regarding dosage. Staff A stated the physician wanted him to have the Novolog 8 units he was supposed to get this morning. Staff A stated that the sliding scale was just added this morning. Staff A stated that the order read to give Novolog 8 units and Novolog-R 5 units. Staff A stated, if he had gotten his 8 units this morning, he may have not been close to 300 now and needed sliding scale insulin. Residents Affected - Few On 06/29/22 at 12:45 p.m. Staff A, LPN/UM entered Resident #1's room and apologized for his medications being so late. Resident #1 stated, they have promised things would get better and they have not. This has been going on for 3 weeks. Staff A asked if he wanted his insulin now or after lunch because he was eating. Resident #1 said now. Staff A administered both insulin doses into the right upper arm per resident request. The Novolog 8 units was in a quick pen and the Novolog-R 5 units was from a vial. On 06/29/22 at 12:50 p.m. with Staff C, LPN observed medication administration of the 9:00 a.m. medications for Resident #1. Ferrous Sulfate 325 mg (milligrams) / 65 mg daily for anemia [NAME] / plus 8.6 mg daily for constipation Montelukast Sodium 10 mg daily for allergies Ropinirole HCL 0.5 mg every 12 hours for restless legs Pantoprazole 40 mg daily for gastroesophageal reflux disease (GERD) Amiodarone HCL 200 mg daily for arrhythmia Carvedilol 25 mg every 12 hours for Hypertension Citalopram Hydrobromide 20 mg daily for depression Lisinopril 10 mg daily Hypertension On 06/29/22 at 12:50 p.m., Staff A/UM, Staff C, and the DON verified there was no Percocet 5-325 mg give one by mouth every 4 hours as needed for severe pain in the narcotic drawer in the medication cart. The resident had his last dose on 06/29/22 at 6:12 a.m. per the June Medication Administration Record (MAR). The DON called the pharmacy to check on the arrival time of the Percocet and for authorization to remove one from the EDK (emergency drug kit) kit. She told the pharmacy it had been ordered. The pharmacy staff stated that they would get the Percocet to the facility tomorrow evening (06/30/22). The three staff members went to the EDK and there was no Percocet listed. The pharmacy stated if they do not use the medication within a certain time frame it will be discontinued from the EDK. On 06/29/22 at 2:15 p.m., Staff A, UM called the physician to change the Percocet order to another pain medication. On 06/29/22 at 3:30 p.m., Staff A, UM and the DON stated the Percocet order was lost at the pharmacy. The physician called the pharmacy and was unable to connect with anyone, and the pharmacy was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 29 of 31 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 04/22/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unable to connect with the physician. The physician called the facility and told them to have the pharmacy call him. Staff A, UM and the DON got an order for a one-day dose of Hydrocodone 10 mg for Resident #1 from the physician. They placed a stat order on the Percocet, which means it will be at the facility within 2 hours. The DON stated Resident #1 had not asked for pain medication until 1:30 p.m. (Observed the resident tell Staff C, LPN he had pain and wanted pain medication at 11:52 a.m.) The DON stated he was offered Tylenol but declined wanting to wait on the Hydrocodone. Review of the June 2022 MAR showed he received Hydrocodone-Acetaminophen 10-325 mg for pain at 1721 (5:21 p.m.). Per his orders he could have had a dose of Percocet at 10:15 a.m. if it had been available. Review of the progress notes written for Resident #1 revealed on 06/29/22 an entry made at 18:00 (6:00 p.m.) written by Staff A, LPN/UM. The health status note stated at approximately 11:30 a.m. this writer was alerted that resident did not receive scheduled 0900 medications. At this time writer notified Healthcare Provider that 0900 scheduled medications were not administered including 0730 insulin. This writer obtained new orders at this time, may administer 0900 medications unscheduled, may administer [blood glucose monitoring] at 11:30, may discontinue Humalog Kwik Pen Solution Pen-injector 100 units/ml (insulin Lispro (1 Unit Dial) may start Novolog Flex Pen Solution Pen-injector 100 unit / ml (Insulin Aspart) 8 units with meals. At approximately 12:30 p.m. resident complained of pain. Assigned licensed staff went to pull narcotic from draw and was unavailable at this time. Pharmacy was called and acquired authorization from pharmacy. This writer attempted to obtain Percocet with second licensed staff member. Percocet unavailable from the medication dispensing system. This writer called Healthcare Provider, Physician, new order obtained may give Norco 10-325 one-time dose only for pain management. Norco administered at this time. During observation and interview on 06/29/22 at 8:33 a.m. Staff C, LPN entered Resident #13's room. He was sitting in his room with his breakfast tray in front of him. He had eaten part of his breakfast. He stated that he had not received his insulin yet, and he was supposed to get it before he ate. Staff C performed a blood glucose measurement (with an order time of 7:30 a.m.) on Resident #13 with a blood glucose result of 429. Staff C stated the blood glucose results were outside of the sliding scale parameters, and she needed to call the physician. Staff C received an order to administer 10 units of Novolog. At 8:50 a.m., Staff C administered 10 units of Novolog insulin to Resident #13 in his left arm in the hallway. At this time, the observation involving Resident #13 was discussed with Staff A and Staff C. Staff A stated her expectation was for the nurse to call the physician if the medication was going to be administered late. Staff A, LPN/UM verified that Staff C was administering medications late and the physician needed notifying. Review of Resident #13's active physician orders revealed an order dated 6/26/22 for Novolog sliding scale subcutaneously before meals for diabetes, call physician if blood sugar over 400 (scheduled at 7:30 a.m.). Medication Admin Audit Report showed Novolog (Aspart) given on 06/29/22 at 9:31 a.m. by Staff C, LPN. During an interview on 06/30/22 at 2:01 p.m., the DON verified the expectation was for the nurse to give the medications timely. If they are not timely the nurse was to call the physician, make him aware, and obtain an order to administer the medication outside of the parameters. The possible negative outcomes that could occur related to late medications could include: if twice a day medication, they would be administering doses too close together; if an insulin was missed and blood glucose results were elevated, they may have to administer more insulin than desired; if blood pressure medications were not timely, the resident's blood pressure may be elevated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 30 of 31 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 04/22/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/01/22 at 3:36 p.m., the Pharmacy Manager stated that medications should be given per the schedule. Record review of the facility's policy, Preparation and General Guidelines, dated 2006 showed handwashing and hand sanitation: the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident. 4) FIVE RIGHTS-right resident, drug, dose, route and time. 11) if a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit. B Administration 11) a schedule of routine dose administration times is established by the facility and utilized on the administration records. 12) medications are administered within (60 minutes) of scheduled time, except before, with or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Record review of the facility's Medication Administration Times, showed one daily was at 9:00 a.m. twice daily was at 9 a.m. and 5 p.m. three times daily was at 9 a.m., 1 p.m. 5 p.m. before meals was at 6:30 a.m. and 11 a.m. every 12 hours was 9 a.m. and 9 p.m. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105394 If continuation sheet Page 31 of 31