Health inspection·February 12, 2021

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and policy review the facility failed to ensure that the confidential medical information for one (Resident # 109) of six residents reviewed during the facility task of Medication Administration, was secured when he left the computer screen displaying Resident #109's record unattended on his cart on multiple occasions during a medication pass. Residents Affected - Few Findings included: During the evening medication pass of 02/11/21 at 4:45 p.m. Staff C, Registered Nurse (RN) stepped away from his medication cart to verify that a glucometer was stored in Resident #109's room. Staff C, locked his cart when he stepped away but neglected to lock the screen or close the computer that sits atop the cart and displayed the confidential medical information for Resident # 109. Staff C returned to the cart and proceeded to prepare his supplies when he noticed that he did not have any gloves, he locked the cart but did not close the computer leaving the private confidential information pertaining to Resident #109's medication in full view on the computer screen. Once Staff C, RN had gathered all the necessary supplies, he locked his cart but did not close the computer, he entered Resident # 109's room. Staff C left the computer screen displaying Resident # 109's private medical information. Several residents and other employees were seen in the hallway. When he returned to the cart, he confirmed that the computer screen should be closed to ensure the privacy of resident records when the cart was unattended. He confirmed that education related to confidentiality of the medical record was provided to him during orientation. Staff C stated, As a nurse, I know that this medical information is private and I should have locked the screen. A request was made to the Director of Nursing (DON) and a Regional Clinical Resource for the policy pertaining to ensuring that the private confidential information of the residents was not at risk during medication administration, but review of the provided policy did not provide any additional information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 2 of 4 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 105417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Bay 2916 Habana Way Tampa, FL 33614 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. Based on observations, interviews and record review the facility failed to maintain drugs and biological's used in the facility in a safe, secure, and orderly manner in three of five inspected medication carts and one of two inspected medication storage rooms. Findings include: On 2/11/21 at 4:25 p.m., an observation of the second-floor low side medication cart was conducted with Staff G, Registered Nurse (RN). The nurse was asked to open the narcotic drawer to verify the narcotic count. Staff G opened the narcotic drawer without a key. Photographic evidence was obtained. The nurse was asked how long the narcotic drawer had been broken and the lock propped with a straw. The nurse stated it had been like that for a while maybe two years. In the top drawer of the medication cart, an Insulin pen had no open date or expired date on the packaging or the pen. Photographic evidence obtained. A second Insulin pen was observed to be expired (opened on 1/8 and expired on 2/6). Photographic evidence obtained. An interview with Staff G was conducted. Staff G stated she was responsible for making sure all medications in the cart were not expired and when Insulin was removed from the refrigerator and placed in the cart it was the policy to date it with an open and an expire date. On 2/11/21 at 4:45 p.m., an observation of the second-floor medication storage room was conducted with Staff G. A small refrigerator located inside the storage room was opened for inspection by the nurse. Seven vials of Lorazepam 2 mg/ml, a schedule II medication, in two bags were observed in a non-affixed small metal box sitting on the shelf and able to be removed from the refrigerator for inspection. Photographic evidence obtained. An interview with Staff G was conducted. The nurse stated the medications had always been kept that way to her knowledge. On 2/11/21 at 5:15 p.m., an observation of the second-floor high side medication cart was conducted with Staff C, RN. In the top drawer of the medication cart an Insulin vial was observed with no open or expiration date on the label or the bottle. Photographic evidence obtained. A second vial of Insulin was observed to be expired (opened on 1/7, expired on 2/5). Photographic evidence obtained. A third vial of Insulin was observed with no open or expiration date on the label or the bottle. Photographic evidence obtained. Loose pills were observed in the second drawer of the medication cart. Photographic evidence obtained. In the bottom drawer of the medication cart a large bag of Perforomist 20 mcg/2 ml with two stickers on the bag stating REFRIGERATE. Photographic evidence obtained. An interview was conducted with Staff C. The nurse indicated he was not aware of why the medication would be in the medication cart when it was labeled to refrigerate. The nurse confirmed expired medications should not be in the medication cart and should be disposed of. The nurse stated when Insulin was removed from the refrigerator, they were to label it with an open date and an expiration date per policy. On 2/12/21 at 12:50 p.m., an observation of the third-floor low side medication cart was conducted with Staff H, RN. On the top drawer of the medication cart a vial of Insulin was observed to have no open or expired date on the packaging or the vial. Photographic evidence obtained. An interview was conducted with Staff H. The nurse confirmed that all Insulin was to be dated with an open date and an expired date once removed from the refrigerator and placed in the medication cart according to policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 3 of 4 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 105417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Bay 2916 Habana Way Tampa, FL 33614 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 On 2/12/21 at 2:21 p.m., a telephone interview was conducted with the facility Consulting Pharmacist. She indicated the facility was to keep all Schedule II-V medications in a separate locked area and in a fixed compartment that could not be removed. She indicated there were fixed drawers in some of the refrigerators. The Consulting Pharmacist stated all Insulin were to be dated with an open date and an expire date once it was removed from the refrigerator and stored in the medication carts. She stated the Perforomist should also be dated once it was removed from the refrigerator to assure it did not expire. A review of the facility policy entitled Storage and expiration dating of medications, biologicals, syringes, and needles (revised 10/28/2019) indicated the following: Applicability: This policy 5.3 sets for the procedures relating to storage and expiration dates of medications, biological, syringes and needles. Procedure: 2 Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. 3.1 Facility should store Schedule II-V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key to access device 3.1.1 Store all drugs and biologicals in locked compartment, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. 5 Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. 11 Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the Untie States Pharmacopeia guideline for temperature ranges. 17 Facility should destroy or return all discontinued, outdated/expired, or deteriorated medication or biologicals in accordance with Pharmacy return/destruction guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 4 of 4