Health inspection·April 1, 2022

F 0553 Procedure - Request that the resident and/or resident representative contact the facility designee to confirm or reschedule the date/time for the resident's conference. 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: 105417 If continuation sheet Page 2 of 21 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 04/01/2022 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 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, and record reviews the facility failed to review and revise the Resident Centered Care Plan related to 1) adding interventions after a fall for one (Resident #50) of three residents sampled for falls, and 2) adding a focus area with interventions implemented for range of motion for one (Resident #50) of three residents sampled for range of motion. Findings included: On 3/29/22 at 10:47 a.m., Resident #50 was observed lying in the bed in his room. Resident #50 was unable to speak but could understand and nod yes or no to questions. A hand splint was noted sitting on the nightstand next to the resident's bed. Photographic evidence was obtained. Resident #50 indicated the splint was not his and he was not supposed to have it on. Resident #50 was noted to have a contracture to his right hand. A review of the medical record for Resident #50 revealed the resident was admitted on [DATE] with a diagnosis of Cerebral Vascular Accident (CVA) with right (R) hemiplegia and hemiparesis, R hand contracture, abnormalities of gait and mobility, and muscle weakness. A review of the Order Summary Report for Resident #50 on 3/30/22 revealed an order for Occupational Therapy (OT) to evaluate and treat as indicated dated 1/15/22, there were no orders for treatment or therapies related to a splint. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed under Section C-Cognitive Patterns, Resident #50 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The assessment revealed under Section G-Functional Status, Resident #50 required extensive assistance by one to two persons for Activities of Daily Living (ADL). A review of the progress notes for Resident #50 revealed a note dated 2/1/22, indicating: Fall risk score of 55, High Risk. Patient found lying on floor next to bed. Assisted back to bed. Resident stated he only had pain in left knee which appeared to have a skin tear. Resident stated he did not hit his head on anything. MD (medical doctor) notified will monitor. A Change of Condition dated 2/16/22 revealed Resident #50 had an unwitnessed fall and was found on the floor. The resident showed no signs of pain or distress and was placed back in bed. Neurological checks were begun. A review of the Comprehensive Care Plan for Resident #50 revealed the following: Focus area-The resident is at risk for falls related to CVA with Hemiparesis and Hemiplegia, gait/balance problems, hypertension, incontinence, psychoactive drug use. (Initiated 1/26/22, Revised 1/26/22) Goal-Minimize the risk of sustaining a serious injury through the review date Interventions related to fall incidents, included but not limited to: Actual fall 2/16/22 0400 IDT (interdisciplinary team) reviewed MD (Medical Doctor) ordered CBC (Complete Blood Count), BMP (Baseline Metabolic Profile), and UA (Urinalysis), C&S (Culture and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 3 of 21 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 04/01/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Sensitivity) to be completed. There was no indication of a fall on 2/1/22 or an intervention added related to the fall that occurred on 2/1/22. The care plan did not reflect a focus area related to Resident #50 having a contracture of the right hand or a range of motion focus area related to the diagnosis of CVA and use of a splint. Residents Affected - Few On 3/31/22 at 11:39 a.m. Resident #50 was observed lying in the bed in his room. A splint was noted on his right hand securely in place. Resident #50 indicated by nodding his head the splint had been put in place by staff. On 4/1/22 at 10:11 a.m. an interview was conducted with the Director of Rehabilitation (DOR) and the Risk Manager (RM). The DOR stated Resident #50 had a splint from OT and the resident was being trialed on it for a few weeks to increase the range and wearing schedule. The DOR stated there should be an order for the splint and the therapist or the nurse should make sure the order is in the record. The DOR stated he did attend all care plan meetings and all residents are discussed as far as current therapies go. The DOR stated the splint was being trialed due to the contracture of the right hand for Resident #50. The DOR stated contractures should be on the care plan and he does up date resident therapies and treatments in the care plan meetings. On 4/1/22 at 10:33 a.m. an interview was conducted with the MDS Case Manager. She stated range of motion with a contracture would be a focus area on the care plan. She confirmed the contracture for Resident #50 should be included in the care plan and verified it was not there. She stated the process of care planning is done by reviewing the history and physical and observing and interviewing the resident. She stated social services, activities, therapy, and nursing all play a role in making sure the assessment is correct and areas of concern get on the care plan. She stated the process is completed within the first 14 days and additions to the care plan are done every morning in the meetings when all residents are discussed. She indicated the DOR attends the meetings to give updates to the care plan. The Case Manager stated when a resident has a fall it is placed on the care plan with any interventions added as a result of the fall review. She indicated new interventions should be added after a fall. She stated falls are also part of the morning meeting discussions and interventions are added at the time of the meeting. A review of the Order Summary Report for Resident #50 supplied by facility on 4/1/22, revealed a late entry order dated 4/1/22 as follows: 3/16/22 for Occupation Therapy (OT) five times a week for four weeks. Treatment may include: orthotic training and management for right hand, orthotic training subsequent encounters, therapeutic exercise, neuromuscular reeducation, self-care management, group therapy, ultrasound, and therapeutic activities. A review of the policy entitled Plans of Care, with an effective date of 11/30/2014 and a revision date of 09/25/2017 revealed the following: Policy: An individual person-centered plan of care will be established by the interdisciplinary team with the resident and/or resident representative to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedure: Review, update and /or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident in in response to current interventions after the completion of each MDS assessment, and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintain the highest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 4 of 21 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 04/01/2022 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 0657 practicable physical, mental, and psychosocial well-being. 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: 105417 If continuation sheet Page 5 of 21 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 04/01/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 policy reviews the facility failed to ensure proper care for activities of daily living (ADLs) related to nail care and incontinence care for two (Resident #95 and Resident #63) out of four residents sampled for activities of daily living. Residents Affected - Few Findings included: 1. Medical record review for Resident #95 revealed an admission date of 7/13/2021 with diagnoses to include end stage renal disease, dependence on renal dialysis, legal blindness, muscle weakness, type 2 diabetes mellitus without complications, wedge compression fracture of first lumbar vertebra, and subsequent encounter for fracture with routine healing. A review of Resident #95's quarterly Minimum Data Set (MDS) assessment completed on 2/14/2022 indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section C-Cognitive function of his MDS indicated no concerns with memory or mental status. Section G-Functional abilities of the MDS indicated the resident needs extensive assistance with toilet use, personal hygiene, bed mobility, dressing and transfers. The resident required limited assistance for walking in his room and corridor. A review of the care plan revealed a focus care area dated 11/24/2020 for ADL self-care performance deficit related to impaired balance. Interventions included: prefer all meals to be served in bowls, restorative ambulation/locomotion, gait training, bathing/showering check nail length and trim and clean on bath day and as necessary, toilet use, resident requires assistance by one staff member for toileting, encourage resident to use bell to call for assistance. A focus area was in place for Bladder incontinence, interventions included clean peri-area with each incontinence episode and monitor/document for signs and symptoms of UTI (urinary tract infection). An observation and interview was conducted for Resident #95 on 03/30/22 at 08:48 AM. Resident #95 was resting in bed with the call bell within reach. Observation of the resident's fingernails revealed they were untrimmed and had dark matter underneath the nail beds. The resident stated he must sit soiled for a long time waiting for assistance with incontinence care. Resident #95 stated when he pressed his call bell Staff G, Certified Nursing Assistant (CNA) has laughed and told the resident he, is bossy. The resident stated sometimes when he rings his bell, the CNAs will turn the light off and tell him they will be back, but it takes a while. Resident #95 stated he just wants to be changed. The resident stated he would do things himself if he could. The resident reported his bath days were Tuesday, Thursday and Saturday. An observation and interview was conducted for Resident #95 on 4/1/2022 at 12:45 PM. Resident #95's nails were still long, untrimmed, and soiled with dark matter underneath the nail beds. The resident stated he has asked for his nails to be trimmed and has been told they will get to it. The resident stated it was a while ago that he asked, not in the last week. Resident #95 stated the foot doctor comes and does his feet, but no one does his fingernails. He stated he would like his nails to be cut. An interview was conducted with Staff F, CNA on 4/1/2022 at 2:40 PM. Staff F was assigned to Resident #95 for her shift on 4/1/2022. She stated when residents are showered, they also clip their nails and shave them if they want it. She stated the central supply on the floor is out of nail clippers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 6 of 21 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 04/01/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this week and she doesn't get to trim nails. She stated she has only worked at the facility for one week. Staff F was observed going to the supply closet and searching for clippers with no nail clippers being located. An interview was conducted with Staff G, CNA on 4/1/2022 at 2:45 PM. Staff G said the supply closet on the second floor is out of nail clippers sometimes. He calls downstairs to central supply and can usually get clippers from them. Review of policy and procedure revised 9/1/2017 titled Care of Nails indicates an emery board, orange stick and nail clippers be used for nail care. Procedures include trim fingernails and clean nails. 2. An interview was conducted with Resident #63 on 3/31/2022 at 12:27 PM. The resident stated she has had several problems with not getting changed when soiled. The resident stated she calls, and someone will come and say, I will be back then they don't come back for at least 30 mins. Resident #63 stated she has had to wait 2 hours before when soiled. A medical record review indicated Resident #63 was admitted on [DATE] with diagnoses including chronic kidney disease. A review of Resident #63's admission MDS assessment dated [DATE] revealed a Brief Interview for Metal Status (BIMS) score of 15, indicating intact cognition. Section H-Bowel and Bladder of the resident's MDS indicated she was always incontinent of bowel and bladder. A review of the orders for Resident #63 indicated the following: UA/CS (urinalysis/culture and sensitivity) every night shift for recurrent UTI for 1 day on 4/1/2022. A nursing note dated 3/16/2022 reported urine results positive for ESBL (extended spectrum beta-lactamase). The physician gave orders for Amoxicillin 875/125mg (milligrams) by mouth every 12 hours for 7 days. Nurse notified of new orders. Nursing to continue to monitor. A care plan (Initiated 2/16/2022) was in place for bowel and bladder incontinence. The interventions included clean peri-area with each incontinence episode, wash, rinse and dry perineum. change clothing prn after incontinence episodes, monitor/document for signs and symptoms of UTI, monitor/document/report as needed any possible causes of incontinence. An interview was conducted with Staff L, CNA on 3/31/2022 at 6:00 PM. Staff L stated when a call light goes off it should be answered as soon as possible. She added, sometimes CNAs are in another room taking care of patients and it takes a few minutes. Staff L stated she continually goes from room to room during her shift checking on her residents, especially those who are more dependent on staff for incontinence care. She stated, They need to be changed as quick as possible. Staff L stated she was responsible for them and doesn't want anything to happen to them. She said there was not enough staff for the number of residents. She stated the agency staff come in to assist and usually cannot be found anywhere. She stated they are smoking or go get food and are not around. An interview was conducted with Staff G, CNA on 4/1/2022 at 2:45 PM. Staff G stated he is often assigned to the same hall as Resident #95 and Resident #63 but doesn't always have them on his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 7 of 21 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 04/01/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm assignment. Staff G stated when call lights go off, he goes as quick as possible and if he is doing something with another resident, he will go tell the resident who called he will be back when he is finished. He stated he finishes what he was doing and then returns to assist the resident with incontinence care. Staff G stated he does not forget to go back to the resident who called for help. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 8 of 21 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 04/01/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure weight loss was monitored and assessed timely, as evidenced by lack of weekly weights and lack of food consumption documentation, which resulted in a significant weight loss for one (Resident #67) out of seven residents sampled for nutrition. Residents Affected - Few Findings included: On 3/29/22 at 1:02 p.m., Resident #67 was observed sitting in the bed in his room. He was alert and able to answer questions related to his care. He stated he really dislikes the pureed food he is getting and cannot eat it. He stated he has had no upper teeth for a long time, and he can eat regular food just fine. He stated he just wants regular food so he can eat. He stated he has to rely on what he can get to eat from the outside, and it is not enough. A review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with a diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), opioid dependence, Congestive Heart Failure (CHF), dysphagia, underweight, and anemia. A review of the Order Summary Report on 3/30/22 for Resident #67 indicated the following orders were active: -Regular diet dysphagia mechanical soft texture, regular/thin liquids consistency. Add fortified foods (started on 11/11/21). -Med Pass put amount ordered oral in add directions three times a day for supplements 240 milliliters (ml) (started on 11/10/21). -Speech Therapy (ST) evaluate and treat as indicated (started on 11/09/21). A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #67 revealed in Section C-Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment revealed in Section G-Functional Status the resident was independent for eating with assistance for set up only. The assessment revealed in Section K-Swallowing/Nutritional Status, the resident had no swallowing disorder, a weight loss of more than 5% in a month or 10% in the last six months and not on a prescribed weight loss regimen. A review of the Weight Summary for Resident #67 revealed the following: Height 65 inches BMI (Basal Metabolic Index) 17.6 11/9/21 106.0 lbs. (pounds)Standing 12/3/21 105.2 lbs. Wheelchair 1/14/22 107.8 lbs. (no indication of method) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 9 of 21 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 04/01/2022 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 0692 1/26/22 100.2 lbs. Wheelchair Level of Harm - Actual harm 2/2/22 86.9 lbs. Standing Residents Affected - Few 3/3/22 99.4 lbs. (no indication of method) Resident #67 had a 13.3% weight loss in one month from 1/26/22 to 2/2/22. Resident #67 had a 6.23% weight loss in less than three months from 11/19/21 to 3/3/22. Review of the Comprehensive Care Plan for Resident #67 revealed the following: Focus: The resident has an activities of daily living self-care performance deficit related to disease processes. (initiated 3/1/22) Goal: Resident will maintain current level of function through review date. Interventions included but not limited to: The resident is able to feed self with setup. Focus: Resident #67 has a nutritional problem related to significant weight loss. (initiated 2/8/22) Goal: Resident will maintain adequate nutritional status as evidenced by maintaining at least 76-100% meal portions and supplements consumed ongoing through next review as well as weight stability/increase. Interventions: Provide and serve diet as ordered; Provide, serve diet as ordered. Monitor intake and record each meal. RD to evaluate and make diet change recommendations as needed. A review of the Nutrition Evaluation Initial, Annual and Significant Change record dated 11/12/21 indicated Resident #67 was on a dysphagia mechanical soft solid diet with thin liquids, had missing teeth, and no chewing or swallowing concerns. The document indicated Resident #67 had an Ideal Body Weight (IBW) of 142 lbs. and a current weight of 104.6 lbs. No history of weights was available. The meal intake level was reported as 76-100%. The document indicated the resident was at risk for malnutrition as evidenced by need for continued strong oral intake, limited oral intake documentation thus far, limited oral intake available, and a goal for the resident to continue to consume at least 76-100% meal portions daily. A review of the Nutrition Evaluation Initial, Annual and Significant Change record dated 2/8/22 indicated Resident #67 was on a dysphagia mechanical soft solid diet with thin liquids, had missing teeth, and no chewing or swallowing concerns. The document indicated Resident #67 had an IBW of 136 lbs. and a current weight of 100.2 lbs. The evaluation indicated a significant weight change of -5% since 1/14/22 with a BMI of 16.7. The meal intake level was reported as 76-100%. The document indicated the resident was at risk for malnutrition as evidenced by inadequate calorie and protein intake, inadequate food and beverage intake, significant weight loss with a goal to consume at least 51-100% meal portions daily as well as supplements provided, fortified foods, med pass 240 ml three times a day, weekly weights. On 3/30/22 at 1:00 p.m., Resident #67 was observed in the hallway on the second floor of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 10 of 21 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 04/01/2022 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 0692 facility walking with his meal tray and yelling I can't eat this [expletive], as he brought the tray to staff members who were in the hallway. Level of Harm - Actual harm Residents Affected - Few On 3/31/22 at 12:30 p.m., Resident #67 was observed seated in his room with his lunch tray on the overbed table. The resident stated he cannot eat that pureed [expletive]. He had finely chopped meatloaf, brown gravy, pureed seasoned green peas, mashed au gratin potatoes, sliced peaches, pureed dinner roll/bread, and margarine on his tray. The resident had only eaten the fruit. He was picking at the meat. The rest of the tray had been untouched. He stated there was no reason he could not get normal food, and he cannot get anyone to listen to him so he can eat. He stated he has had no teeth for a long time and has never eaten pureed food. He stated he has no problems eating and drinking. A review of the eating percentages documented in the tasks section of the medical record revealed only one day (3/18/22) of meal percentages had been recorded for Resident #67 between 3/16/22 and 3/31/22. On 4/1/22 at 10:25 a.m., an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated an evaluation was completed for Resident #67 by speech therapy for swallowing due to weight loss. He stated at the time the resident had no concerns with the diet. On 4/1/22 at 11:09 a.m., an interview was conducted with the Registered Dietician (RD) and the Risk Manager, RN (RM). The RD stated he had been working at the facility for a year doing all the assessments. He stated he is physically in the facility three times a week. He stated he has one remote dietician who assists with quarterly assessments. He stated the nursing staff are responsible for the weekly weights and nursing is responsible for making sure all recommendations are carried out. The RD stated there is a weekly meeting on Fridays to discuss weights and determine gains or losses for the residents. The RD stated he was not aware the weekly weights were not completed as planned for Resident #67. The RD stated he was not aware Resident #67 had not been consuming his diet. The RD stated he was not aware the diet percentages had not been recorded as planned for Resident #67. The RD stated he noticed a significant weight loss for Resident #67 when he did his evaluation on 2/8/22 and he put in recommendations at that time. He stated all likes and dislikes for a resident are to be reported and the Certified Dietary Manager can make changes as needed. The RD confirmed meal percentages and weekly weights had not been completed for the resident or reported to him and stated he would evaluate the residents needs right away. The RM had nothing to add related to a lack of follow up by the RD. A policy was requested for Nutritional Assessment/Management for residents, and it was not supplied by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 11 of 21 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 04/01/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 the facility failed to provide necessary respiratory care and services, related to storage of oxygen, and nebulizer tubing's and supplies, consistent with professional standards of practice for six residents (#56, #69, #95, #178, #378, #381) of ten facility residents receiving respiratory treatments. Residents Affected - Some Findings included: 1) On 3/29/22 beginning at 10:00 am a tour of the facility was conducted. Resident #56 was observed lying in her bed in the room. An oxygen tubing with nasal cannula was observed on the floor next to the resident's bed. Photographic evidence was obtained. The resident stated she does use oxygen sometimes. A review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with a diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), anxiety, shortness of breath, nicotine dependence, and asthma. A review of the orders for Resident #56 revealed an order dated 3/3/22 for Oxygen as needed at 2 liters/minute. The order was discontinued on 3/25/22. A review of the Treatment Administration Record (TAR) dated March 2022 revealed the following: Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. Every night shift every Thursday. (signed off by nursing as completed on 3/24/22) Oxygen as needed 2 liters/minute (start date 3/3/22-discontinue date 3/25/22) 2) On 3/29/22 at 10:15 a.m., Resident #69 was observed in her room. An oxygen tubing with nasal cannula was observed draped over a cord and on the floor in the room. Photographic evidence was obtained. The resident stated the concentrator and oxygen was for her. A review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure, asthma, and CHF. A review of the Order Summary Report revealed the following: Oxygen as needed at 2 liters if oxygen saturation less than 90% (start date 3/3/22). Change tubing, mask and/or nasal cannula weekly. May change sooner as needed for hygiene (start date 3/3/22). 3) On 3/29/22 at 12:00 p.m., Resident #178 was observed walking down the hallway coming from the shower room towards her room. An interview was conducted with the resident when she reached her room. An oxygen tubing was observed draped over the resident's bed. Photographic evidence was obtained. A nebulizer machine, tubing and mask was observed sitting on the nightstand. The tubing and mask were not stored in a plastic bag. Photographic evidence was obtained. The resident stated she is on oxygen and does get respiratory treatments at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 12 of 21 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 04/01/2022 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 0695 A review of the medical record for Resident #178 revealed the resident was admitted to the facility on [DATE] with a diagnosis of carcinoma in situ of bronchus and lung, COPD, and CHF. Level of Harm - Minimal harm or potential for actual harm A review of the Order Summary Report for Resident #178 revealed the following: Residents Affected - Some Respiratory oxygen 2 liters continuous every shift (started on 3/17/22). Ipratropium-Albuterol solution 0.5-2.5 milligrams/milliliter 3 milliliter inhale orally every eight hours as needed for shortness of breath. A review of the Medication Administration Record (MAR) for March 2022 revealed the last nebulizer treatment of Ipratropium-Albuterol was given on 3/19/22 and signed off by nursing. The document revealed nursing was signing off the oxygen order daily each shift. On 3/30/22 at 10:15 a.m., an interview was conducted with the Infection Control Nurse (ICN), RN. The nurse stated all oxygen and nebulizer tubing, and supplies should be cleaned and kept in a clean plastic bag for continued use. The nurse stated the tubing and supplies are changed every Friday for sanitary reasons. A review of the policy titled Oxygen Therapy with an effective date of 11/30/14 and a revision date of 8/28/17 indicated the following: Policy: Oxygen therapy is the administration of a FiO2 (oxygen concentration) greater than 21% by means of various administration devices to: raise the resident's PaO2 (percent arterial oxygen) to an acceptable baseline using the lowest FiO2, to treat arterial hypoxemia, to decrease work of breathing, to reverse and prevent tissue hypoxia, and to decrease myocardial work. Procedure: .Gather necessary equipment, follow infection control procedures, as appropriate A review of the policy titled Nebulizer with an effective date of 11/30/14 and a revision date of 3/20/18 indicated the following: Note: Small volume nebulizers are used to deliver medication aerosols to the respiratory tract to relieve bronchospasm, to deliver medications, to improve the effectiveness of the cough and to relieve mucosa edema. Small volume nebulizers create a mist from a liquid medication solution that can be inhaled into the bronchial tree. Droplets of mist are delivered through a facemask or mouth piece and absorbed into the bloodstream through alveoli with in the lung tissue. Procedure: Disassemble device and rinse the mouthpiece and nebulizer cup with water and air dry. Place entire unit in a bag to be maintained in the resident's room. 4) During a facility tour on 03/29/22 at 10:28 AM an observation was conducted for Resident #95. Resident #95's oxygen tubing was on the floor with the oxygen concentrator running. The resident was out of the facility at the time (Photographic evidence obtained.) A medical record review indicated Resident #95 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, legal blindness, muscle weakness, Type 2 Diabetes Mellitus without complications, wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 13 of 21 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 04/01/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident's orders included: Oxygen as needed (PRN) 2 liters if oxygen levels <93%. Start date 3/3/2022, Change tubing, mask and/or nasal cannula weekly, may change sooner as needed for hygiene and every night shift Thu for hygiene, Pulse Ox every day shift for monitoring. Start date 3/4/2022 Resident #95's Minimum Data Set (MDS) review completed on 2/14/2022 and indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G-Functional Abilities of the MDS indicated resident needs extensive assistance with toilet use, personal hygiene, bed mobility, dressing and transfers and for walking in his room and corridor, resident needs limited assistance. 5) During a facility tour on 3/29/2022 at 10:29 AM an observation was conducted for Resident #381. Resident was in bed sleeping with nasal cannula in place. His nebulizer tubing and mouthpiece were lying on the bedside table, uncovered (Photographic evidence obtained.) Medical record review indicated Resident #381 was admitted on [DATE] with diagnoses including encephalopathy, sepsis, dementia without behavioral disturbances, muscle weakness, chronic pain, dysphagia. The resident's orders included: Oxygen via nasal cannula at 4 liters/min to maintain oxygen sats (saturation) above 90% as needed for treatment. Start date 3/27/2022; Ipratropium-Albuterol Solution 0.5-2.5 milligrams(mg)/3 milliliters(ml). 3ml inhale orally every 12 hours as needed for SOB (shortness of breath) and wheezing. Start date 3/7/2022. A MDS review on 3/11/2022 indicated a BIMS should not be conducted. Section C of the MDS indicated Resident #381's cognitive skills for daily decision making are severely impaired. Resident in totally dependent or needs extensive assistance for all activities of daily living (ADLs.) 6) During a facility tour on 03/29/2022 at 11:44 AM Resident #378's oxygen tubing was observed lying on the floor, resident was not in his room at the time (Photographic evidence obtained.) A review of medical records indicated Resident #378 was admitted on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, hypokalemia, other pulmonary embolism without acute COR pulmonale. The resident's orders included: Respiratory oxygen- continuous at 2L Revision date 3/27/2022, Change tubing, mask and/or nasal cannula weekly, may change sooner if needed. As needed for hygiene and every night shift every Friday. Start date 3/27/2022. MDS review is in progress from admission. BIMS score was indicated to be 15, indicating intact cognition. No respiratory/oxygen care plans were in place. Review of the electronic medication administration record (eMAR) documented breath sounds are being checked and vital signs taken as ordered. An interview was conducted with Staff E, Registered Nurse (RN) and Infection Preventionist on 3/30/2022 at 10:15 AM. Staff E stated the expectation would be for respiratory equipment such as oxygen tubing and nebulizer masks to be stored in a plastic bag. She stated the equipment should not be on the floor or uncovered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 14 of 21 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 04/01/2022 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 ensure proper storage of drugs and biologicals as evidenced by: 1) not maintaining refrigerator temperatures within reference range for three of three medication refrigerators, and 2) not storing four vials of Lorazepam 2 mg (milligrams)/ml (milliliter), a Schedule IV medication, in a permanently affixed compartment in the refrigerator for one of three medication storage rooms. Findings included: On 3/31/22 at 12:15 p.m., a medication storage room observation on the second floor of the facility was conducted with Staff H, Registered Nurse (RN). The refrigerator inside of the storage room was locked and a log of temperature checks was observed on the outside of the refrigerator. Photographic evidence obtained. The log indicated the temperature range for the refrigerator was to be between 35 degrees Fahrenheit and 46 degrees Fahrenheit. The document indicated the aim was to be at 40 degrees Fahrenheit and alerted staff to take immediate action to correct a temperature that was out of range. A check of the temperature gauge in the refrigerator indicated the temperature was reading 50 degrees Fahrenheit. The refrigerator was noted to be dripping water from the small freezer area. Photographic evidence obtained. The nurse indicated the temperature was too high and she would call maintenance to get it looked at. The refrigerator contained medications at the time of the observation. On 4/1/22 at 2:15 p.m., a medication storage room observation on the fourth floor of the facility was conducted with Staff I, RN. The refrigerator inside the storage room was locked and a log of temperature checks was observed on the outside of the refrigerator. Photographic evidence obtained. A check of the temperature gauge in the refrigerator indicated the temperature was reading 51 degrees Fahrenheit. The refrigerator was noted to be dripping water from the small freezer area. Photographic evidence obtained. The nurse indicated the temperature was too high and he would call maintenance to get it looked at. The refrigerator contained medications at the time of the observation. The refrigerator contained a clear plastic box on the top shelf, it was unlocked and able to be removed from the refrigerator for inspection. The box contained two plastic sleeves. The first plastic sleeve was labeled for Resident #40 and contained two vials of Lorazepam 2 mg/ml, a Schedule IV medication. The second plastic sleeve was labeled for Resident #43 and contained two vials of Lorazepam 2 mg/ml, a Schedule IV medication. Photographic evidence obtained. The nurse stated the drawer just broke yesterday and it should be secured and locked. On 4/01/22 at 02:45 p.m., a medication storage room observation on the third floor of the facility was conducted with Staff J, RN. The refrigerator inside the storage room was locked and a log of temperature checks was observed on the outside of the refrigerator. Photographic evidence obtained. A check of the temperature gauge in the refrigerator indicated the temperature was reading 24 degrees Fahrenheit. Photographic evidence obtained. The nurse indicated the temperature was too low and she would call maintenance to get it looked at. The refrigerator contained medications at the time of the observation. On 4/1/22 at 3:15 p.m., the Director of Nursing was notified of the findings related to medication storage. The DON indicated the refrigerators were to be checked on the night shift and the narcotics are to be kept in the clear box with a lock and secured to the refrigerator on the inside. She stated she would have this corrected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 15 of 21 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 04/01/2022 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 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, record review, interviews, policy review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice during a recertification survey that was conducted on 03/29/2022 through 04/01/2022 and was cited F692 and F761. On 05/18/2022 the facility was recited for F692 and F761. The facility had developed a POC with a compliance date of 05/01/2022. Findings include: 1. Ongoing non-compliance was identified during the revisit survey related to nutritional supplement interventions with appropriate documentation in the medical record. The facility had developed a POC that included: DCS [Director of Clinical Services]/designee re-educated current licensed nurse 04/20/2022 on the components of this regulation with emphasis on ensuring appropriate documentation of a registered dietitian assessment, nutritional supplement interventions, physician/responsible party notification and weights obtain timely with appropriate documentation in the medical record for residents with a weight loss. DCS/Designee to conduct quality monitoring of residents with weight loss to ensure appropriate documentation of a registered dietitian assessment, nutritional supplement interventions, Physician/responsible party notification and weights obtain timely with appropriate documentation in the medical record 2 times weekly x [for] 4 weeks, then weekly x 2 months and PRN [as needed] as indicated. Review of Resident #12's admission record revealed she was readmitted to the facility on [DATE] with diagnoses that include but are not limited to Dementia with Behavioral disturbance, anxiety disorder, major depressive disorder, and stage 3 chronic kidney disease. Review of Resident #12's physician orders revealed an order to start on 4/23/22 with no end date: MedPass put Amt [amount] ordered PO [by mouth] in add direc. [additional directions] three times a day supplement. The additional directions were reviewed with no indication of how much MedPass to administer to Resident #12. Review of Resident #12's dietary note dated 4/23/22 revealed Resident w/16% wt [weight] loss since 12/8/21. BMI [body mass index] = 25.8 (WNL) [within normal limits]. s/p [status post] hospital stay. Intake 76-100% thus far. Receiving regular diet w/ fortified foods w/ pureed solids . Adding medpass 120ml TID [three times daily]. Will con't [continue] to monitor weekly wts [weights] and discuss at weekly SOC [standards of care] and provide additional recc's [recommendations] as indicated. Review of Resident #12's interdisciplinary team (IDT) note dated 4/23/22 revealed met to discuss resident weight loss post hospital stay. Resident was noted in restraints and combative at hospital. Resident is on weekly weights. Resident 76-100% po [by mouth] intake. Resident has orders for MVI [multivitamins], regular diet pureed solids, zinc, vitamin C. orders to add fortified foods, Medpass 120ml TID. IDT will continue to monitor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 16 of 21 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 04/01/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #12's medication administration record revealed from 4/23/22 at 5:00p.m. to 5/18/22 at 1:00 p.m. the resident received MedPass three times a day. There was no indication of how much MedPass to give and there was no documentation of how much MedPass was given. An interview with Staff D, Registered Nurse (RN) was conducted on 5/19/22 at 2:40 p.m. she stated she was Resident #12's nurse and she said, I give her 30ml's [milliliters] I think it is, a whole cup full of MedPass. Staff B, Licensed Practical Nurse (LPN), Unit Manager was next to Staff D, RN at the time of the interview, and she said she believes a full cup is 240ml's. Staff B, LPN, Unit Manager reviewed Resident #12's orders and she confirmed the order does not specify how much to give. An interview was conducted with the Director of Nursing (DON) on 5/18/22 at 2:18 p.m. She stated Resident #12's MedPass order should indicate how much of the MedPass to give. A nutritional assessment/management policy was requested, and the facility indicated they did not have one. Review of the facility's Physician Orders policy revised on 3/3/21 revealed Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. 2. Ongoing non-compliance was identified at the revisit related to storage of resident medications and biologicals in refrigerators with proper temperature controls. The facility developed a POC that included: Current Licensed Nurses re-educated by the DCS/designee on 4/20/2022 regarding the components of this regulation with emphasis on ensuring the facility must store all drugs and biologicals in locked compartments under proper temperature controls. Quality monitoring of medication rooms to be completed by the DCS/designee to ensure the refrigerator is maintained under proper temperature controls 5 times weekly x 4 weeks, 3 times weekly x 4 weeks then twice weekly and PRN as indicated. An observation was conducted on 5/18/22 at 10:30 a.m. of the 4th floor medication storage fridge. The thermometer was observed to be at 50 degrees Fahrenheit. Staff A, Registered Nurse (RN) confirmed the fridge thermometer was 50 degrees. She stated she was unsure what the temperature was supposed to be set at (Photographic evidence was obtained). An interview was conducted on 5/18/22 at 10:33 a.m. with the 4th floor unit manager, Staff B, Licensed Practical Nurse (LPN). She stated the night shift does the documenting of the fridge temperatures. She stated the fridge temperature should be 40 degrees and said she will call maintenance to fix the fridge. A second observation of the 4th floor medication storage fridge was conducted on 5/18/22 at 2:47 p.m. the thermometer in the medication storage fridge read 50 degrees Fahrenheit. Staff C, RN confirmed the thermometer read 50 degrees and also confirmed there were resident medications stored in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 17 of 21 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 04/01/2022 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 0867 fridge. Level of Harm - Minimal harm or potential for actual harm Observation of the medication storage fridge located on the 2nd floor was conducted on 5/18/22 at 10:02 a.m. Residents Affected - Few The 2nd floor medication storage fridge was observed to be crowded with medication. Inside the fridge was wet with dripping water. The thermometer was observed at 50 degrees Fahrenheit. Staff D, RN confirmed the thermometer read 50 degrees. Staff E, RN also confirmed the fridge was too warm and all the medications needed to be moved to another fridge for proper storage. She stated she will contact maintenance to fix the fridge (Photographic evidence obtained). A second observation was conducted of the 2nd floor medication storage fridge on 5/18/2 at 2:45 p.m. The fridge was observed still be overcrowded with medications and the thermometer was observed to be at 48 degrees Fahrenheit. Staff B, RN confirmed the thermometer read 48 degrees. On 5/18/22 at 3:02 p.m. the Maintenance Director and the Nursing Home Administrator (NHA) were interviewed, and the Maintenance Director said this morning he looked at the 2nd floor medication storage fridge and it was packed full of medications. He stated he was going to check the fridges. An interview was conducted with the Director of Nursing (DON) on 5/18/22 at 12:15 p.m. She indicated the medication storage fridges should not be above 46 and not below 36 degrees Fahrenheit. She said she tasked the Unit Managers to check the fridge temperatures. Review of the facility's Temperature Log for Refrigerator-Fahrenheit undated revealed: Danger! Temperatures above 46 [degrees Fahrenheit] are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately! Danger temperatures below 36 [degrees Fahrenheit] are too cold! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately! Review of the facility's policy Storage and Expiration Dating of Medications, Biologicals Revised on 1/1/22 revealed: Procedure -3. 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. -11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the Unit States Pharmacopeia guidelines for temperature ranges . -11.2 Refrigeration 36 degrees - 46 degrees F [Fahrenheit]. -12. Facility should monitor refrigerated storage for evidence of moisture and condensation (humidity) and may consult with pharmacy regarding medication integrity. -12.1 when moisture is observed in the refrigerator, facility staff should evaluate how often the refrigerator door is opened, and consider a faulty door, broken thermostat, or blocked vent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 18 of 21 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 04/01/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -12.2 allowing air to circulate around the items stored (i.e., not overcrowding item) will promote low humidity. An interview was conducted on 5/18/22 at 4:56 a.m. with the NHA and the Risk Manager (RM). They indicated the facility's Quality Assurance and Performance Improvement team met several times to develop and review their POC. The NHA and the RM said they discovered some audits were not being completed. The RM indicated losing a unit manager, using agency staff, and trying to complete all the audits between herself and the DON was hard to get done. The RM also indicated the POC audits were reviewed during the clinical morning meetings, but the Quality Assurance and Performance Improvement team had not met to do a complete review of the audits. Review of the facility's Performance Improvement Committee (Quality Assurance) policy revised on 8/19/2020 revealed: Policy: The Performance Improvement Committee will meet to review, recommend, and act upon activities of the facility, performance improvement teams and/or department activities. The committee shall direct all activities including approving proposed monitoring, evaluating and review of services. The committee will assure QAPI activities have indicators and standards/thresholds for evaluation, that appropriate actions are implemented, and that such correction has been evaluated by subsequent monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 19 of 21 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 04/01/2022 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of policy and maintenance logs, the facility did not ensure the transportation services were adequate related to the air conditioning not cooling residents during transport in the facility's van for two residents (Resident #380 and Resident #77) of two residents transported in the facility's only van during the week of March 28, 2022. Residents Affected - Few Findings included: An interview was conducted with Resident #380 on 3/31/2022 at 12:30 PM. The resident stated she was transported in the facility van on 3/30/2022 to a doctor's appointment and the van was very hot. She stated she was sitting in the back of the van in her wheelchair. She stated she was fanning herself and she started feeling sick from overheating. She stated she threw up as soon as she reached the doctor's office and in the van when she was returning to the facility. A review of Resident #380's Minimum Data Set (MDS,) dated 2/7/2022, has a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section C of the MDS showed no mental, memory or cognitive concerns. She needs extensive assistance for mobility, transport and locomotion. The resident stated her appointment was at 3:30 PM. An interview was conducted with Staff C, Transport Van Driver on 3/31/2022 at 12:45 PM, he stated the facility has only one van. It is a 2007. Staff C stated he is the primary driver and responsible for ensuring the van works properly. He stated the air conditioning works in the van, but it takes a little bit for it to cool off, maybe 20-30 minutes. He stated there is only one vent in the rear of the van, so it does not get as cool as the front. He stated he tries to go out and start the van before loading the resident and can do it most of the time, however, he did not start it prior to the transport of Resident #380 yesterday. Staff C stated the van is always running when a resident is in it. While transporting Resident #380 on 3/30/2022 he noticed she was fanning herself with papers and she said it was hot. He stated he had the air conditioning on maximum cooling. He stated the resident did vomit on the way back to the facility. He stated upon return to the facility he did not report the heat concerns to anyone or notify the resident's nurse she had gotten sick. He stated her son followed them to and from the appointment in his vehicle and the son went back up to her room with her. An observation was conducted on 3/31/2022 at 12:45 PM with Staff C. He went outside and turn the van on at 12:47 PM with the air conditioning on maximum cool. The temperature was taken with a thermohygrometer. The starting temperature inside the back of the van measured to be 80.9 degrees Fahrenheit (F). After ten minutes the temperature reading inside the van was 79.7 degrees F in the back, where residents are seated. The air temperature decreased 1.2 degrees in ten minutes of running the air conditioning on maximum cooling. The air temperature when tested directly coming from the vent, in the middle of the van, was 70.7 degrees F. There was one vent in the back section of the van observed with limited air flow in the area where wheelchairs would be positioned for transport. The vehicle has very little to no tint on the windows. (Photographic evidence obtained) The weather in [NAME], Florida (FL) on 3/31/2022 at time of testing was 83 degrees F and mostly cloudy. The weather in [NAME], FL at time the of transport on 3/30/2022 at 3:00 pm was 88 degrees F and sunny, with a few clouds. Reference: https://www.weather.gov. An interview was conducted with Resident #77 on 3/31/2022 at 2:40 PM, resident stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 20 of 21 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 04/01/2022 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transported on 3/28/2022. She stated sat in the back of the van in her wheelchair for transport. She stated it was a little bit hot. Resident 77's transport was 3/28/2022 at 11:00am. An interview was conducted with Staff D, Registered Nurse (RN) 04/01/2022 at 04:33 PM. Staff D indicated he was the nurse taking care of Resident #380 when she returned from transport on 3/30/2022. He stated no one told him the resident had gotten sick or had any concerns. He said when a resident is transported back, the transport driver usually puts the resident in their room and tell staff they are back. He stated there was no report to him of resident's change in condition. Staff D stated later in the evening the resident mentioned in passing to him the van was hot. He stated he had no idea she had gotten sick. He said he would expect to be told if the resident had a change of condition while they were gone so he could check on the resident and follow up. A review of the van's maintenance log showed the van was last in for regular service on 8/13/2021. Air conditioning problems for the van were previously diagnosed and serviced on 9/8/2020, 5/31/2019, and 4/17/2018. A review of the facility policy titled Motor Vehicle Safety (effective 11/30/2014) indicated the following It is the facility policy to ensure motor vehicle safety in providing and maintaining a safe working environment. The facility considers the use of automobiles as part of the working environment. Procedures showed 4. Accident recordkeeping, reporting, analysis 6. Vehicle inspection and maintenance. The Transportation Request for Resident #380 shows the transport was from the facility to the doctor's office. This was a distance of 19 miles and approximately 28 minutes. The Transportation Request for Resident #77 show transport was from the facility to a doctor's appointment. This was a distance of 10 miles and approximately 23 minutes. According to the Health in Again Foundation When the temperature climbs above 80&deg;F, older adults need to be proactive and take precautions to avoid ailments due to excessive heat. The Health in Aging Foundation is the official foundation of the American Geriatrics Society. https://www.healthinaging.org FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 21 of 21