Inspection·January 12, 2024

F 0600 resident known to wander from the facility without the staff knowledge. Level of Harm - Immediate jeopardy to resident health or safety A review of the facility policy titled Missing Patient/Resident, last revised on 8/1/2020, revealed under the section titled Overview, staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. The policy also revealed the following facility procedure under the section titled Procedure: Residents Affected - Few Check the Leave of Absence (LOA) book and medical record to ensure the patient/resident is not on an authorized leave or medical appointment. Announce (resident name) please return to your room, over the public announcement (PA) system. Repeat three times to alert staff of a missing patient/resident. Assign staff to search the Center and grounds. If the patient/resident is not located after an initial search, the point person will notify the Nursing Home Administrator (NHA), the Director of Nursing (DON), the resident representative, and the Primary Care Physician (PCP). The NHA and/or DON or designee will notify local law enforcement. A review of Resident #1's hospital history and physical (H&P), dated 12/13/2023 revealed Resident #1 arrived at the emergency department with a critically high blood pressure of 233/151, a heart rate of 101, and was unresponsive with active convulsions. Resident #1 was determined to be in critical condition with a risk of worsening seizures, stroke, or death. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 12/29/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section S: Physical Function, Resident #1 ambulated with standby assistance and required no assistive devices to ambulate. The transfer form revealed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of epilepsy, unspecified, intractable, with status epilepticus, difficulty walking, essential hypertension, other symptoms and signs involving cognitive functions and awareness, diabetes mellitus, occlusion and stenosis of the right carotid artery, non-ST elevation (NSTEMI) myocardial infarction, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and history of falling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 2 of 20 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 01/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety A review of Resident #1's Admission/readmission Data Collection assessment dated [DATE] and completed by Staff B, Registered Nurse (RN), revealed under Section B: Cognition, Resident #1 was alert and oriented to person, place, and time. The assessment also revealed under Section N2: Elopement Risk Evaluation, Resident #1 was not cognitively impaired, was not independently mobile (either ambulatory or in a wheelchair), did not have poor decision-making skills, did not have the ability to exit the facility, and was not at risk for elopement. Residents Affected - Few A review of the facility policy titled admission Assessment, last revised on 8/22/2017 revealed at the time of admission or readmission, the nurse shall initiate the admission Data Collection Form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with resident and family, and review of the resident's available medical records. A telephone interview was conducted on 1/10/2024 at 12:02 PM with Resident #1's Primary Care Physician (PCP). The PCP stated he evaluated Resident #1 on 12/30/2023 and the resident appeared stable but was confused, disoriented to time, and did not give appropriate responses to questions. Resident #1 had a history of stroke and new onset seizures. The PCP stated he was notified of Resident #1's elopement from the facility on 12/31/2023 and of the resident's return on 1/1/2024. The PCP ordered lab work for Resident #1 upon his return to the facility and no abnormalities were found. The PCP stated Resident #1 was in danger during his elopement from the facility because he does not know what's fully going on and the resident had a possibility of increased seizure risk without his seizure medications. A review of Resident #1's physician's orders showed the resident missed evening and morning doses of his two medications for seizures and missed his three morning medications for hypertension: An order dated 12/30/2023 for Lacosamide 100 milligrams (mg) by mouth in the morning and at bedtime for a diagnosis of seizures. An order dated 12/30/2023 for Levetiracetam 1000 mg by mouth in the morning and at bedtime for a diagnosis of seizures. An order dated 12/30/2023 for Lisinopril 5 mg by mouth once daily for a diagnosis of hypertension. An order dated 12/30/2023 for Hydralazine Hydrochloride (HCl) 25 mg by mouth once daily for a diagnosis of hypertension. An order dated 12/30/2023 for Amlodipine Besylate 10 mg by mouth once daily for a diagnosis of hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 3 of 20 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 01/12/2024 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 0600 - Level of Harm - Immediate jeopardy to resident health or safety An order dated 1/1/2024 for an electronic elopement device to the right lower extremity. Residents Affected - Few An order dated 1/1/2024 to verify placement of the electronic elopement device to the resident's right lower extremity every shift. - An order dated 1/1/2024 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. A review of Resident #1's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 12/31/2023 at 7:41 PM and authored by Staff A, Licensed Practical Nurse (LPN) and Unit Manager (UM), revealed under the section titled Situation Resident #1 could not be located in the facility. The note also revealed under the section titled Appearance Staff A, LPN UM looked for Resident #1 on the first floor of the facility after the resident did not return to the unit for the dinner meal. Staff A, LPN UM was not able to locate Resident #1 and the facility's elopement protocol was initiated. Resident #1's Primary Care Physician (PCP) was also notified of Resident #1's elopement at 9:00 PM and a recommendation was made to call 911. A review of Resident #1's care plan revealed a problem, dated 1/1/2024, indicating Resident #1 was a risk for elopement/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness. Listed interventions included the following: distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, or a book; applying an electronic elopement device to the resident's right lower extremity; monitor the resident's location frequently; and identify patterns of wandering. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/2/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. The assessment also revealed under Section E - Behavior, Resident #1 displayed behaviors of wandering 1 to 3 days of the assessment period, which placed Resident #1 at significant risk of getting to a potentially dangerous place. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 4 of 20 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 01/12/2024 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 0600 ia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%2 Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted on 1/9/2024 at 12:59 PM with Staff A, LPN UM, who was Resident #1's assigned nurse on 12/31/2023 for the 3:00 PM to 11:00 PM shift. Staff A, LPN UM stated she was called in to work the 3:00 PM to 11:00 PM shift on 12/31/2023 due to a call off and arrived at the facility around 4:00 PM. Staff A, LPN UM usually worked as the Unit Manager on Resident #1's floor but she was not familiar with Resident #1 because she was off at the time Resident #1 was admitted to the facility. When she arrived to the unit, Staff A, LPN UM did a shift-to-shift report with Staff B, RN, who told her Resident #1 was participating in an activity in the downstairs dining room. Neither staff member verified Resident #1 was at the activity at the time of the report. Staff A, LPN UM stated around 6:00 PM, she noticed Resident #1 did not return to the unit for dinner and his dinner tray in his room was untouched. Staff A, LPN UM went downstairs to the dining room to check on Resident #1 and he was not at the activity. Staff A, LPN UM stated she also checked the smoking porch off of the downstairs dining room and Resident #1 was not found. Staff A, LPN UM asked Staff C, Receptionist, if she had seen Resident #1 because she did not know what the resident looked like and Staff C, Receptionist responded, no. Staff A, LPN UM also checked with the other floor staff in the facility but was not able to locate Resident #1 on any floor. Staff A, LPN UM stated around 7:00 PM, she went to the reception desk and called the DON and told her Resident #1 could not be located in the building. During her telephone conversation with the DON, Staff A, LPN UM heard Staff C, Receptionist tell her she saw a group of people leaving the facility earlier in the day and was not able to state a time, but she was not certain Resident #1 was part of the group because she did not know what the resident looked like. Staff A, LPN UM stated after speaking with the DON, she initiated a code silver and notified Resident #1's representative. Staff A, LPN UM also stated the DON called her around 7:30 PM and told her to call 911. Staff A, LPN UM was connected to local law enforcement and informed them Resident #1 was missing from the facility. Staff A, LPN UM stated she went outside and searched the surrounding area for the resident, but no other staff members assisted her with the search on the outside perimeter of the facility. Staff A, LPN UM also stated local law enforcement arrived at the building around 10:00 PM and she provided Resident #1's information to them. After speaking with local law enforcement, Staff A, LPN UM completed some paperwork and documentation and left the faciity on 1/1/2024 around 12:15 AM. Staff A, LPN UM arrived back at the facility on 1/1/2024 around 7:30 AM and assisted with staff in-services for the 7:00 AM to 3:00 PM staff, related to Resident #1's elopement. Around 2:00 PM, Staff A, LPN UM went to a local gas station Resident #1 frequently visited prior to his admission to the facility and spoke with members of the community in an attempt to locate Resident #1, but the resident was not found at that time. Staff A, LPN UM stated she received a phone call from the NHA around 6:00 PM on 1/1/2024, stating Resident #1 was found and was being returned to the facility. Residents Affected - Few An interview was conducted on 1/9/2024 at 1:38 PM with Staff B, RN, who was Resident #1's assigned nurse on 12/31/2023 for the 7:00 AM to 3:00 PM shift. Staff B, RN stated she was familiar with Resident #1, and she was his nurse when he arrived at the facility on 12/29/2023. Staff B, RN also stated she completed Resident #1's admission assessment on 12/29/2023 and the resident was alert, but a little bit confused. Staff B, RN stated Resident #1 was able to appropriately answer questions, had knowledge of his surroundings, able to state where he was, and was able to state his name. Staff B, RN also stated at the time of his admission assessment, Resident #1 did not seem cognitively impaired and did not have any diagnoses to indicate cognitive impairment. Staff B, RN addressed Resident #1 did have a diagnosis of dementia and was independently mobile but was not able to state why Resident #1's admission assessment revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 5 of 20 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 01/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident was cognitively intact, was not independently mobile, and did not have the ability to leave the facility. Staff B, LPN UM stated she observed Resident #1 on 12/31/2023 around 2:45 PM go onto the facility elevator wearing a jacket and Resident #1 stated to her he was going downstairs to participate in an activity. Staff B, LPN UM also stated around 3:00 PM, she did a shift-to-shift report with Staff A, LPN UM and told her Resident #1 was downstairs participating in an activity, but neither staff member verified Resident #1 was downstairs. After giving the shift-to-shift report, Staff B, RN left the facility. Staff B, RN stated she returned to the facility on 1/1/2024 and was told by Staff A, LPN UM Resident #1 was missing from the facility. Staff B, RN also stated Resident #1 was returned to the facility by local law enforcement on 1/1/2024 around 7:00 PM. Staff B, RN completed a skin assessment for Resident #1 and the resident had no injuries. Staff B, RN stated Resident #1 appeared more confused upon his arrival and was wearing different clothing than the previous day. An interview was conducted on 1/9/2024 at 11:06 AM with Resident #1 in the resident's room. Resident #1 was observed sitting on the side of the bed in his room and was able to get up from the bed and walk to the door without difficulty and without the use of assistive devices. Resident #1 spoke clearly during the interview but was not able to appropriately answer questions. Resident #1 was not able to state where he was, what day it was, or why he was at the facility but was able to state his name, which he repeated several times during the interview. Resident #1 was not able to recall his elopement from the facility on 12/31/2023. An interview was conducted on 1/9/2024 at 2:02 PM with Staff F, Certified Nurse Aide (CNA). Staff F, CNA stated he was familiar with Resident #1 during previous interactions with the resident on 12/30/2023 and stated the resident was in and out when describing the resident's cognition. Staff F, CNA also stated the resident was able to hold a conversation, but only some things made sense, and Resident #1 was not aware of his surroundings. Staff F, CNA stated he worked on Resident #1's floor on 12/31/2023 during the 7:00 AM to 3:00 PM shift and saw the resident dressed to leave around 2:10 PM, but he did not see Resident #1 get onto the elevator or go downstairs during the shift. Staff F, CNA also stated he did not see the resident again before his shift ended at 3:00 PM because he was not assigned to the resident during the shift. Staff F, CNA stated he did not see Resident #1 until 1/2/2024 during the 7:00 AM to 3:00 PM shift. Staff F, CNA also stated he asked Resident #1 about his elopement from the facility but Resident #1 was not able to respond appropriately. An interview was conducted on 1/9/2024 at 2:23 PM with Staff D, Activity Coordinator (AC). Staff D, AC stated she worked at the facility on 12/31/2023 and she set up a football party activity in the first-floor dining area. Staff D, AC also stated she was not familiar with the resident and did not know what the resident looked like prior to his elopement on 12/31/2023. Staff D, AC stated she was assisting residents with a smoke break around 2:15 PM on 12/31/2023 and went to the reception desk to retrieve the smoking supplies when she saw a group of about 3 or 4 people leaving the facility through the front entrance. Staff D, AC was not able to state if Resident #1 was with the group of people exiting the facility because she was not familiar with the resident at the time. Staff D, AC left the facility around 3:15 PM and was told upon her return to the facility on 1/1/2024 Resident #1 was missing from the facility. Staff D, AC stated she assisted several other facility staff members in looking for the resident in the community on 1/1/2024 around 8 or 9 AM, but they were not able to find the resident. A telephone interview was conducted on 1/10/2024 at 10:27 AM with Staff C, Receptionist. Staff C, Receptionist stated she worked at the facility from 8 AM to 8 PM on 12/31/2023 and works mostly weekends. Staff C, Receptionist also stated she was not familiar with Resident #1 prior to the elopement and had never seen the resident before. Staff C, Receptionist stated on 12/31/2023 around 1:30 PM or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 6 of 20 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 01/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2:00 PM, she observed a group of people exiting the facility through the front entrance. Staff C, Receptionist stated she just clicked the buzzer to open the door and let the group out because she assumed it was just a group of visitors leaving the facility and did not think a resident was with them. Staff C, Receptionist stated on 12/31/2023 around 7:00 PM, she noticed Staff A, LPN UM downstairs looking for the resident. Staff C, Receptionist told Staff A, LPN UM she saw a group of people leaving the facility around 1:30 PM or 2:00 PM but she was not sure if the resident was with the group because she did not know what the resident looked like. Staff C, Receptionist stated a code silver was initiated and she assisted Staff A, LPN UM with calling Resident #1's family members in an attempt to notify and locate the resident. Staff C, Receptionist also stated she assisted in searching for Resident #1 outside of the facility for about 10 or 15 minutes but had to leave the facility at 8:00 PM. Staff C, Receptionist returned to the facility at 10:00 PM to assist staff in trying to locate Resident #1 and left the facility around 11:00 PM. Staff C, Receptionist stated she returned to the facility on 1/1/2024 around 8:00 AM and joined several other facility staff for a good hour in trying to find Resident #1 out in the community, but Resident #1 was not found. A telephone interview was attempted on 1/10/2024 at 11:46 AM with Staff E, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 7:00 AM to 3:00 PM shift. Staff E, CNA did not answer the phone call and a message was left for call back by Staff H, Social Services Aide (SSA), who assisted with translation. The phone call was not returned by Staff E, CNA. A telephone interview was conducted on 1/10/2024 at 11:50 AM with Staff G, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 3:00 PM to 11:00 PM shift. Staff G, CNA stated she was not familiar with Resident #1 and had not seen the resident before his return on 1/1/2024. Staff G, CNA also stated she arrived at the unit on 12/31/2023 around 3:00 PM and conducted shift-to-shift rounds with Staff E, CNA. Staff G, CNA stated she only did a verbal shift-to-shift report with Staff G, CNA and neither staff member verified where Resident #1 was at the time of the shift change. Staff G, CNA assisted another CNA with resident care at the beginning of the shift and noticed Resident #1 was not in his room when she brought his dinner tray to the room. Staff G, CNA stated she reported to Staff A, LPN UM Resident #1 was missing from the unit and a code silver was initiated. Staff G, CNA also stated she assisted in searching the facility for Resident #1 for about 15 to 20 minutes before returning to the unit to provide care for the other residents, but Resident #1 was not found. Staff G, CNA left the facility around 11:00 PM and returned on 1/1/2024 around 3:00 PM. Staff G, CNA stated Resident #1 returned to the facility 1/1/2024 and she provided a dinner tray for the resident upon his return. A review of a law enforcement report dated 12/31/2023 at 10:48 PM revealed Resident #1 eloped from the facility at approximately 2:00 PM and local law enforcement dispatched several units in the community to locate Resident #1. Local law enforcement spoke with Resident #1's representative, who told law enforcement Resident #1 recently suffered a seizure due to not taking his seizure medications and staff feared for the resident's safety. The local law enforcement report dated 12/31/2023 at 10:34 PM also revealed an interview with the NHA, who stated Resident #1 walked out of the facility at approximately 2:00 PM due to staff assuming the resident was a visitor at the facility. Local law enforcement obtained a description of Resident #1 and were told by the NHA Resident #1 had confusion and was unable to care for himself. A Local law enforcement interview with Resident #1's representative (RR) on 12/31/2023 at 10:43 PM revealed the following: [Local law enforcement] spoke to the [RR] via phone The [RR] stated she is the [RR] of the missing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 7 of 20 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 01/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few party [Resident #1] and that he suffered a stroke [approximately] 5 [years] ago. [Resident #1] recently suffered a severe seizure which resulted in brain injury and was recently transferred from the hospital to the [facility] on Friday. [RR] stated that [Resident #1] cannot speak and his English [is] garbled and that he is easily confused and cannot take care of himself. [RR] stated that it is likely that [Resident #1] has no former knowledge of the area and would not attempt to go back to local address or friends' home (as he cannot recall them). [RR] stated that [Resident #1] can move with a crowd of people if they were crossing a cross walk but would have difficulty on his own. [RR] stated [Resident #1] has no money and no cellphone and no means of contacting family or friends. [RR] is concerned for [Resident #1's] safety. [RR] stated that the [Resident #1] suffered from the earlier seizure due to his not taking his meds and fears that without said medication he could have further incidents. A local law enforcement report dated 1/1/2024 at 7:22 PM revealed local law enforcement responded to an apartment complex at approximately 6:40 PM after a member of the community reported possibly seeing the resident through the window of an abandoned apartment. The report also revealed Resident #1 was standing near a stairway outside and identified himself to local law enforcement. Resident #1 was incoherent and was not able to answer any questions, but appeared in good physical condition and did not require medical attention. Resident #1 was returned to the facility by local law enforcement. A review of Resident #1's psychiatry evaluation dated 1/5/2024 revealed Resident #1 was alert and oriented only to self and was not able to answer questions appropriately. The evaluation also revealed Resident #1 was independently mobile, had disjointed thought process, and had poor short- and long-term memory. An interview was conducted on 1/8/2024 at 3:00 PM with the facility's NHA and DON. The NHA stated on 12/31/2023, Resident #1 eloped from the facility. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews: On 12/31/2023 around 2:00 PM, Staff F, Certified Nursing Assistant (CNA) and Staff B, RN observed Resident #1 standing next to his room door, which was located across the hallway from the unit elevator, wearing a jacket, hat, and shoes. On 12/31/2023 around 2:30 PM, Staff F, CNA and Staff B, RN observed Resident #1 getting onto the unit elevator and both staff assumed Resident #1 was going to the downstairs dining room to participate in an activity. On 12/31/2023 at 3:00 PM, Staff G, CNA arrived to the unit for the 3:00 PM to 11:00 PM shift and did shift-to shift rounding with Staff F, CNA. Staff F, CNA informed Staff G, CNA Resident #1 was downstairs participating in an activity. Neither staff member verified Resident #1 was downstairs in the activity at the time of the shift-to-shift report. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 8 of 20 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 01/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 12/31/2023 around 5:30 PM, food trays arrived for the dinner meal and Staff G, CNA dropped off a dinner tray to Resident #1's room. Resident #1 was not in the room, and it was assumed by staff he was downstairs participating in an activity in the downstairs dining room. On 12/31/2023 around 6:00 PM, Staff A, LPN UM observed Resident #1's dinner tray was untouched, and Resident #1 did not return to his room for the dinner meal. Staff A, LPN UM went downstairs to the dining area to check if Resident #1 was participating in the activity. Staff A, LPN UM was not able to find Resident #1 in the first-floor dining room or on the first floor of the facility. Staff A, LPN UM initiated the facility's code silver protocol and facility staff began searching other floors in the facility for Resident #1 as well as outside of the facility. Staff A, LPN UM notified the DON, NHA, PCP, and resident representative of Resident #1's elopement. The facility staff conducted a 100% head count of every other resident in the facility and all other residents were accounted for at the time. On 12/31/2023 around 7:40 PM, Staff A, LPN UM notified local law enforcement of Resident #1's elopement from the facility and contacted nearby hospitals to attempt to locate Resident #1. Resident #1 was not found. On 12/31/2023 around 8:40 PM, The NHA drove to Resident #1's previous residence to see if Resident #1 was there and spoke to Resident #1's family member around 9:00 PM. Resident #1 was not at his previous address. On 12/31/2023 around 10:00 PM, local law enforcement arrived at the facility and gathered information from the facility about Resident #1 to assist in finding the resident. Local law enforcement advised the facility a search in the local community would be conducted to find Resident #1. On 1/1/2024 around 8:16 AM, Staff A, LPN UM contacted local hospitals in an attempt to locate Resident #1. Several facility staff conducted searches throughout the community in an attempt to locate Resident #1. Resident #1 was not located at any surrounding hospital and was not found in the community. On 1/1/2024 at 6:28 PM, the NHA was notified by facility staff a member of the community may have located Resident #1 at a nearby apartment complex approximately 0.2 miles from the facility in a vacant apartment. Local law enforcement was notified, and facility staff went to the apartment complex. Resident #1 was discovered inside of the vacant apartment and was brought back to the facility around 7:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 9 of 20 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 01/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The NHA stated following Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. Nursing staff also applied an electronic elopement device to Resident #1's right ankle following the elopement, in preparation for the installation of the system the next day. During the facility's investigation, interviews were conducted with Staff C, Receptionist and Staff D, AC, who stated they observed a group of four or so people exiting the facility on 12/31/2023 around 1:30 PM to 2:00 PM and they thought Resident #1 may have been in the group of people without staff knowledge at the time. The facility conducted a root cause analysis of the elopement and determined Resident #1 left with the group of visitors without staff knowledge due to not being recognized as a resident of the facility, facility staff not conducting proper shift-to-shift rounding to verify Resident #1's whereabouts at shift change, staff failing to recognize signs of elopement as e[TRUNCATED] Event ID: Facility ID: 105417 If continuation sheet Page 10 of 20 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 01/12/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 10 residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits and history of dementia, epilepsy, and confusion before admission to the facility. The facility staff failed to ensure the safety of Resident #1; on 12/31/2023 at approximately 2:30 PM, Resident #1 ambulated from the second floor of the facility, entered the facility elevator, and rode the elevator down to the first floor of the facility. Resident #1 exited the facility through the front door, which was equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked) and was opened by reception staff who thought Resident #1 was a visitor at the facility. Resident #1 was able to walk out the front door of the facility, travel approximately 0.2 miles along a 4-lane road and was found more than 24 hours later at a nearby apartment complex in a vacant apartment by a member of the community. Resident #1 was discovered by a member of the community on 1/1/2024 at approximately 7:00 PM in a vacant apartment and was returned by facility staff at approximately 7:30 PM. The facility failed to take action to prevent the resident from exiting the facility by not determining and providing the necessary level of supervision, and not distinguishing the resident from visitors of the facility. The resident was not located for approximately 28 hours and 30 minutes. The failure created a situation that resulted in a likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 12/31/2023. The findings of Immediate Jeopardy were determined to be removed on 1/12/2024 and the severity and scope was reduced to a D. Findings included: A review of Resident #1's Change in Condition Situation, Background, Assessment, and Recommendation (SBAR) Communication and Progress Note dated 12/31/2023 at 7:41 PM and authored by Staff A, Licensed Practical Nurse (LPN) and Unit Manager (UM), revealed under the section titled Situation Resident #1 could not be located in the facility. The note also revealed under the section titled Appearance Staff A, LPN UM looked for Resident #1 on the first floor of the facility after the resident did not return to the unit for the dinner meal. Staff A, LPN UM was not able to locate Resident #1 and the facility's elopement protocol was initiated. Resident #1's primary care physician (PCP) was also notified of Resident #1's elopement at 9:00 PM and a recommendation was made to call 911. A review of the facility policy titled Missing Patient/Resident, last revised on 8/1/2020, revealed under the section titled Overview, staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. The policy also revealed the following facility procedure under the section titled Procedure: Check the Leave of Absence (LOA) book and medical record to ensure the patient/resident is not on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 11 of 20 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 01/12/2024 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 0689 an authorized leave or medical appointment. Level of Harm - Immediate jeopardy to resident health or safety Announce (resident name) please return to your room, over the public announcement (PA) system. Repeat three times to alert staff of a missing patient/resident. Residents Affected - Few Assign staff to search the Center and grounds. If the patient/resident is not located after an initial search, the point person will notify the Nursing Home Administrator (NHA), the Director of Nursing (DON), the resident representative, and the Primary Care Physician (PCP). The NHA and/or DON or designee will notify local law enforcement. A review of Resident #1's hospital history and physical (H&P), dated 12/13/2023 revealed Resident #1 arrived at the emergency department with a critically high blood pressure of 233/151, a heart rate of 101, and was unresponsive with active convulsions. Resident #1 was determined to be in critical condition with a risk of worsening seizures, stroke, or death. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 12/29/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form also revealed under Section S: Physical Function, Resident #1 ambulated with standby assistance and required no assistive devices to ambulate. The transfer form revealed under Section U: Mental/Cognitive Status at Transfer, Resident #1 was alert and disoriented but could follow simple instructions. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of epilepsy, unspecified, intractable, with status epilepticus, difficulty walking, essential hypertension, other symptoms and signs involving cognitive functions and awareness, diabetes mellitus, occlusion and stenosis of the right carotid artery, non-ST elevation (NSTEMI) myocardial infarction, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and history of falling. A review of Resident #1's Admission/readmission Data Collection assessment dated [DATE] and completed by Staff B, Registered Nurse (RN) revealed under Section B: Cognition, Resident #1 was alert and oriented to person, place, and time. The assessment also revealed under Section N2: Elopement Risk Evaluation, Resident #1 was not cognitively impaired, was not independently mobile (either ambulatory or in a wheelchair), did not have poor decision-making skills, did not have the ability to exit the facility, and was not at risk for elopement. A review of the facility policy titled admission Assessment, last revised on 8/22/2017 revealed at the time of admission or readmission, the nurse shall initiate the admission Data Collection Form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with resident and family, and review of the resident's available medical records. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 12 of 20 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 01/12/2024 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 0689 A review of Resident #1's physician's orders revealed the following: Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Few - An order dated 1/1/2024 for an electronic elopement device to the right lower extremity. An order dated 1/1/2024 to verify placement of the electronic elopement device to the resident's right lower extremity every shift. An order dated 1/1/2024 to verify functioning of the electronic elopement device to the resident's right ankle every shift for safety. An order dated 12/30/2023 for Lacosamide 100 milligrams (mg) by mouth in the morning and at bedtime for a diagnosis of seizures. An order dated 12/30/2023 for Levetiracetam 1000 mg by mouth in the morning and at bedtime for a diagnosis of seizures. An order dated 12/30/2023 for Lisinopril 5 mg by mouth once daily for a diagnosis of hypertension. An order dated 12/30/2023 for Hydralazine Hydrochloride (HCl) 25 mg by mouth once daily for a diagnosis of hypertension. An order dated 12/30/2023 for Amlodipine Besylate 10 mg by mouth once daily for a diagnosis of hypertension. A review of Resident #1's care plan revealed a problem, dated 1/1/2024, that Resident #1 was a risk for elopement/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness. Interventions included to distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, or a book, applying an electronic elopement device to the resident's right lower extremity, monitor the resident's location frequently, and identify patterns of wandering. A review of Resident #1's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/2/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 13 of 20 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 01/12/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (BIMS) score of 3, which indicated severely impaired cognition. The assessment also revealed under Section E - Behavior, Resident #1 displayed behaviors of wandering 1 to 3 days of the assessment period, which placed Resident #1 at significant risk of getting to a potentially dangerous place. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%2 An interview was conducted on 1/9/2024 at 12:59 PM with Staff A, LPN UM, who was Resident #1's assigned nurse on 12/31/2023 for the 3:00 PM to 11:00 PM shift. Staff A, LPN UM stated she was called into work the 3:00 PM to 11:00 PM shift on 12/31/2023 due to a call off and arrived at the facility around 4:00 PM. Staff A, LPN UM usually worked as the Unit Manager on Resident #1's floor but she was not familiar with Resident #1 because she was off at the time Resident #1 was admitted to the facility. When she arrived to the unit, Staff A, LPN UM did a shift-to-shift report with Staff B, RN, who told her Resident #1 was participating in an activity in the downstairs dining room. Neither staff member verified Resident #1 was at the activity at the time of the report. Staff A, LPN UM stated around 6:00 PM, she noticed Resident #1 did not return to the unit for dinner and his dinner tray in his room was untouched. Staff A, LPN UM went downstairs to the dining room to check on Resident #1 and he was not at the activity. Staff A, LPN UM stated she also checked the smoking porch off of the downstairs dining room and Resident #1 was not found. Staff A, LPN asked Staff C, Receptionist if she had seen Resident #1 because she did not know what the resident looked like and Staff C, Receptionist responded no. Staff A, LPN UM also checked with the other floor staff in the facility but was not able to locate Resident #1 on any floor. Staff A, LPN UM stated around 7:00 PM, she went to the reception desk and called the DON and told her Resident #1 could not be located in the building. During her telephone conversation with the DON Staff A, LPN UM heard Staff C, Receptionist tell her she saw a group of people leaving the facility earlier in the day and was not able to state a time, but she was not certain Resident #1 was part of the group because she did not know what the resident looked like. Staff A, LPN UM stated after speaking with the DON, she initiated a code silver and notified Resident #1's representative. Staff A, LPN UM also stated the DON called her around 7:30 PM and told her to call 911. Staff A, LPN UM was connected to local law enforcement and informed them Resident #1 was missing from the facility. Staff A, LPN UM stated she went outside and searched the surrounding area for the resident, but no other staff members assisted her with the search on the outside perimeter of the facility. Staff A, LPN UM also stated local law enforcement arrived at the building around 10:00 PM and she provided Resident #1's information to them. After speaking with local law enforcement, Staff A, LPN UM completed some paperwork and documentation and left the faciity on 1/1/2024 around 12:15 AM. Staff A, LPN UM arrived back at the facility on 1/1/2024 around 7:30 AM and assisted with staff in-services for the 7:00 AM to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 14 of 20 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 01/12/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 3:00 PM staff, related to Resident #1's elopement. Around 2:00 PM, Staff A, LPN UM went to a local gas station Resident #1 frequently visited prior to his admission to the facility and spoke with members of the community in an attempt to locate Resident #1, but the resident was not found at that time. Staff A, LPN UM stated she received a phone call from the NHA around 6:00 PM on 1/1/2024, stating Resident #1 was found and was being returned to the facility. An interview was conducted on 1/9/2024 at 1:38 PM with Staff B, RN, who was Resident #1's assigned nurse on 12/31/2023 for the 7:00 AM to 3:00 PM shift. Staff B, RN stated she was familiar with Resident #1, and she was his nurse when he arrived at the facility on 12/29/2023. Staff B, RN also stated she completed Resident #1's admission assessment on 12/29/2023 and the resident was alert, but a little bit confused. Staff B, RN stated Resident #1 was able to appropriately answer questions, had knowledge of his surroundings, able to state where he was, and was able to state his name. Staff B, RN also stated at the time of his admission assessment, Resident #1 did not seem cognitively impaired and did not have any diagnoses to indicate cognitive impairment. Staff B, RN addressed Resident #1 did have a diagnoses of dementia and was independently mobile but was not able to state why Resident #1's admission assessment revealed the resident was cognitively intact, was not independently mobile, and did not have the ability to leave the facility. Staff B, LPN UM stated she observed Resident #1 on 12/31/2023 around 2:45 PM go onto the facility elevator wearing a jacket and Resident #1 stated to her he was going downstairs to participate in an activity. Staff B, LPN UM also stated around 3:00 PM, she did a shift-to-shift report with Staff A, LPN UM and told her Resident #1 was downstairs participating in an activity, but neither staff member verified Resident #1 was downstairs. After giving the shift-to-shift report, Staff B, RN left the facility. Staff B, RN stated she returned to the facility on 1/1/2024 and was told by Staff A, LPN UM Resident #1 was missing from the facility. Staff B, RN also stated Resident #1 was returned to the facility by local law enforcement on 1/1/2024 around 7:00 PM. Staff B, RN completed a skin assessment for Resident #1 and the resident had no injuries. Staff B, RN stated Resident #1 appeared more confused upon his arrival and was wearing different clothing than the previous day. An interview was conducted on 1/9/2024 at 11:06 AM with Resident #1 in the resident's room. Resident #1 was observed sitting on the side of the bed in his room and was able to get up from the bed and walk to the door without difficulty and without the use of assistive devices. Resident #1 spoke clearly during the interview but was not able to appropriately answer questions. Resident #1 was not able to state where he was, what day it was, or why he was at the facility but was able to state his name, which he repeated several times during the interview. Resident #1 was not able to recall his elopement from the facility on 12/31/2023. An interview was conducted on 1/9/2024 at 2:02 PM with Staff F, CNA. Staff F, CNA stated he was familiar with Resident #1 during previous interactions with the resident on 12/30/2023 and stated the resident was in and out when describing the resident's cognition. Staff F, CNA also stated the resident was able to hold a conversation but only some things made sense and Resident #1 was not aware of his surroundings. Staff F, CNA stated he worked on Resident #1's floor on 12/31/2023 during the 7:00 AM to 3:00 PM shift and saw the resident dressed to leave around 2:10 PM, but he did not see Resident #1 get onto the elevator or go downstairs during the shift. Staff F, CNA also stated he did not see the resident again before his shift ended at 3:00 PM because he was not assigned to the resident during the shift. Staff F, CNA stated he did not see Resident #1 until 1/2/2024 during the 7:00 AM to 3:00 PM shift. Staff F, CNA also stated he asked Resident #1 about his elopement from the facility but Resident #1 was not able to respond appropriately. An interview was conducted on 1/9/2024 at 2:23 PM with Staff D, Activity Coordinator (AC). Staff D, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 15 of 20 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 01/12/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few AC stated she worked at the facility on 12/31/2023 and she set up a football party activity in the first floor dining area. Staff D, AC also stated she was not familiar with the resident and did not know what the resident looked like prior to his elopement on 12/31/2023. Staff D, AC stated she was assisting residents with a smoke break around 2:15 PM on 12/31/2023 and went to the reception desk to retrieve the smoking supplies when she saw a group of about 3 or 4 people leaving the facility through the front entrance. Staff D, AC was not able to state if Resident #1 was with the group of people exiting the facility because she was not familiar with the resident at the time. Staff D, AC left the facility around 3:15 PM and was told upon her return to the facility on 1/1/2024 Resident #1 was missing from the facility. Staff D, AC stated she assisted several other facility staff members in looking for the resident in the community on 1/1/2024 around 8 or 9 AM, but they were not able to find the resident. A telephone interview was conducted on 1/10/2024 at 10:27 AM with Staff C, Receptionist. Staff C, Receptionist stated she worked at the facility from 8 AM to 8 PM on 12/31/2023 and works mostly weekends. Staff C, Receptionist also stated she was not familiar with Resident #1 prior to the elopement and had never seen the resident before. Staff C, Receptionist stated on 12/31/2023 around 1:30 PM or 2:00 PM, she observed a group of people exiting the facility through the front entrance. Staff C, Receptionist stated she just clicked the buzzer to open the door and let the group out because she assumed it was just a group of visitors leaving the facility and did not think a resident was with them. Staff C, Receptionist stated on 12/31/2023 around 7:00 PM, she noticed Staff A, LPN UM downstairs looking for the resident. Staff C, Receptionist told Staff A, LPN UM she saw a group of people leaving the facility around 1:30 PM or 2:00 PM but she was not sure if the resident was with the group because she did not know what the resident looked like. Staff C, Receptionist stated a code silver was initiated and she assisted Staff A, LPN UM with calling Resident #1's family members in an attempt to notify and locate the resident. Staff C, Receptionist also stated she assisted in searching for Resident #1 outside of the facility for about 10 or 15 minutes but had to leave the facility at 8:00 PM. Staff C, Receptionist returned to the facility at 10:00 PM to assist staff in trying to locate Resident #1 and left the facility around 11:00 PM. Staff C, Receptionist stated she returned to the facility on 1/1/2024 around 8:00 AM and joined several other facility staff for a good hour in trying to find Resident #1 out in the community, but Resident #1 was not found. A telephone interview was attempted on 1/10/2024 at 11:46 AM with Staff E, Certified Nurse Aide (CNA), who was Resident #1's assigned CNA on 12/31/2023 during the 7:00 AM to 3:00 PM shift. Staff E, CNA did not answer the phone call and a message was left for call back by Staff H, Social Services Aide (SSA), who assisted with translation. The phone call was not returned by Staff E, CNA. A telephone interview was conducted on 1/10/2024 at 11:50 AM with Staff G, CNA, who was Resident #1's assigned CNA on 12/31/2023 during the 3:00 PM to 11:00 PM shift. Staff G, CNA stated she was not familiar with Resident #1 and had not seen the resident before his return on 1/1/2024. Staff G, CNA also stated she arrived at the unit on 12/31/2023 around 3:00 PM and conducted shift-to-shift rounds with Staff E, CNA. Staff G, CNA stated she only did a verbal shift-to-shift report with Staff G, CNA and neither staff member verified where Resident #1 was at the time of the shift change. Staff G, CNA assisted another CNA with resident care at the beginning of the shift and noticed Resident #1 was not in his room when she brought his dinner tray to the room. Staff G, CNA stated she reported to Staff A, LPN UM Resident #1 was missing from the unit and a code silver was initiated. Staff G, CNA also stated she assisted in searching the facility for Resident #1 for about 15 to 20 minutes before returning to the unit to provide care for the other residents, but Resident #1 was not found. Staff G, CNA left the facility around 11:00 PM and returned on 1/1/2024 around 3:00 PM. Staff G, CNA stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 16 of 20 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 01/12/2024 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 0689 Resident #1 returned to the facility 1/1/2024 and she provided a dinner tray for the resident upon his return. Level of Harm - Immediate jeopardy to resident health or safety A telephone interview was conducted on 1/10/2024 at 12:02 PM with Resident #1's PCP. The PCP stated he evaluated Resident #1 on 12/30/2023 and the resident appeared stable but was confused, disoriented to time, and did not give appropriate responses to questions. Resident #1 had a history of stroke and new onset seizures. The PCP stated he was notified of Resident #1's elopement from the facility on 12/31/2023 and of the resident's return on 1/1/2024. The PCP ordered lab work for Resident #1 upon his return to the facility and no abnormalities were found. The PCP stated Resident #1 was in danger during his elopement from the facility because he does not know what's fully going on and the resident had a possibility of increased seizure risk without his seizure medications. Residents Affected - Few A review of a law enforcement report dated 12/31/2023 at 10:48 PM revealed Resident #1 eloped from the facility at approximately 2:00 PM and local law enforcement dispatched several units in the community to locate Resident #1. Local law enforcement spoke with Resident #1's representative, who told law enforcement Resident #1 recently suffered a seizure due to not taking his seizure medications and staff feared for the resident's safety. The local law enforcement report dated 12/31/2023 at 10:34 PM also revealed an interview with the NHA, who stated Resident #1 walked out of the facility at approximately 2:00 PM due to staff assuming the resident was a visitor at the facility. Local law enforcement obtained a description of Resident #1 and were told by the NHA Resident #1 had confusion and was unable to care for himself. A Local law enforcement interview with Resident #1's representative (RR) on 12/31/2023 at 10:43 PM revealed the following: [Local law enforcement] spoke to the [RR] via phone The [RR] stated she is the [RR] of the missing party [Resident #1] and that he suffered a stroke [approximately] 5 [years] ago. [Resident #1] recently suffered a severe seizure which resulted in brain injury and was recently transferred from the hospital to the [facility] on Friday. [RR] stated that [Resident #1] cannot speak and his English [is] garbled and that he is easily confused and cannot take care of himself. [RR] stated that it is likely that [Resident #1] has no former knowledge of the area and would not attempt to go back to local address or friends' home (as he cannot recall them). [RR] stated that [Resident #1] can move with a crowd of people if they were crossing a cross walk but would have difficulty on his own. [RR] stated [Resident #1] has no money and no cellphone and no means of contacting family or friends. [RR] is concerned for [Resident #1's] safety. [RR] stated that the [Resident #1] suffered from the earlier seizure due to his not taking his meds and fears that without said medication he could have further incidents. A local law enforcement report dated 1/1/2024 at 7:22 PM revealed local law enforcement responded to an apartment complex at approximately 6:40 PM after a member of the community reported possibly seeing the resident through the window of an abandoned apartment. The report also revealed Resident #1 was standing near a stairway outside and identified himself to local law enforcement. Resident #1 was incoherent and was not able to answer any questions, but appeared in good physical condition and did not require medical attention. Resident #1 was returned to the facility by local law enforcement. A review of Resident #1's psychiatry evaluation dated 1/5/2024 revealed Resident #1 was alert and oriented only to self and was not able to answer questions appropriately. The evaluation also revealed Resident #1 was independently mobile, had disjointed thought process, and had poor short- and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 17 of 20 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 01/12/2024 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 0689 long-term memory. Level of Harm - Immediate jeopardy to resident health or safety An interview was conducted on 1/8/2024 at 3:00 PM with the facility's NHA and DON. The NHA stated on 12/31/2023, Resident #1 eloped from the facility. During the investigation into Resident #1's elopement, the facility developed the following timeline of events through staff interviews: Residents Affected - Few On 12/31/2023 around 2:00 PM, Staff F, Certified Nursing Assistant (CNA) and Staff B, RN observed Resident #1 standing next to his room door, which was located across the hallway from the unit elevator, wearing a jacket, hat, and shoes. On 12/31/2023 around 2:30 PM, Staff F, CNA and Staff B, RN observed Resident #1 getting onto the unit elevator and both staff assumed Resident #1 was going to the downstairs dining room to participate in an activity. On 12/31/2023 at 3:00 PM, Staff G, CNA arrived to the unit for the 3:00 PM to 11:00 PM shift and did shift-to shift rounding with Staff F, CNA. Staff F, CNA informed Staff G, CNA Resident #1 was downstairs participating in an activity. Neither staff member verified Resident #1 was downstairs in the activity at the time of the shift-to-shift report. On 12/31/2023 around 5:30 PM, food trays arrived for the dinner meal and Staff G, CNA dropped off a dinner tray to Resident #1's room. Resident #1 was not in the room, and it was assumed by staff he was downstairs participating in an activity in the downstairs dining room. On 12/31/2023 around 6:00 PM, Staff A, LPN UM observed Resident #1's dinner tray was untouched, and Resident #1 did not return to his room for the dinner meal. Staff A, LPN UM went downstairs to the dining area to check if Resident #1 was participating in the activity. Staff A, LPN UM was not able to find Resident #1 in the first-floor dining room or on the first floor of the facility. Staff A, LPN UM initiated the facility's code silver protocol and facility staff began searching other floors in the facility for Resident #1 as well as outside of the facility. Staff A, LPN UM notified the DON, NHA, PCP, and resident representative of Resident #1's elopement. The facility staff conducted a 100% head count of every other resident in the facility and all other residents were accounted for at the time. On 12/31/2023 around 7:40 PM, Staff A, LPN UM notified local law enforcement of Resident #1's elopement from the facility and contacted nearby hospitals to attempt to locate Resident #1. Resident #1 was not found. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 18 of 20 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 01/12/2024 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 0689 - Level of Harm - Immediate jeopardy to resident health or safety On 12/31/2023 around 8:40 PM, The NHA drove to Resident #1's previous residence to see if Resident #1 was there and spoke to Resident #1's family member around 9:00 PM. Resident #1 was not at his previous address. Residents Affected - Few On 12/31/2023 around 10:00 PM, local law enforcement arrived at the facility and gathered information from the facility about Resident #1 to assist in finding the resident. Local law enforcement advised the facility a search in the local community would be conducted to find Resident #1. On 1/1/2024 around 8:16 AM, Staff A, LPN UM contacted local hospitals in an attempt to locate Resident #1. Several facility staff conducted searches throughout the community in an attempt to locate Resident #1. Resident #1 was not located at any surrounding hospital and was not found in the community. On 1/1/2024 at 6:28 PM, the NHA was notified by facility staff a member of the community may have located Resident #1 at a nearby apartment complex approximately 0.2 miles from the facility in a vacant apartment. Local law enforcement was notified, and facility staff went to the apartment complex. Resident #1 was discovered inside of the vacant apartment and was brought back to the facility around 7:00 PM. The NHA stated following Resident #1's return to the facility, a skin assessment was performed, and Resident #1 had no injuries from the elopement. Nursing staff also applied an electronic elopement device to Resident #1's right ankle following the elopement, in preparation for the installation of the system the next day. During the facility's investigation, interviews were conducted with Staff C, Receptionist and Staff D, AC, who stated they observed a group of four or so people exiting the facility on 12/31/2023 around 1:30 PM to 2:00 PM and they thought Resident #1 may have been in the group of people without staff knowledge at the time. The facility conducted a root cause analysis of the elopement and determined Resident #1 left with the group of visitors without staff knowledge due to not being recognized as a resident of the facility, facility staff not conducting proper shift-to-shift rounding to verify Resident #1's whereabouts at shift change, staff failing to recognize signs of elopement as evidence by Resident #1 getting on the facility elevator with his hat and jacket on, and Resident #1's elopement assessment not being properly completed upon his admission to the facility on [DATE]. The NHA said on 1/1/2024, a third-party vendor was contacted to install an elopement management system for the facility's front door and the unit was installed on 1/2/2024. The elopement management system works with the resident's electronic elopement device to prevent elopement by locking the door as the resident approaches it and sounding an audible alarm. The DON stated the facility now has a staff member in place on the first floor on a 24 hour basis by the facility elevator to ensure no residents at risk for elopement attempt to leave the facility. The DON also stated all facility staff had in-service education related to elopement and the elopement policy, abuse, neglect, and exploitation, the leave of absence (LOA) policy, and identification of wandering/elopement behaviors, which was completed on 1/4/2024. The DON also stated all nursing staff have been educated on the admission assessment process in order to properly identify elopement risks upon admission to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 19 of 20 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 01/12/2024 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 0689 the facility. The DON stated CNA staff have been educated on shift-to-shift reports and ensuring Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105417 If continuation sheet Page 20 of 20