Inspection·February 12, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm In-service sign-in sheets were provided dated 9/23/2019 and 10/28/2019. The topic addressed was resident rights. Brief Description of Presentation: Upon entering resident room, knock first and then wait for resident permission to enter room. Signatures from staff working all shifts (7:00 a.m.-3:00 p.m., 3:00 p.m.-11:00 p.m., and 11:00 p.m.-7:00 a.m.) were shown. In-service was conducted by clinical staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 2 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on observation, interview and record review, the facility failed to complete an accurate assessment of the resident's capacity for one (#30) of 37 sampled residents. Residents Affected - Few Findings included: On 02/10/20 at 11:50 a.m., Resident #30 was alert and oriented in a wheelchair in the hallway area next to the nurse's station. Upon greeting Resident #30, she stated, I am having a hard time hearing you. Resident asked staff to step to left side, stating I can hear better on this side. On 02/11/20 at 8:04 a.m., Resident #30 was observed in bed and awake. She stated she was waiting on the hairdresser. Resident #30 stated she was unable to hear and asked if the surveyor could come to the left side of bed. The resident was not observed to have hearing aids in at that time. On 02/11/20 at 3:11 p.m., Resident #30's husband was observed in the room visiting with the resident. He said he bought the first pair of hearing aids when she was at another facility, and they were stolen. He stated, She needs severe hearing aids and I can't afford them right now. They use the standard ones here and sometimes they work for her, other times they don't. Resident #30 stated Nurses give them to me when they have time. They don't give it to me every morning. One time, I swear ______, they didn't give it to me until 3:00 p.m. They are supposed to give them to me at 7 in the morning. On 02/12/20 at 11:48 a.m., an interview with Staff N, Minimum Data Set (MDS) Coordinator, was conducted. She stated I am very familiar with the resident and her family. The resident is hard of hearing and does have hearing aids. I'd say sometimes they work and sometimes they don't, but she can hear with and without them. The resident might've had her hearing aids out when the assessment was done, but I can get a print-out of the assessment for you. Social services actually sat with the resident to assess her. I can have him come down. On 02/12/20 at 12:31 p.m., an interview with the Social Services Director was conducted. He stated, I actually look to see if the resident is wearing any hearing aids and then I complete the Brief Interview for Mental Status (BIMS) part of the assessment. I am familiar with Resident #30. She can tell me her needs. You do have to speak a little louder for her. I've never seen her wear hearing aids. I probably marked the wrong thing on the assessment. Review of Quarterly minimum data assessment, Section B: Hearing, Speech, and Vision dated 6/12/19, 9/04/2019 and 10/01/2019 revealed resident #30's ability to hear was adequate and resident did not use hearing aids. MDS Coordinator was unable to provide a policy for the accurate completion of the MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 3 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure interventions were implemented for one (#38) out of 39 sampled residents after a fall with a major injury. Findings included: Resident #38 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to: subsequent encounter for closed fracture with routine healing unspecified fracture of right femur; onset 11/28/19, and subsequent encounter for closed fracture with routine healing unspecified fracture of left femur; onset 12/6/19. The significant change in status Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 11, indicating a moderate cognitive impairment. An observation on 2/10/20 at 9:41 a.m., revealed Resident #38 lying in bed with a trapeze overhead. The call light was observed tied around the raised bed rail, hanging down the side of the bed. The resident attempted and was unable to reach the call light. Staff Member I, Certified Nursing Assistant (CNA), unwrapped the bed control cord and call light cord from the raised bed rail and handed it to the resident. At 9:11 a.m. on 2/12/20, the resident was observed lying on the bed, the bed was above knee level, the call light was within reach, and there were no fall mats on the floor surrounding the bed. The observation revealed Resident #38's room did not contain floor mats. When asked about Resident #38's fall, Staff Member I stated the resident had rolled onto floor, had pain, and the resident removed the braces from lower limbs. At 9:26 a.m. on 2/12/20, Staff Member I stated the resident used the bed control to lower and raise the bed. The staff member confirmed the room did not have floor mats. Resident #38 was identified as a risk for falls: weakness with impaired mobility related to (r/t) fall with right distal femur and left femur on 11/2019, non-weight bearing to bilateral lower extremities. The care plan focus revealed the resident lowers/raises the bed randomly, as well as lowerS head/foot of bed. Staff frequently needed to assist with positioning using bed remote, initiated 12/14/17 and revised on 2/3/20. The interventions for the risk of falls included: - bed in low position, initiated 1/31/20 and revised 2/2/20. - fall mat(s), initiated and created 1/31/20. - Place call light within reach while in bed or close proximity to the bed, initiated and created 12/14/17. A Situation, Background, Appearance, and Review (SBAR), dated 11/27/19, identified Resident #38 had suffered a fall. The SBAR indicated the resident's legs were both straight with feet pointing towards the right and had complained of pain to the right knee. The Situation section on the SBAR, dated 1/31/20, indicated the change in condition, symptoms, or signs observed and evaluated were due to a fall. The SBAR acknowledged the primary care clinician was notified without any recommendations. The radiology results report, dated 11/27/19, of the right femur, interpreted a distal femoral shaft fracture with posterior-lateral displacement and angulation of the distal fracture fragment and regional osteoporosis. The conclusion was an acute distal femoral fracture. The radiology report, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 4 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/15/20, of the right femur indicated a healing fracture above the knee arthoroplasty and the left femur indicated a subacute/partial healing supracondylar fracture on the medial aspect of the knee with severe demineralization. The facility event tracking log indicated Resident #38 had a fall/lowered to floor on 11/27/19 at 6:30 a.m., an unobserved event/injury on 12/6/19 at 7:00 p.m., and on 1/31/20 at 12:30 a.m., had a fall/lowered to floor. The reportable event tracking log indicated Resident #38 had an alleged allegation of injury on 12/6/19. On 2/12/20 at 10:39 a.m., the Nursing Home Administrator (NHA) was interviewed regarding Resident #38's falls. She stated the fall, on 11/27/19, was witnessed by an aide, as the resident repositioned self in the wheelchair then slid out onto the floor with both feet in front of her. Resident #38 complained of pain to her right lower extremity and was sent to the hospital. The NHA stated about a week later, the resident complained of left lower extremity pain, an X-ray was obtained, and previously obtained bloodwork was returned as critical. The resident was sent to the hospital prior to the results of the X-ray. The X-ray at hospital and the one obtained by the facility showed a left femur fracture. The NHA stated the facility had multiple interventions in place, which included a low bed and to engage the resident to assist with fidgeting with the braces and frequent clinical interventions. On 2/12/20 at 11:00 a.m., an observation was conducted with the Nursing Home Administrator, who was also the facility Risk Manager, of Resident #38 and her room. The resident's bed was not at the lowest position and there were no fall/floor mats in the room. The observation, on 2/12/20 at 11:00 a.m., was confirmed by the NHA. The policy titled, Person-Centered Care Plan, effective 11/28/16, reviewed 6/12/19, and revised 7/1/19, identified the center must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. The policy revealed the interdisciplinary team, in conjunction with the patient and/or resident representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 5 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one (#113) out of seven residents with a nothing by mouth diet did not receive oral intake. Residents Affected - Few Findings included: Resident #113 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified cerebral infarction and dysphagia following cerebral infarction. The quarterly Minimum Data Set (MDS), dated [DATE], identified the Brief Interview of Mental Score (BIMS) of 9, indicating a moderate cognitive impairment. The Swallowing/Nutritional status portion of the MDS indicated the resident had a feeding tube, received more than 51% of intake and 501 cc (cubic centimeters) per day or more from an artificial route. An interview was attempted and an observation of Resident #113 was made at 9:52 a.m. on 2/10/20. The observation revealed there was no enteral nutrition infusing into the resident. The resident stated he did not know if he got nutrition through a feeding tube. On 2/11/20 at 5:04 p.m., Resident #113 was observed lying in bed with an emesis basin sitting next to him. The resident confirmed feeling nauseous and said he did not like the dining room, and got a meal tray. A review, on 2/11/20, of Resident #113's physician order report indicated an order, dated 10/30/19, which indicated a diet of Nothing by Mouth (NPO) and NPO texture. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #113, dated 2/1-2/29/20, revealed the resident had a NPO diet with NPO texture. A Video Swallow study, dated 1/16/2020, recommended regular texture food and nectar-thick liquids. The recommendations indicated the resident was to sit upright when eating and drinking, multiple swallows, small bites/sips, 1:1 feed due to impulsivity, and supplemental nutrition via PEG (percutaneous endoscopic gastrostomy) until meeting adequate nutrition by mouth. The swallow study indicated to continue PEG feed and start oral (po) food with Speech therapy (ST). A physician order, dated 2/1/20 at 13:02 (1:02 p.m.) indicated Resident #113 was to receive a nothing by mouth (NPO) diet with a NPO texture. On 2/12/20 at 8:49 a.m., when asked if Resident #113 ate, Staff Member G, Certified Nursing Assistant (CNA), confirmed Yes, he eats, we're going to feed him. As Staff G and Staff H (CNA), searched the meal cart that sat on the unit, Staff G stated the resident's meal was thickened and that she had seen the resident's meal tray in the cart. Staff G located a meal tray in the cart that did not have a diet ticket and stated she thought this was for him. Staff H stated the resident had a regular diet. Staff G went to Staff Member B, Licensed Practical Nurse (LPN), who stated she had to review the chart; after reviewing she stated the resident had been made NPO on 2/1/20. On 2/12/20 at 9:26 a.m., Staff Member E, Dietary Manager, told an aide to take Resident #113 his meal tray. At that time she stated she had a diet order for the resident in her office. Staff E supplied two Diet Order and Communication forms, dated 2/3 and 2/12/20, which indicated a regular/liberalized diet with nectar-like liquids. Staff E stated the order was clarified by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The physical record for Resident #113 revealed two Diet Order and Communication forms: - dated 1/29/20, revealed an order for regular/liberalized diet with nectar-like liquids, three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 6 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 times a day with staff supervision. Level of Harm - Minimal harm or potential for actual harm - dated 2/4/20 at 1815 (6:15 p.m.), indicated a diet order change to NPO and a tube feeding of Nepro 40 milliliters/hour (mL/hr). Residents Affected - Few The physical record did not include the diet order forms that had been obtained by the Dietary Manager. The progress notes of Resident #113 revealed the following documentation regarding the resident nutrition: On 2/1/29 at 12:40 p.m., resident vomited three times, physician notified and orders included no food by mouth. On 2/5/20 at 14:04 (2:04 p.m.), communication sent to primary clinician physician (PCP) with new order to resume oral (po) diet, meals to be in dining room with 1:1 supervision. Tube feeding adjusted to previous order. The Plan of Care (POC) history indicated staff documented the percentage of a meal eaten by mouth by Resident #113 as follows: 2/2/20: 100% at 10:18 a.m., 50% at 12:59 p.m., and 100% at 19:33 (7:33 p.m.) 2/5/20: 25% eaten at 18:37 (6:37 p.m.) 2/6/20: 25% at 8:07 a.m. and 50% at 18:37 (6:37 p.m.) 2/7/20: 25% at 8:24 a.m. and 25% at 12:00 p.m. 2/8/20: 25% at 8:00 a.m., 12:00 p.m., and 20:44 (8:44 p.m.) 2/9/20: 25% twice at 13:57 (1:57 p.m.) and 25% at 22:48 (10:48 p.m.) 2/10/20: 25% twice at 14:58 (2:58 p.m.) and 25% at 18:52 (6:52 p.m.) 2/11/20: 25% twice at 12:43 p.m. and 25% at 18:44 (6:44 p.m.) An order was created by the Director of Nursing (DON), on 2/12/20 at 9:16 a.m., for a regular/liberalized diet with regular texture and nectar-thick liquids. The order indicated it was a clarification order as of 2/4/20. The DON authored a progress note, dated 2/12/20 at 9:03 a.m, which indicated a call was placed to the MD and the diet was clarified as of 2/4/20. During an interview, on 2/12/20 at 9:54 a.m., the DON stated she had changed the order on 2/4/20 and the resident had been NPO. She stated she had spoken with the physician on 2/4 to adjust back to regular diet after holding the tube feeding. The DON stated the order was clarified on 2/12/20 after the nurse had informed her that writer had questioned the resident's diet. She confirmed the staff was assisting Resident #113 with eating without a diet order. She reviewed the physician orders, printed on 2/11/20 and confirmed there was not an order for the resident's oral diet and had called the physician this morning and clarified the order. The DON reviewed the physician orders and stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 7 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 NPO order should have been discontinued. 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: 105419 If continuation sheet Page 8 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/11/2020 at 5:35 p.m., Resident #74 was observed lying in bed with her over-the-bedside tray containing her dinner meal in front of her. She appeared to have only eaten a few bites of each food item. A sheet was lying on her right side bunched up in a ball. She was wearing a shirt and her incontinent brief was exposed. Resident #74 appeared comfortable and was non-verbal to one worded asked questions. The resident's nursing assistant entered the room and was overheard asking her if she was going to eat any more of her meal. She then pushed the table at him, shaking her head at him in the no gesture. The Certified Nursing Assistant (Staff P) said that he had been working at the facility for seventeen years and was familiar with the resident. He then remarked about her sheet being off, She always takes everything off, as he picked up her sheet and tried to cover her. He said that sometimes she would refuse care. But he would come back at a later time and she would usually be cooperative. A medical record review was conducted for Resident #74 that indicated she had been residing at the facility for over three years, per the admission Record face sheet. The face sheet contained her history with the primary diagnosis of Parkinson's disease. Further history documented for spastic hemiplegia affecting right dominant side, unspecified dementia without behavioral disturbances, anxiety, other schizophrenia disorders, and major depressive disorder. Physician orders dated 1/18/2020 read as follows: Risperdal Consta suspension reconstituted extended release (ER) inject 37.5 mg intramuscularly one time a day every two weeks on Saturday (Sat) related to unspecified mood (affective) disorder; other schizoaffective disorders. The medication did not indicate what behavior the resident was exhibiting for its use. Further review of Physician orders revealed: Lexapro 10 mg give 1 tablet by mouth one time a day related to major depressive disorder, started on 10/26/2019. And Depakote Sprinkles capsule delayed release sprinkles 125 mg by mouth two times a day related to other schizoaffective disorders with a start date of 11/24/2019. No target behavior was listed that indicated what behavior was being treated. Review of the medical record listed admission Record: Behaviors-Interventions-Side Effects. No site of administration data found for Behaviors-Interventions-side Effects. No monitoring was located during the survey process for the use of Risperidone, which is an antipsychotic medication, and no monitoring for the use of the antidepressant. Additionally, no monitoring was located for the potential side effects. On 02/12/20 12:04 p.m. Resident #74 was lying in her bed and smiled; she appeared comfortable when approached. The television in the room was off. She lay there alone, holding on to the left-hand railing of the bed. 3. On 2/09/2019 at 10:59 a.m., Resident #80 was observed lying in bed, sleeping under the blankets. Her assistant was asked if she got out of bed. She said, yes, when she wanted to. On 02/10/20 at 11:49 a.m. Resident #80 was observed lying in bed sleeping. The sheet was pulled up to her neck as she laid on her right side. She appeared comfortable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 9 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm The medical record was reviewed that indicated per the admission Record form, she was in her early nineties and had been at the facility since April 2019. The description of her primary diagnosis included an onset date on 10/2019 where she had suffered a traumatic subdural hemorrhage with loss of consciousness. Other diagnosis of unspecified dementia without behavioral, Alzheimer's, depressive disorder, and generalized anxiety. Residents Affected - Few Physician orders were reviewed for Lexapro tablet 10 mg give 1 tablet by mouth one time a day for depression with a start date on 10/22/2019 and for Xanax tablet 0.5mg give 1 tablet by mouth two times a day for anxiety dated on 10/4/2019. Review of Psychotropic/Therapeutic Medication use Evaluation dated on 12/31/2019 listed under Evaluation (6a) targeted behaviors for newly initiated medication. State why medication was started (refer to behavior monitoring and intervention flow record as well as Nursing /Social Services progress notes: anxious, restlessness, crying, sadness. Resident # 80's care plan was reviewed for her listed targeted behaviors as the DON had indicated on 2/11/2020 at 5:45 p.m. The focus said that Resident exhibits or is at risk for distressed/fluctuating mood symptoms related to: anxiety/fear/sadness caused by dx of anxiety, depression and dx of dementia. Resident frequently asseverates on the location of her family. The goal of the care plan is that resident/patient will demonstrate maintained mood state as evidenced by calm appearance, and happy demeanor, etc., through next review. The care plan interventions said they would monitor medications, especially new/changed/discontinued, for side effects and resident's response contributing to mood state, including anticholinergics, opioids, benzodiazepines (recent drug discontinuations, omission or decrease in dose) drug interactions, adverse reaction, drug toxicity or error. The plan of care did not address Lexapro, which belongs to a class of drugs known as selective serotonin reuptake inhibitors (SSRI) antidepressant. On 02/11/20 at 4:53 p.m., Resident #80 was lying on top of her made bed, dressed appropriately and wearing shoes. She was approached and looked briefly at the surveyor when asked if she was okay. She closed her eyes and did not respond. No current or active monitoring was found for the use of the antianxiety nor for the use of the antidepressant medication. No monitoring was found for the potential side effects of the medications. 4. On 2/10/2020 at 4:15 p.m., Resident #83 was observed lying in bed as he was approached and appeared comfortable. He made eye contact when spoken to about his pressure injury. He did not respond verbally, nor did he gesture when asked for a simple yes or no response, as he presented with a flat affect contact. Medical record review stated per the admission Record form that he had been at the facility for a year. He was in his early sixties with his primary diagnosis of cerebrovascular disease, cognitive communication deficit, major depressive disorder, unspecified mood (affective) disorder and obstructive sleep disorder. On 2/11/2020 at approximately 4:00 p.m., the resident was observed lying in his bed as he made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 10 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 brief eye contact and then closed his eyes. He remained non-verbal as he appeared comfortable. Level of Harm - Minimal harm or potential for actual harm Resident #83's current Physician orders were reviewed for Trazodone HCI tablet 50 mg give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, mild, dated 7/25/2019 and Sertraline HCI tablet 50 mg give 1 tablet by mouth one time a day related to major depressive disorder recurrent, mild, dated 1/1/2020. Both medications are classified as antidepressants. Residents Affected - Few Review of Psychotropic/therapeutic Medication use Evaluation dated on 12/31/2019 did not include an evaluation of targeted behaviors nor did it state as to why the medication was started. Resident #83's care plan was reviewed with its focus stating Resident is at risk for complications related to the use of psychotropic drugs Medications: Trazadone, Zoloft. The listed interventions of the care plan were to monitor for changes in mental level and functional level, and monitor for side effects. No target behaviors were identified for the licensed nurses to document the effectiveness of the medication that was being administered. There was no monitoring in place for the use of the two antidepressant medications, and no monitoring was found for the potential side effects of the medication. On 02/11/20 at 2:22 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). She was asked where the documentation would be located for behavioral and side effect monitoring for the Lexapro and Risperdal. She stated We don't chart daily. It's only on exception. She said all the psychotropic medications were reviewed monthly. She was asked at that time for the facility's process on monitoring psychoactive medications. On 02/11/20 at 5:45 p.m. an interview was conducted with the Director of Nursing; she stated, We don't monitor for routine psychoactive medications. Only the 'as needed' ones. She was asked how the nurses were able to identify what the target behavior was for the medication that they were administering. She said in the resident's care plan. On 02/12/20 at 2:05 p.m.,an interview was conducted with the facility Pharmacist. She stated, I look for the monitoring of the medications. She was asked where the monitoring was located. She said that they have a book; just ask them for it, they will show it to you. She confirmed that she was aware they would mark in the book on the sheet if there was a behavior, and if no behavior, they did not mark it. The Pharmacist stated, I have found that facilities have been doing it differently. Some are doing it on exception and others are doing it daily. The Pharmacist was informed that the facility indicated they documented on the 'as needed' (PRN) psychoactive medications, but not on the routine psychoactive medications. The facility provided a copy of their policy titled Behaviors Management of Symptoms with a revision date on 11/01/ 19. 5. If a patient can be managed in the center, initiate a Behavioral Monitoring and Interventions Flow Record. 5.2 If the form is being used for patients receiving psychotropic medications including antipsychotic, use of the form will be continued for as long as a patient is taking the medication. 5.2.1 The license nurse will monitor and document drug side effects on the behavior monitoring and interventions flow record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 11 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7. Reviewed behavior monitoring interventions flow record to identify patterns possible causes results of non-pharmacological interventions, and side effect of medications, if present. Based on observation, interview and medical record review, the facility failed to ensure that psychoactive medications for four (#113,# 74, #80, and # 83) out of five residents were being monitored for target behaviors and side effects. Findings Included: 1. Resident #113 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified schizophrenia and other recurrent depressive disorders. The residents' physician orders included an order for Fluoxetine 20 milligram - give 2 capsules via Percutaneous endoscopic gastrostomy (PEG) tube at bedtime related to other recurrent depressive disorders, start date 10/29/19. The February 2010 Medication Administration Record (MAR) indicated the resident had received Fluoxetine daily at bedtime. According to medlineplus.gov, Fluoxetine was used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks. The side effects may cause nervousness, anxiety, difficulty falling asleep or staying asleep, nausea, diarrhea, dry mouth, heartburn, yawning, weakness, uncontrollable shaking of a part of the body, loss of appetite, weight loss, changes in sex drive or ability, excessive sweaty, and headache, confusion, weakness, difficulty concentrating or memory problems. A review of the electronic record included a Behavior Monitoring record which did not include any information; the Medication and Treatment Adninistration Records did not include monitoring for the number of episodes that Resident #113 exhibited, the types of behaviors that the resident exhibited, side effects caused by the medication, non-pharmaceutical interventions, and/or the effectiveness of the anti-depressant, Fluoxetine. The physical record indicated a Behavior Monitoring and Interventions record, dated 10/31/19, which did not include any behavior symptoms, number of episodes, or non-pharmacologic interventions. The care plan for Resident #113 indicated the resident exhibited or was at risk for distressed/fluctuating mood symptoms related to sadness/depression caused by functional changes and the diagnosis (dx) of schizoeffective disorder, initiated 8/27/19 and revised on 9/16/19. The interventions instructed staff to observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. The Psychotropic/Therapeutic Medication Use Evaluation, effective 12/31/19, indicated staff were to refer to Behavior Monitoring and Intervention flow record as well as Nursing/Social Services progress notes to assess the behavior trends since the last evaluation. The facility answered the behavior trends as N/A behavior symptoms not present prior to this review. The summarization indicated no behaviors were noted at the time of the evaluation. The non-pharmacological interventions summary indicated staff listened to the resident and redirected with positive effect, and was to refer to the Behavior Monitoring Intervention flow record. The evaluation indicated an increase in medication on 10/29/19. The evaluation instructed staff to refer to the Behavior Monitoring and Interventions flow record and the Medication Administration Record to assist with answering the question regarding the monitoring for side effects. The facility indicated no side effects were noted. The evaluation revealed the recommendation for the care plan was to monitor for side effects and consult physician and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 12 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 pharmacist as needed. 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: 105419 If continuation sheet Page 13 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, policy and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two (#94 and #58) of four residents observed. These errors constituted an 8.00% medication error rate. Residents Affected - Few Findings included: 1. On 2/11/20 at 10:08 a.m., an observation of medication administration with Staff Member D, Registered Nurse (RN), was conducted with Resident #94. Staff Member D was observed administering the following medications: - Losartan Potassium 100 milligrams (mg) orally - Duloxetine 60 mg orally - Furosemide 40 mg orally - Metformin 500 mg orally - Hydralazine 50 mg orally - Cetirizine Hydrochloride (HCl) 10 mg orally - Senna Plus 8.6-50 mg orally - Guaifenesin Extended Release (ER) 600 mg orally - Polyethylene Glycol 17 gram (gm) orally - Fluticasone Propionate 50 microgram (mcg) nasal spray - Gabapentin 100 mg - 6 capsules (600 mg) orally - Oxycodone Immediate Release (IR) 10 mg orally A review of the physician orders and the Medication Administration Record (MAR) for Resident #94 revealed the above medications and a Multiple Vitamin tablet were scheduled to be administered at 9:00 a.m.; however the Multiple Vitamin was not observed to be administered. 2. On 2/11/20 at 11:47 a.m., an observation of medication administration with Staff Member J, RN, was conducted with Resident #58. Staff Member J was observed administering the following medications: - Novolog 100 unit/milliliter (u/mL) Flexpen 10 units subcutaneously The observation revealed Staff Member J obtained a blood glucose level of 271, while the resident was eating lunch. Resident #58's meal tray contained a plate of macaroni and cheese, a bowl which contained one piece of stewed tomato, and two drinking glasses, one of which had a residue of liquid in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 14 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it and the other had a red-colored liquid in it. The staff member returned to the medication cart, withdrew the Flexpen, removed the cap, and applied a needle. The staff member kept the Flexpen in a horizontal position and dialed the pen to 10 units then returned to the resident room and administered the insulin in the right lower abdominal quadrant. A review of the physician orders and the Medication Administration Record for Resident #58 revealed the above medication was to be administered per a sliding scale subcutaneously before meals and at bedtime. The sliding scale indicated 10 units of Novolog was to be administered for a blood glucose level of 271. After the administration of the Novolog, at 12:03 p.m. on 2/11/20, the observation of not priming the Flexpen was discussed with Staff Member J, who stated the Flexpen had been primed. During an interview, on 12/12/20 at 2:04 p.m., when asked about her expectation for priming the Flexpen prior to use, the Consulting Pharmacist stated she was not sure about priming the pen prior to use and was unsure if the resident received the correct dose of Insulin. According to novo-pi.com/novolog, the instructions for use of a Flexpen educated users to give an airshot before each injection, as small amounts of air may collect in the cartridge during normal use and to avoid injecting air and to ensure proper dosage. The guide instructed users to apply a needle, turn the dose selector to 2 units, hold the Flexpen with the needle pointing up, tap the cartridge a few times to make any air bubbles collect at the top of the cartridge, and push the button all the way until the dose selector returns to zero (0). The policy titled, Medication Administration: General, effective 1/1/04, reviewed 5/31/19, and revised on 11/1/19, indicated the policy and procedures are guidelines and are not intended to replace the informed judgment and professional discretion of individual clinicians, nor are they intended to establish the standard of care applicable to the assessment or treatment of any particular condition and the unique needs of each patient. The purpose of the policy was to provide a safe, effective medication administration process. The policy did not address the procedure for administering medications as ordered by the physician unless there was a discrepancy with the order which needed clarification. The policy titled, Medication Administration: Injectable (Intramuscular (IM), Subcutaneous (Sub-Q, Z-track), effective 1/1/04 and revised 11/1/19. The policy did not address the procedure for Insulin administration with an Insulin Flexpen. The policy titled, Insulin Pens, effective 10/1/12, reviewed 3/1/16, and revised 11/1/19, did not include the procedure for the administration of insulin utilizing a Flexpen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 15 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, and interviews, the facility failed to store medications safely, per manufacturer recommendations, and inaccessible to unauthorized persons in two (North 400 back & North 400 front) out of three observed medication carts and one out of one observed treatment carts (400 hall). Findings included: On [DATE] at 9:39 a.m., a treatment cart was observed on the 400-hall, unlocked and unattended by licensed personnel. The treatment cart contained multiple containers of medicated topical creams/ointments. Photographic evidence was obtained. At the time of the observation, Staff Member O, Registered Nurse (RN), was overheard exclaiming, Oh snap, then began yelling for Staff Member B, Licensed Practical Nurse (LPN). At 9:41 a.m., Staff Member B arrived to the treatment cart and confirmed the cart had been left unlocked. On [DATE] at 5:07 p.m., an observation was conducted with Staff Member M, Registered Nurse (RN), of the North 400-back medication cart. The observation revealed the following: - a vial of Novolog 100 unit/milliliter (u/mL) Insulin, which was dated as opened on [DATE]. A pink sticker label, attached to the vial, indicated the vial was to be discarded after 28 days. The observation was conducted 43 days after the vial was opened. - Bottle of Artificial Tears, labeled as opened on [DATE]. - One prefilled syringe of Heparin 10 units/milliliter (u/mL) was located in a bag with disposable dental swabs and mulitple prefilled syringes of Normal Saline. The syringe was not labeled with a resident name. Photographic evidence was obtained. Staff Member M confirmed the observations made of the North 400-back medication cart. The staff member confirmed the vial of Insulin should have been discarded, the bottle of Artificial Tears would be discarded, and Heparin syringes are patient-specific and should not be stored as it was found. An observation was conducted, on [DATE] at 5:34 p.m., with Staff Member B, Licensed Practical Nurse (LPN) of the North Front medication cart. The observation revealed the following: - 2 unopened Novolog Flexpens in plastic bags, labeled Refrigerate, and the pens had pink stickers instructing staff to refrigerate until opened. One of the pens was delivered on [DATE] and the other on [DATE]. - A bottle of opened Artificial Tears, undated with open date. - An opened Flexpen, for which Staff Member B did not recognize the name. After a review of the resident roster and electronic record, the staff member stated the resident had discharged on [DATE]. - A package of Lidocaine topical patches were observed stored amongst blister packages of oral medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 16 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 Photographic evidence was obtained. Level of Harm - Minimal harm or potential for actual harm During the observation, Staff Member B stated the Lidocaine patches should not be stored with oral medications, due to different routes of administration. Residents Affected - Few On [DATE] at 2:04 p.m., the Consulting Pharmacist stated opened bottles of Artificial Tears are expired 28 days after opening, due to contamination, and topical medications should not be stored with oral medications. The Consultant stated 10% of the medication carts were reviewed during visits. According to novo-pi.com/novolog, unused Novolog FlexPens are to be stored in the refrigerator at 36 - 46 degrees Fahrenheit (F), and opened multiple dose vials are to be discarded after 28 days. The policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles, effective [DATE] and revised [DATE], [DATE], and [DATE], indicated the following: - Facility should ensure that external use medicatons and biologicals are stored separately from internal use medications and biologicals. - Facilty should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. - Facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines, or have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. - Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. - Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 17 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure food was served at an appetizing temperature and menu items were changed according to season. On 2/11/20 at 11:00 a.m., a Comprehensive Tour was done of the kitchen with Staff E, Dietary Manager. Six staff members were observed present and assisting with meal preparation. Staff E stated she would be checking the temperature of each food item, and that the temperature for the items had not been taken prior. Staff E stated, All of the puree food items were served hot because that's the way the residents like it. Staff E stated, It's been that way since I've been here. Findings included: Milk at 41 degrees Fahrenheit Regular Buttermilk Coleslaw at 40 degrees Fahrenheit Buttermilk Coleslaw Puree at 200 degrees Fahrenheit Deluxe Mac and Cheese Regular at 200 degrees Fahrenheit Mac and Cheese Puree at 190 degrees Fahrenheit Stewed Tomatoes Regular at 170 degrees Fahrenheit Alternative veggie at 180 degrees Fahrenheit Cheese sauce at 180 degrees Fahrenheit BBQ Pulled at 180 degrees Fahrenheit Tater Totes at 160 degrees Fahrenheit A copy of the recipe for Buttermilk [NAME] Slaw was provided and reviewed. Procedures states: 2 Cover and Chill for at least 2-3 hours to allow flavors to blend. Chill to 41 degrees or below for services. Notes states: Puree: Prepare per recipe. Cover and chill to 41 degrees or below for service. On 02/11/20 at 1:44 p.m., an interview with the Dietician was conducted. She said the puree food items should be soft and well cooked. She stated, I know since I've been here, all the pureed food items were served hot, but I tell them when in doubt, follow the menu's instructions. The coleslaw should be chilled, I would have preferred it be served cold. This is the first I've heard of a coleslaw being heated, instead of cooled. They should have maybe used an alternative like buttermilk mashed potatoes, instead of the coleslaw. On 02/11/20 at 01:54 p.m., the Dietary Manager stated, For the residents who receive puree diets, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 18 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few we give them all hot. I find that when the purees are hot, they consume them. The coleslaw was served in this meal as a garnish as a 2oz portion. During Resident Council on 2/11/20 at 02:13 p.m. food items were discussed, and Resident #111 stated, I eat my food puree and coleslaw should never be served hot. Was there mayonnaise in it? Can't you get poisoned? I don't like my stuff all mixed up. Other residents in attendance stated they just don't eat the food. Resident #37 stated I am president of the food committee and they always make excuses when we voice our concerns about the food. On 02/11/20 at 3:50 p.m. the facility Dietician stated We received a response back from the corporate Dietician, who stated that the food item should have been changed out, due to the season change. The coleslaw should have been changed to another food item. The ingredients state the food item should be chilled and so that is how I would expect the item to be. The food item will be changed immediately. (Email provided) Review of email from Healthcare Services groups with subject State Survey in building, revealed Genesis previously allowed cold salads that were pureed smooth up until Fall/Winter menu was released with the new diet manual. This item was missed with the update. If you let me know what facility you are at, we can update the food item immediately, and then check other accounts in your area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 19 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. On 02/09/20 at 2:06 p.m., a Certified Nursing Assistant (Staff A), was observed standing outside of Resident #166's door. She appeared to be speaking to a family member that was in the bedroom. At that time, the family member handed Resident #166's meal tray to Staff A. Staff A placed the tray in the left palm of her hand and her right hand held the corner edge of it. She balanced the tray for approximately 5 feet where she approached the meal cart. With her right hand, she opened the door of the cart and placed the tray inside, then used her right hand to close the cart door and lock the latch. Staff A walked approximately twenty-five feet to the end of the hallway and used the wall hand sanitizer. Residents Affected - Few At 2:10 p.m. Licensed Practical Nurse F was in the hallway. She confirmed that Resident #166 was on isolation. She was asked why the resident was on isolation. She stated Clostridioides Difficile (C-diff). LPN F was then asked how hand care was conducted after touching residents' items in their rooms. She stated, You're supposed to use soap and water for C-diff. At 2:20 p.m. an interview was conducted with the Infection Control Preventionist. She confirmed that hands should be washed with soap and water and not hand sanitizer. Medical record review was conducted that revealed on the admission Record form, the resident was admitted at the end of January 2020, with the diagnosis of C-diff. According to the Centers for Disease Control and Prevention (at https://www.cdc.gov/cdiff/prevent.html), Clostridioides difficile is formerly known as Clostridium Difficile and often called C. Difficile or C. diff. C. diff is a bacterium (germ) that causes diarrhea and colitis (an inflammation of the colon). Most cases of C. diff occur while you're taking antibiotics or soon after you've finished taking antibiotics. C. diff can be deadly. C. diff germs are carried from person to person in poop. If someone with C. diff (or caring for someone with C. diff) doesn't clean their hands with soap and water after using the bathroom, they can spread the germs to everything they touch. When someone else touches the skin of that person, or the surfaces that person touched, they can pick up the germs on their hands. C. diff germs are so small relative to our size that if you were the size of the state of California, a germ would be the size of a baseball home plate. There's no way you can see C. diff germs on your hands, but that doesn't mean they're not there. Washing with soap and water is the only way to prevent the spread from person to person. 4. On 2/11/20 at 11:20 a.m., wound care observation was conducted with Licensed Practical Nurse (LPN), Staff C. She indicated the wound care was for Resident #83's left heel. Resident #83 was noted from outside of the bedroom door lying in bed and appeared comfortable. He made eye contact but did not verbally respond as the nurse spoke with him. Staff C had already prepared the supplies; they were present in his bedroom on a barrier that laid on top of his over the bedside table. Staff C put on a yellow gown and a clean pair of gloves. The room was entered; the bedside table was noted containing a pair of scissors with a purple handle, two slit dry dressings, one small non-adherent dressing, a bottle of normal saline, paper tape and Kerlix. She was asked what was in the souffle cup; she stated it was Santyl ointment. A barrier had been placed under the resident's left foot. Staff C cut off the dressing to his foot with the scissors. The scissors were then placed on the barrier under his foot. The old dressing was noted with a moderate amount of yellow and red drainage. Staff C disposed of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 20 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 0880 the dressing along with her gloves and washed her hands. Level of Harm - Minimal harm or potential for actual harm The wound presented in an irregular shape with the border appearing maceration from 9 to 12. The wound bed contained red and yellow tissue without odor or active drainage. Staff C poured normal saline on the split dressing and cleaned the wound with normal saline and disposed of the soiled dressing in a red bag. With the same gloves, she picked up a clean split dressing and lightly patted the wound dry. She disposed of the dressing in the red bag. She picked up a clean cotton tipped applicator and placed it inside of the cup that contained the Santyl. Then the Santyl was applied to the wound bed. The non-adhering dressing was placed on the wound, followed by the Kerlix wrap. The table that contained the supplies were disposed of in a red bag. Staff C picked up the scissors and exited the bedroom. The scissors were placed on top of the treatment cart's bare surface. Residents Affected - Few At 11:40 a.m., the scissors with the purple handle were observed being cleaned. At that time, the Director of Nursing was on the unit and was asked about bringing items in and out of a resident's bedroom that was on isolation for Methicillin-resistant Staphylococcus aureus (MRSA). The DON stated, The scissors should have been left in the bedroom. Medical record review was conducted for Resident #83 that contained Lab Result Report with the report dated on 02/09/2020. The report indicated two organisms were present. One of the two stated light growth methicillin resistant staph aureus. Wound notes indicated that the wound to the left heel was a diabetic wound, measuring 3.81 cm length and 2.36 cm in width. According to Wikipedia (at https://en.wikipedia.org/wiki/Methicillin-resistant_Staphylococcus_aureus), MRSA Super bug Bacteria Description: Methicillin-resistant Staphylococcus aureus refers to a group of Gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans. Both surgical and nonsurgical wounds can be infected with HA-MRSA.[1][5][20] Surgical site infections occur on the skin surface, but can spread to internal organs and blood to cause sepsis.[1] Transmission can occur between healthcare providers and patients because some providers may neglect to perform preventative hand-washing between examinations. According to the Centers for Disease Control and Prevention (at https://www.cdc.gov/mrsa/community/environment/index.html), Methicillin-resistant Staphylococcus aureus (MRSA) can survive on some surfaces, like towels, razors, furniture, and athletic equipment for hours, days, or even weeks. It can spread to people who touch a contaminated surface, and MRSA can cause infections if it gets into a cut, scrape, or open wound. The DON provided a copy of their policy and procedure titled, Infection Control Policies and Procedures, that contained revision date on 6/15/19. Policy: In addition to Standard Precautions, Contact Precautions will be used for disease transmitted by direct or indirect contact with the patient or the patient's environment. State regulations will be followed when applicable. Purpose: To reduces the risk of epidemiologically import microorganisms by direct or indirect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 21 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 0880 contact. Level of Harm - Minimal harm or potential for actual harm 5. Dedicate personal care equipment (e.g., thermometer, blood pressure cuff, stethoscope, etc.) or use disposable equipment when available. Residents Affected - Few Based on observation, interview and medical record & policy review, the facility failed to ensure that applied infection control practices for four (# 58, 94, 166, and 84) of thirty-nine sampled residents were consistent with facility policy and/or current standards of practice including: 1. An invasive device was cleaned and sanitized in between use for one (#58) resident; 2. That a non-invasive device was cleaned and sanitized after use for one (#94) resident; 3. That appropriate hand hygiene was utilized for one (#166) resident with Clostridioides Difficile; 4. And that personal care equipment was not removed from the room after being used for one (#84) resident with Methicillin-resistant Staphylococcus aureus to a wound. Findings Included: 1. During the observation of medication administration, which began at 10:08 a.m. on 2/11/20, Staff Member D, Registered Nurse (RN), was observed obtaining a blood pressure of Resident #94. The staff member removed a purple blood pressure cuff and stethoscope from the bottom of drawer of the medication cart. Staff Member D placed the blood pressure cuff around the left arm of the resident and laid the manometer on the bed next to the resident. After the medication administration, the staff member returned to the cart, applied gloves, and removed a bleach wipe from a container in the bottom drawer. Staff Member D used the bleach wipe to clean the stethoscope and while holding the cuff in one hand, the staff member used the bleach wipe to wipe the purple cloth of the manual cuff, then placed both in the bottom drawer. The staff member did not disinfect the manometer or tubing that had been in contact with the resident's bed linens. At 10:36 a.m. on 2/11/20, Staff Member D confirmed the blood pressure cuff tubing and meter had been lying next to the resident during medication administration and had not been cleaned after use. 2. An observation was conducted, on 2/11/20 at 11:25 a.m., with Staff Member J, Registered Nurse (RN). Staff Member J removed an Evencare G2 glucometer and supplies from the medication cart, then entered the resident's room. The staff member was observed washing hands prior to obtaining a blood glucose level of a resident. The observation revealed no visible soap bubbles on the staff member's hands or in the sink. After obtaining the blood glucose level, Staff Member J washed hands for approximately 10 seconds with minimal soap then returned to the medication cart. The staff member wiped the glucometer with a Clorox Healthcare Bleach wipe, placed it in a plastic cup, cleaned an extra lancet and the bottle of test strips, then disposed of the bleach wipe. The staff member stated she was going to wait 3-4 minutes for the glucometer to dry. Staff Member J dispensed the resident's oral medications and withdrew a vial of Novolog from the top drawer of the medication cart. After disinfecting the top of the insulin vial, the staff member drew up 4 units, laid the syringe cap on top of the cart, and while holding the cap with left hand, the staff member inserted the needle back into the cap with her right hand. Staff Member J laid the medication and syringe onto the over-the-bed table (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 22 of 23 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 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in front of the resident and went into the bathroom. The staff member washed hands for 4 seconds (utilized the one thousand one method). The staff member applied gloves and administered the insulin to the resident. On 2/11/20 at 11:47 a.m., Staff Member J was observed obtaining a blood glucose level from Resident #58. After obtaining the level, the staff member wiped the glucometer with a Clorox bleach wipe, then placed it in a plastic cup to allow to dry. The staff member used the bleach wipe to clean the test strip bottle, then disposed of the wipe. At 12:03 p.m. on 2/11/20, when the observation was reviewed, Staff Member J stated maybe she needed to use more soap and wash hands for longer. The technical information for Clorox Healthcare Bleach wipes indicated users were to wipe surface with wipe until completely wet, and to disinfect surfaces, the surface was to remain wet for the contact time: - Bacteria - 30 seconds. - Viruses - 1 minute. - C. Difficile spores - 3 minutes. The policy titled, Cleaning and Disinfecting, effective 9/1/04, reviewed 11/15/19, and revised 7/24/18, indicated cleaning and disinfecting of patient care items and environment will be conducted based on risk of infection involved. The practice standards instructed staff to follow manufacturer's recommendations for product use and dwell time and safety precautions when using disinfectants. The policy titled, Glucose Meter, effective date 6/1/96 and revised 11/1/19, revealed the meter was to be disinfected before and after each patient use. The user guide for the Evencare G2 Blood Glucose Meter indicated cleaning of the meter allows for disinfection to ensure gems and disease causing agents are destroyed on the meter. The guide instructed users to wipe all external areas of the meter until visibly clean and allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipes directions. The policy titled, Hand Hygiene, effective 2/15/01, reviewed 11/15/19, and 11/28/17, instructed the facility personnel in the procedure of washing hands with soap and water: - wet hands with warm water, apply soap to hands, and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel and to use a clean, dry, and disposable towel to turn off faucet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 23 of 23