Inspection·October 29, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident, did not introduce themselves, and did not give the resident any explanation of why they were there. They began moving her bed, first with the controller to attempt to raise the bed, and then began physically moving the bed away from the wall toward the center of the room with the resident in the bed. The resident began moving and pulled the pink blanket over her head. When asked, the staff identified themselves as housekeeping staff and said they were there to clean the floor under and behind the bed. During this observation the resident's call light was observed on top of the bed at the foot of the bed and out of reach of the resident. (Photographic evidence obtained) Review of Resident #30's medical record revealed diagnoses on her admission record that included dementia and schizophrenia. The Minimum Data Set (MDS), dated [DATE], revealed impaired short- and long-term memory and severely impaired cognitive skills for daily decision making. The MDS revealed the resident required supervision with one-person physical assist for eating. Her care plan revealed a focus area for impaired cognitive function and thought process which included disorientation to place, time and situation. Interventions included, .Explain care before providing it .Have resident's attention before asking questions and identify yourself with each contact . Her care plan also included a focus area for nutrition with interventions that included, Assist with dining. Observation was conducted of the lunch meal on Resident #30's unit on 10/28/21. At 12:16 p.m., Resident #30 was observed awake in her bed in her room. The head of the bed had been raised, the lights were on, the resident was moving her arms and hands in a restless manner and talking to herself. She was not engageable. Her lunch tray was observed placed unopened on the tray table next to the bed but out of her reach. The tray had not been setup and none of the food items had been opened. At 12:20 p.m., Staff C, CNA was observed feeding a resident in the room across the hall from Resident #30's room. She said that Resident #30 could feed herself if her tray was set up for her and positioned in front of her. At 12:21 p.m. and 12:26 p.m., observation revealed that Resident #30's tray had still not been set up. At 12:27 p.m., Staff B, RN was interviewed at the nurse's station on the unit. She said she was new to the facility and did not know the process for how CNAs were assigned for assisting residents with dining. She said she assumed they were responsible to assist or to feed the residents in their room assignments. She revealed the CNA room assignments which showed that Resident #30 was assigned to Staff C. During the interview with Staff B, Staff C was observed entering Resident #30's room. At 12:30 p.m. Staff C was interviewed. She confirmed she had entered Resident #30's room and set up her lunch tray for her. She said Staff D, CNA had delivered the tray. She said, he's (Staff D) agency so he doesn't know the residents. She could not identify any process by which the CNAs knew what kind of assistance residents needed with dining and said she knew because she had been working in the facility for 20 years and knew the residents well. At 12:41 p.m., Resident #30 was observed in her room in bed feeding herself using her fingers, no staff were present in the room. She was observed trying to open an unopened carton of milk. She was unable to open it. Staff C was found and came in the room and opened the carton for the resident and found a straw in the bedside table drawer which she placed in the milk carton. Staff C confirmed that the call light was on top of the bed near the foot of the bed and out of reach of the resident. She said the resident did not use her call light and was restless and regularly threw the call light and blankets around and off the bed. She said the process for care of Resident #30 was to anticipate her needs and check on her frequently. 3. During observation of the lunch meal on the north wing on 10/26/21 at 12:25 p.m., Resident #57 was observed in his bed in his room. A towel had been placed over his chest covering his upper body from his neck to his lap. His lunch tray had not been delivered. His roommate was observed with his lunch tray and engaged in eating. Resident #57 confirmed he had not received his tray yet and said someone would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 2 of 13 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 10/29/2021 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few brining it and feeding him because he could not feed himself. At 12:31 p.m., Staff A was observed delivering his lunch tray and beginning set up of the items on the tray. She was standing at the bedside while performing the task and began feeding the resident while standing. There was a chair present at the bedside. Staff A was interviewed and said sometimes she sat when feeding residents and sometimes she stood, she said it depended on the height of the bed and said if the bed was low to the ground she would sit. She said she had not received specific training from the facility on technique for maintaining dignity while assisting with dining and said back in school she had been taught to sit when feeding someone. At 12:54 p.m., Staff A was observed continuing to stand while feeding Resident #57. An observation was conducted of the breakfast meal on 10/27/21. At 8:10 a.m., Staff A was observed standing and feeding Resident #57. There was a chair present at the bedside. At 8:29 a.m., Staff A was observed continuing to feed the resident from a standing position. An observation was conducted of the lunch meal on 10/28/21. At 12:11 p.m., Staff I was observed preparing the positioning of the bed and placement of a towel over Resident #57 in preparation for lunch. At 12:13 p.m., Staff I delivered his lunch tray and began to set up the items on the tray. He was standing at the bedside while performing the task. At 12:22 p.m., Staff I was observed feeding the resident from a standing position despite a chair present at the bedside. Staff I was interviewed about his usual practice when providing residents with assistance with eating. He said he sometimes sat while feeding residents. The chair at the bedside was pointed out to him and he said, the chair's a little low. Staff I said he had not received any specific training from the facility on technique for assisting residents with eating. At 12:26 p.m., Staff I was observed continuing to feed Resident #57 from a standing position. Review of Resident #57's medical record revealed diagnoses on his admission record that included dysphagia and muscular dystrophy. The MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which meant he did not have cognitive impairment. The MDS revealed the resident required extensive physical assist of one person for eating. His care plan revealed a focus area for limitations with performing Activities of Daily Living (ADL) tasks and needing maximum assistance with eating. Interventions on the care plan included, .Staff to maintain (Resident #57's) safety and dignity while assisting him during ADL tasks . An interview was conducted with the Director of Nursing (DON) on 10/29/21 at 10:26 a.m. Observations made of Resident #30 and Resident #57 during the survey were shared with her. She confirmed what was observed did not meet the facility's expectations for preserving dignity for the residents. She said that her expectation for aiding with dining was for the staff to be seated next to the resident they were assisting so that you are at eye level for good communication, engaging them .so that you're not up above them .that's kind of back to CNA 101. Regarding tray delivery and setup, she said, we've kind of realized that are process is broken. She clarified that realization had come from concerns identified during the survey. Regarding process for CNA assignment during dining and for CNAs to know what kind of assistance each resident needed she said, a lot of it has fallen on change of shift report with the CNAs and if not, they come ask me .they ask the nurses .I tell people communication is key. She said, the process has been broken .we haven't had unit managers since a while and a lot of it has fallen through the cracks. Regarding the observation made of the housekeeping staff moving Resident #30's bed she said, normally we would get the resident out of the bed .for safety .my first thing would be first knock on the door . introduce self and let the resident know what's being done. She said Resident #30 did not like to get out of bed and in a case like that an offer should still be made to move the resident out of the bed or out of the room until the cleaning was done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 3 of 13 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 10/29/2021 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of an undated facility policy titled Promoting/Maintaining Resident Dignity revealed compliance guidelines that included explain care or procedures to the resident before initiating the activity. Review of facility policy titled Serving a Meal revealed compliance guidelines including: .Prepare the room or serving area for mealtime ( .position comfortably) .Remove dome lid from the tray .Arrange the dishes and silverware so the resident can reach them easily .Open all cartons .Cut up meats and assist the resident as needed .Be sure the resident has everything they need before leaving the room. Check on the resident at regular intervals .Place the call light within easy reach for the resident if you are leaving the room. Review of facility policy titled Meal Supervision and Assistance revealed compliance guidelines including: .The resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position .Ensure that the necessary non-food items ( .straw .) are on the tray .Open all cartons and remove all lids from items on the tray . Based on observations, interviews, and policy review, the facility failed to treat four (Residents #30, #31, #37, and #57) of thirty sampled residents with dignity and respect. Findings included: 1. During a facility tour on 10/26/21 at 10:06 a.m., Staff I, RN (Registered Nurse) was observed entering Resident #31's room without knocking on the door. Staff I walked into the room, interacted with Resident #31, and walked out a couple minutes later. On 10/26/21 12:14 p.m., Staff L, CNA (Certified Nurse's Aide) dropped off a lunch tray into Resident #31's room and left it without initiating meal prep or assistance. On 10/26/21 at 12:39 p.m., Resident #31 was observed in her room in bed, her lunch tray noted by bedside. Resident #31 was not being assisted with her meal. An immediate interview was conducted with Staff I, RN. Staff I stated that Resident #31 received tube feeding from 6:00 p.m. to 8:00 a.m. but ate regular meals during the day. Staff I looked inside Resident #31's room, saw the tray, and walked away. On 10/26/21 at 1:07 p.m., Resident #31 was observed in bed, not being assisted with lunch. On 10/26/21 at 1:10 p.m., Resident #31 received assistance from Staff L, CNA, having waited 56 minutes. Other residents in the hall and finished their meals at the time. Review of Resident #31's resident information sheet revealed that she was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia with behavioral disturbance, Dysphagia, gastronomy status, and unspecified protein-calorie malnutrition. An annual MDS (Minimum Data Set) dated 09/03/21, section C revealed that Resident #31's BIMS (Brief Interview for Mental Status) score was unassessed, which indicated severe cognitive impairment. Section G on functional status showed that Resident #31 required extensive assistance with ADL's (Activities of Daily Living) and was totally dependent for meal assistance. A care plan for Resident #31 dated 09/08/21, showed that Resident #31 had an alteration in her nutrition due to dysphagia and malnutrition. The goal stated that Resident #31 would maintain adequate nutritional and hydration status and remain free of complications associated with G-tube and / or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 4 of 13 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 10/29/2021 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few enteral feeding through review date. For interventions, Resident #31 needed total assistance with tube feeding and water flushes. Resident #31 was noted to be a dependent diner. On 10/26/21 at 12:39 p.m., Staff I was observed in front of the medication cart outside the nurse's station preparing medications for administration. Staff I then walked to Resident # 31's room and did not knock on the door prior to entering. Once inside the room, Staff I was observed administering medications to Resident #31 via tube. Staff I did not draw the privacy curtain or close the door. Resident #31's body was exposed, visible from the hallway during the administration procedure. On 10/26/21 at 12:42 p.m., Staff I was asked why he did not provide privacy during medication administration. Staff I said, I don't know. I know I should. On 10/26/21 at 12:32 p.m., Staff I was observed entering Resident #37's room without knocking. Staff I announced to Resident #37, I need to give you [medicine name]. Staff I stepped out of the room and met a Hospice nurse in the hallway. Staff I was heard talking to the Hospice nurse about Resident #37 in the hallway. Their conversation was audible to everyone in the hallway. On 10/26/21 at 1:10 p.m., Staff I walked into Resident #37's room. Staff I did not knock or request to enter. Staff I announced to Resident #37,The doctor wants me to give you a [medication] Staff I could be heard clearly from the hallway. A review of Resident #37's admission record showed an admission date of 09/09/21 with diagnoses including, but not limited to, senile degeneration of brain, and dementia without behavioral disturbance. An annual MDS dated [DATE], section C revealed that Resident #37 had a BIMS score of 3, which indicated severe cognition impairment. Section G on functional status showed that Resident #37 required extensive assistance with ADLs and required set up assist only for meals. An interview was conducted with Staff I, RN on 10/29/21 at 8:47 a.m. regarding the residents' privacy during care. Staff I stated that he should draw the curtain or close the door. Staff I stated that he should protect the residents' privacy. When asked if he should announce resident's information loud enough to be heard in the hallway, Staff I said, I was trying to explain to her [Resident #37] the treatment orders. Staff I said, I did not mean to be loud. I know I should protect their privacy. On 10/28/21 at 12:09 p.m., Staff C, CNA and Staff D, CNA were observed distributing lunch trays and assisting with meal preparation in the North Hall. Staff C and Staff D were observed not knocking on doors as they went in and out of the rooms. Staff C went in and out of Resident #37's room without announcing self. Staff D, CNA was observed going into Resident #37's room, dropped off water, and then went into Resident #57's room. Staff D went into Resident #31's room again without knocking, grabbed gloves, and went across the hall to assist Resident #57. On 10/28/21 at 12:18 p.m., Staff D went to get coffee for Resident #57 and did not knock prior to entering. Staff D walked into Resident #31's room again, did not knock and was observed putting on gloves as he left the room. Staff D returned to assist Resident #57 and did not knock on the door. On 10/28/21 at 12:30 p.m., Staff C, CNA walked in and out of Resident #37's room and did not knock. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 5 of 13 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 10/29/2021 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 0550 Level of Harm - Minimal harm or potential for actual harm On 10/28/21 at 12:44 p.m., Staff J, CNA removed a lunch tray from Resident #37's room. Staff J was asked if Resident #37 ate her meal. Staff J stated that Resident #37 took two bites only. Staff J was asked if Resident #37 was offered an alternate meal. Staff J said, No, but I can ask her. Staff J went back and asked Resident #37 if she wanted an alternate meal. Staff J stated that Resident #37 wanted soup. Staff J went to the kitchen and got Resident #37 some soup. Residents Affected - Few An interview was conducted with Staff C, CNA. Staff C stated that residents were offered a meal choice only if they ask. Staff C stated that if the residents did not ask, we [staff] should ask them. On 10/28/21 at 12:48 p.m., Staff C was asked about Resident #31 who had not been assisted with her meal yet. Staff C said, She [Resident #31] is a feeder. When asked what that meant, Staff C stated that someone had to help her. Staff C stated that it was not okay for Resident #31 to wait an hour for her meal. Staff C said, No, she should not wait that long. We are kind of shorthanded because a CNA had to go home. Staff C stated that she did not notify the administration that they needed assistance. On 10/28/21 at 12:54 p.m., an interview was conducted with Staff D, CNA. Staff D was asked why he went in and out of Resident #31's room [ROOM NUMBER] times without knocking. Staff D stated that he was going in and out to get gloves. Staff D stated that each room should have a box of gloves, but the other rooms did not. Staff D stated that he should knock prior to entering a resident's room. Staff D, said Yes, this is to show respect. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/28/21 at 12:56 p.m. The ADON was notified that Resident #31 had not received her tray as of 12:56 p.m. The ADON stated that residents should not wait that long to receive their meal. The ADON said, The food is too cold now. The ADON asked Staff J CNA to go get her [Resident #31] a new tray. The ADON stated that if they were short staffed, they should have let her know. She stated that staff should knock prior to entering the rooms all the time. She said, It is their [residents] home. We should treat them with dignity. I will educate the staff. On 10/29/21 at 8:52 a.m. an interview was conducted with the ADON. The ADON stated that the facility protocol was to respect the resident's privacy. She said, Staff should not announce the resident's information to the public. On 10/29/21 12:06 p.m., an interview was conducted with Registered Dietician (RD). The RD stated that the expectation was for resident's food to be served in a timely manner and at a palatable temperature, about 120 degrees. The stated that they had initiated in-services for all the nurses and that they had changed their processes. The RD said, The trays for resident's who need assistance would be plated last and sent out last. Review of an undated facility policy titled, promoting / maintaining resident dignity states that it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under compliance guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 6 of 13 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 10/29/2021 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 0550 5. When interacting with a resident pay attention to the resident as an individual Level of Harm - Minimal harm or potential for actual harm 6. Respond to requests in a timely manner. 10. Speak respectfully to resident; avoid discussions about residents that may be overheard. Residents Affected - Few 12. Maintain resident privacy. 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition. An undated facility policy titled, Meal supervision and assistance stated that the resident will be prepared for a well-balanced meal in a calm environment, location of his/ her preference and with adequate supervision and assistance. A facility policy titled, [Company name] hospitality services with a subtitle, Meal distribution, dated October 2019, stated that it is the center policy that the meals are transported to the dining locations in a manner that insures proper temperature maintenance, .and are delivered in a timely manner. 4. The nursing staff shall be responsible for timely delivery of meals to residents / patients. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 7 of 13 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 10/29/2021 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure urinary catheter care and maintenance was conducted for one (Resident #46) of two sampled residents. Residents Affected - Few Findings Included: An observation of Resident #46 on 10/26/21 at 9:53 a.m., revealed that the resident's catheter was draining dark amber urine with sediment. An observation of Resident #46's catheter on 10/27/21 at 12:10 p.m., revealed the urine that was draining was thick, cloudy, and pink in color. During an observation on 10/27/21 at 12:12 p.m., of the indwelling catheter with Staff G, RN, she said, He does not have an order to flush the catheter but I will check and left the room. Observation of Resident #46's catheter on 10/27/21 at 2:27 p.m., revealed cloudy, pink in color urine with thick white chunks in the catheter tubing. (photographic evidence obtained) Observation and interview was conducted on 10/27/21 at 2:29 p.m. with the Nurse Practitioner. She confirmed that the resident did get sediment in his urine and needed to increase his fluids. She looked at the catheter and stated she would have expected the nurse to alert her and to flush the catheter. The Nurse Practitioner confirmed she would order a urinalysis to check for infection. Review of physician orders dated 02/19/21 were as follows. Irrigate [brand name] catheter with 30 ml normal saline as needed for blockage or sluggishness. Catheter care every shift with soap and water. Review of the Nurse Practitioner's progress note dated 10/27/21 at 6:39 p.m. reflected that the resident was seen due to urine sediment noted in [brand name] catheter tubing and concern that urine was dark. Review of the lab results dated 10/28/21 reflected cloudy yellow urine, positive for blood, protein, urobilinogen, nitrite, leukocytes, red blood cells, white blood cells, bacteria and triple phos crystals. Culture in progress. Review of TAR (Treatment Administration Record) indicated that Staff G, RN signed off as complete for catheter care with soap and water during the day shift from 10/25/21 to 10/27/21. Review of the TAR for irrigation of the [brand name] catheter with 30 ml of normal saline as needed for blockage or sluggishness as needed was not completed from 10/01 - 10/27/2021. During an interview with Staff G, RN on 10/28/21 at 12:14 p.m., she confirmed she signed off on the TAR and stated she relied on the CNA to let her know how the urine looked as they clean and empty the catheter. She would then document that it had been done. During an interview with Staff H, CNA on 10/28/21 at 2:13 p.m., he confirmed he worked with Resident #46 on 10/27/21 and did not clean the catheter. He stated the urine was clear yellow and had no concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 8 of 13 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 10/29/2021 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 0690 Level of Harm - Minimal harm or potential for actual harm An interview with the Director of Nursing (DON) on 10/29/21 at 12:50 p.m, confirmed that her expectation was that the nurse observed the [brand name] catheter prior to signing off on the TAR and documented what the urine looked like and let the Nurse Practitioner know if there were changes. The DON confirmed if the nurse asked the Nurse Practitioner to look at the catheter, she should have documented a note. The DON confirmed the resident was started on an antibiotic for urinary tract infection. Residents Affected - Few Review of facility policy for Catheter Irrigation revised 10/21, Copyright 2020 The Compliance Store, LLC., one page revealed: Urinary catheters may be irrigated to provide for and maintain constant urinary drainage. Review of facility policy for Indwelling catheter use and removal revised on 10/21, Copyright 2021, The Compliance store, 2 pages, revealed: 4. f. Ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 9 of 13 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 10/29/2021 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure that treatment with a continuous positive airway pressure (CPAP) machine was delivered properly and hygienically for one (Resident #59) out of two residents in the facility receiving treatment from a CPAP machine. Residents Affected - Few Findings included: An observation of Resident #59's room was conducted on 10/26/21 at 10:50 a.m. The resident was not present. A CPAP machine was observed on top of the bedside table next to the resident's bed and the CPAP mask was observed hanging by its straps from the mobilizer bar of the bed, the mask was not contained in a bag. (Photographic evidence obtained) On 10/27/21 at 8:20 a.m. Resident #59 was observed in his room. The CPAP machine was observed on top of the bedside table next to the resident's bed and the CPAP mask was observed hanging by its straps from the mobilizer bar of the bed. The resident was interviewed and confirmed that he used the CPAP machine at night, and it was his practice to hang the mask on the mobilizer bar so that the straps did not get tangled. He said the facility had not provided a bag to store the mask in. At 1:16 p.m. the resident's room was observed, and the CPAP machine and mask were in same positions/conditions as previous observation. Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses listed on the admission record included chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (reduced or absent breathing during sleep). The Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which meant the resident was not cognitively impaired. The MDS revealed the resident received treatment from a non-invasive mechanical ventilator (CPAP machine). Review of the physician orders for the resident revealed no orders for the CPAP machine treatment schedule or for the machine settings and parameters. The orders did reveal the following related to CPAP machine care and cleaning: change CPAP face mask and tubing every night shift every 3 months starting on the 15th for 1 day (start date 2/15/21); clean CPAP face mask frame daily after use with soap and water every day shift (start date 01/29/21); replace CPAP disposable filter every night shift every 15 days for COPD (start date 01/24/21); replace headgear every night shift every 6 months starting on the 15th for 1 day for sleep apnea (start date 02/15/21); wash CPAP headgear/straps in warm soapy water and air dry every night shift every Saturday for sleep apnea (start date 01/30/21); wash CPAP tubing with warm soapy water and air dry every night shift every Saturday for COPD (start date 01/30/21). Review of the Treatment Administration Record (TAR) for October 2021 revealed nursing staff had signed off those orders were followed and administered. The resident's care plan revealed a focus area for obstructive sleep apnea with interventions that included Non-invasive mechanical ventilator as ordered (CPAP). An interview was conducted with Staff E, Registered Nurse (RN) on 10/27/21 at 3:58 p.m. She confirmed she was assigned as Resident #59's nurse for that shift. She said that day was her first time working in the facility and therefore did not know the resident and had not met him yet. Regarding the resident's treatment needs, she said she received report from the nurse from the previous shift. She confirmed she did not know the resident had a CPAP machine and confirmed there was nothing in the shift report about the CPAP machine. She said her process would be to consult the physician orders to find out what the treatment schedule and machine settings or parameters were. Staff E consulted the electronic health record (EHR) for Resident #59. She reviewed the physician orders and revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 10 of 13 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 10/29/2021 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there were no orders for treatment schedule or machine settings/parameters. She said, I don't see any order for parameters. Regarding CPAP machines she said, usually it's already set but you still have to check if it's right .with me being my first day here I wouldn't know if it's correct. An observation of Resident #59's CPAP machine was conducted in his room with Staff E on 10/27/21 at 4:07 p.m. Staff E looked at the machine and said, I've never seen this type before. She confirmed she would need a physician's order to know the parameters and how the machine should be set to administer the treatment and monitor it's use. Resident #59 entered the room while Staff E was observing the machine. He was interviewed about the CPAP machine settings, and he confirmed he did not know them and said, I don't know if I've ever known the settings for it. Regarding all aspects of using the machine and cleaning it he said, I do it, but the nurse is supposed to do it, but they don't. The nurse is supposed to clean it (the machine), but they don't .I do it. He said, they're supposed to supply me with distilled water, but I get my own. He said, nobody cleans the mask, and I don't. The resident revealed multiple jugs of distilled water on the floor of his closet and said he used them to refill the machine. The Director of Nursing (DON) was asked to join the observation/interview in the resident's room. She entered on 10/27/21 at 4:17 p.m. The DON confirmed that the resident should not be performing any aspects of the delivery or management of the CPAP machine and said a nurse was supposed to manage all aspects. She observed the distilled water jugs on the floor of the resident's closet. The resident told her, [staff name] went and got these for me. The DON confirmed that staff person no longer worked in the facility. She confirmed that the storage and use of that waster was an infection control concern and confirmed that the water should be stored and provided by the facility, not the resident. (Photographic evidence obtained) After the observation of the resident's room with the DON, a private interview was conducted in her office. She reviewed the physician orders for Resident #59 and confirmed there was no order with parameters, machine settings, or treatment administration schedule and said there should be one. She confirmed there were no orders for self-administration for Resident #59. She said the facility did not have any respiratory service providers or respiratory therapists. The expectation was that the nurses performed all aspects of management for respiratory treatments and equipment. She reviewed the TAR for October 2021, confirmed that staff nurses had signed that care and cleaning was completed. She said based on the resident's reports that they were not performing that care she would be initiating education with the nurses. The DON revealed there was only one other resident in the facility receiving CPAP treatments. She revealed that his medical record included physician orders with machine setting parameters and treatment schedule and said that was how it should be for Resident #59. Review of facility policy titled Oxygen Administration revealed delivery systems included CPAP machines. The policy revealed that administration was performed under physician orders and that the care plan should include when to administer and equipment settings. Review of facility policy titled CPAP/BiPAP (bi-level positive airway pressure) Cleaning revealed, It is the policy of this facility to clean CPAP/BiPAP equipment in accordance with current CDC (Centers for Disease Control) guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. The policy revealed the following within compliance guidelines: .Respiratory equipment can become colonized with infectious organisms and serve as a source of respiratory infections .Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well, Cover with plastic bag or completely enclosed in machine storage when not in use .Weekly cleaning activities: a. Wash headgear/straps in warm, soapy water and air dry. B. Wash tubing with warm soapy water and air dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 11 of 13 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 10/29/2021 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, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed, and four errors were identified for one (Resident #1) of five residents observed. These errors constituted a 15.38% medication error rate. Residents Affected - Few Findings included: 1. On 10/26/21 at 5:09 p.m. an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #1. Staff member F was observed administering the following medications: Admelog Solostar sliding scale 4 units for blood sugar of 263. Sliding scale from 251-300 = 4 units. Staff F gave the insulin in the right arm. Staff F did not prime the insulin pen. Semglee (Lantus) 15 units. Staff F gave the insulin in the left arm. Staff F did not prime the insulin pen. Brimonidine eye drops 2, one drop in the right eye and one drop in the left eye. After confirming the drops were for right eye. Staff F gave one more drop in the right eye. During an interview with Staff F on 10/26/21 at 5:15 p.m. he confirmed he did not prime the insulin pens except when they were newly opened. Staff F confirmed the eye drops should have been two drops in the right eye only. Review of the physician orders revealed: Admelog Solostar 100 unit/ml: inject per sliding scale. Semglee 100 unit/ml solution pen injector, inject 15 units subcutaneous every 12 hours for diabetes. Brimonidine tartrate solution 0.2% instill 2 drops in the right eye two times a day for glaucoma/pain control. An interview on 10/28/21 at 11:20 a.m., with the pharmacist revealed the staff should be priming the insulin pen before using the pen and confirmed the staff were educated related to insulin pens. The pharmacist confirmed the eyedrops should have been documented and the physician called. An interview on 10/28/21 at 10:40 a.m., with the DON confirmed insulin pens should be primed prior to each use with 2 units. The nurse should have called the physician once they corrected the drops in the right eye to let the physician know they put the drop in the left eye. The policy titled Medication Administration , 2021 The Compliance Store, (Revised 4/10/21), acknowledged that Medications are administered in a manner to prevent contamination or infection. 20. Correct any discrepancies and report to nurse manager. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 12 of 13 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 10/29/2021 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 The policy titled Insulin Pen, 2021 The Compliance Store, (Revised on 10/21/21), acknowledged that It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Residents Affected - Few 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. h. Prime the insulin pen: (i.) dial 2 units by turning the dose selector clockwise. (ii.) With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. The policy titled Administration of eye drops or ointments, 2021 The Compliance Store, (Revised on 10/21), acknowledged that Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to treat certain eye conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 13 of 13