Inspection·October 25, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he had cancer everywhere including the new spot in his bones and at times he was in pain because of the cancer. Resident #5 stated since coming back from the hospital that his pain had been managed well. Resident #5 stated he did not tell anyone about cutting his wrists prior to doing it because he didn't know he was going to do it until the moment he cut his wrist. Resident #5 stated he cut his wrist because he is tired of living with cancer and the pain that comes with it. Resident #5 stated the only way things could be better now, is if the cancer would just go away. A review of physician progress note dated 10/12/23 showed, Resident #5 was seen for suicidal ideation. The assessment included: Suicide Attempt- tried to slit his wrists. He was sent out to the hospital and since returned is on oral antibiotics and has seven sutures. During an interview on 10/25/23 at 1:04 p.m. the Nursing Home Administrator (NHA) stated on 10/05/23 at approximately 11:30 a.m. Resident #5's family member came out to the nurses' station and stated Resident #5 was bleeding. The NHA stated Resident #5's nurse saw where he took a fork, stabbed his wrist and drug it down. The NHA stated Resident #5 told his nurse while pumping his fist let me bleed let me bleed so the nurse called a code blue. The NHA stated resident was immediately sent out to a local hospital for a higher level of care. The NHA stated she reported the incident on 10/05/23 within the 2 hours required and could show the reportable submission confirmation to survey team. A review of the state survey agency reporting site Nursing Home Reporting-Federal Five-Day Report Manager the immediate report was initially submitted on 10/06/23 at 11:20 a.m. During an interview on 10/25/23 at 3:00 p.m., the Nursing Home Administrator (NHA) stated the Nursing Home Reporting-Federal Five-Day Report Manager confirmation form showed the immediate report was submitted for Resident #5 on 10/06/2023. The NHA confirmed Resident #5's suicide attempt/self- inflicted injury incident occurred on 10/05/23 around 11:30 a.m. so the immediate report was not reported in a timely manner, within the 2-hour timeframe. Review of Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised date 10/2023 showed, 2a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery of forming the suspicion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 2 of 12 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 10/25/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 implement provider orders for one diabetic ulcer and document the presence of a developed wound whose etiology was to be determined for one (#1) out of one resident sampled for diabetic foot ulcers resulting in a delay of treatment. Residents Affected - Few Findings included: The admission Record for Resident #1 identified the resident was admitted on [DATE] with diagnoses not limited to Type 2 Diabetes Mellitus with hyperglycemia, dependence of renal dialysis, and unspecified protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS), dated [DATE], for Resident #1 identified a Brief Interview of Mental Status score of 9, indicating a moderate impaired cognition. The MDS revealed the resident did not have a pressure ulcer, diabetic foot ulcer(s), infection of the foot, or other open lesion(s) on the foot. The review of Resident #1's Admit/Readmit Screener, dated 7/14/23, identified the resident had no areas of skin breakdown and the resident had scored 15 out of 18 on the Braden Scale for Predicting Pressure Score Risk, indicating the resident was at risk. A Skin and Wound Note, by the Wound Care Nurse Practitioner (NP) dated 7/24/23, identified Resident #1 was a new admission to the facility and was seen for a full skin assessment. The note identified the resident had no open areas or wounds present on assessment today. A review of the Skin and Wound Note, signed by the Wound NP, dated 8/23/23, revealed the reason for the visit was subsequent encounter for skin and wound care. The note identified Resident #1 was being seen for diabetic foor ulcer (DFU) to bilateral heels and a new wound to right great toe; etiology to be determined. The assessment of the wounds included the following with plans of treatments: - Right Heel, DFU. Stable eschar, full thickness with exposed dermis tissue. The wound base was 100% eschar and the wound measured: 3 centimeter (cm) x 2.4 cm x 0 cm with a calculated are of 7.2 square cm. The treatment plan was for staff to cleanse with normal saline, apply Betadine to base of the wound, secure with leave open to air, and change daily. - Right Toe, etiology to be determined. New wound with full thickness, measuring 0.5 cm x 0.5 cm x 0.3 cm, calculated area of 0.25 sq cm. The wound base consisted of 1-24% slough and 75-99% epithelial. The treatment plan instructed staff to cleanse with wound cleanser, apply Santyl, nickel thick, to wound base and slough to base of the wound, secure with bordered gauze, and change daily and as needed (prn) (for) dislodged or soiled. The Wound NP revealed the New Recommendations were Complete Blood Count (CBC), comprehensive panel, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and wound culture of right great toe laboratory tests, imaging to r/o osteomyelitis, and arterial and venous duplex of ABI measurement of RLE, All recommendations to be reviewed with the [physician name] by facility per primary request by wound nurse. A review of Resident #1's progress notes, dated 8/23 - 8/29/23 did not identify the recommendations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 3 of 12 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 10/25/2023 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 0684 made by the Wound NP had been implemented. Level of Harm - Minimal harm or potential for actual harm The Skin and Wound Note, signed by the Wound NP for 8/29/23 at 9:02 am, identified the history and physical of the visit was subsequent encounter for Resident #1's skin and wound care, diabetic foot ulcer (DFU) on bilateral heels and new wound to right great toe; etiology to be determined. The note revealed the following wound assessments completed by the Wound NP and the facility Wound Care Nurse with corresponding treatments: Residents Affected - Few - Right Heel, DFU. Stable eschar, full thickness with exposed dermis tissue. Wound base: 100% eschar. Measurements: 3 cm x 2.4 cm x 0 cm with a calculated area of 7.2 sq cm. Wound pain at rest: 1. The treatment plan instructed staff to cleanse with normal saline, apply Betadine to base of the wound, secure with leave open to air, and change daily. - Right Toe, etiology to be determined. Full thickness. Wound base was 1 - 24% slough and 75-99% epithelial. Measurement 0.5 cm x 0.5 cm x 0.3 cm. Wound pain at rest: 5. The treatment plan instructed staff to cleanse with wound cleanser, apply Santyl, nickel thick, to wound base and slough to base of the wound, secure with bordered gauze, and change daily and as needed (prn) (for) dislodged or soiled. The note revealed wound care had been discussed with staff and the resident required offloading of foot ulcer, glycemic control, and routine wound dressing management. The note identified the provider was recommending a CBC, comprehensive panel, ESR, and CRP laboratory tests, imaging to r/o osteomyelitis, and arterial and venous duplex of ABI measurement of RLE, with all recommendations to be reviewed with the primary care physician by the facility. A progress note written by the Wound NP for Resident #1, dated 8/29/23 at 9:04 am, identified Labs and arterial/venous duplex still pending. A review of a Situation, Background, Appearance, and Review/Notify (SBAR), dated 8/29/23, identified Resident #1 had a change in condition related to a skin wound or ulcer. The SBAR revealed the Primary Care Clinician was notified and the facility received the recommendation to send to emergency room (ER) for evaluation (eval) and treatment (tx) due to (d/t) worsening to right foot. A progress note, from the previous Director of Nursing (DON), effective 8/29/23 at 1:30 pm, identified Resident #1 had informed family member of increased pain and the family addressed the issue with an unknown nurse. At that time, the Wound Care Nurse Practitioner (NP) noted the recommendations for a wound culture of right great toe, imaging to rule out (r/o) osteomyelitis, and arterial and venous duplex with Ankle Brachial Index (ABI) measurement of right lower extremity (RLE) were not addressed on 8/24/23. The resident was sent to hospital. Review of Resident #1's August Medication and Treatment Administration Records (MAR and TAR), did not identify an order for treatment to the resident's right great toe, and the resident's left (DFU) and right heel (DFU) wound care, ordered on 8/3/23, was not completed on Friday 8/18, Saturday 8/19, and Monday 8/28/23. A physician order, dated 8/1/23, revealed the resident was to have skin prep applied to Both heels every shift for pressure Deep Tissue Injury (DTI). The TAR identified skin prep had not been applied during the evening shift on 8/2, 8/3, 8/7, and 8/18 or during the day shift on 8/18, 8/28, and 8/29/23. Review of Resident #1's August TAR identified an order, dated 8/3/23 and discontinued on 8/15/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 4 of 12 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 10/25/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed the resident was to receive wound care Right leg of [NAME] finger, Cleaned with normal saline (NS), pat dry, apply (brand name of petrolatum gauze), and then cover with (w/) Border gauzed, one time a day for skin tear. The TAR identified the treatment had not been completed on 8/7, 8/9, and 8/11/23 (the MAR identified the resident left the faciity on Monday, Wednesday, and Friday for Dialysis). A review of Resident #1's Weekly Skin Evaluations, ordered to begin on 8/1/23 and discontinued on 8/29/23, revealed the following: - 7/14/23: identified dry skin, right shoulder chest area catheter, and discolorations to right and left arms. - 8/1/23: signed on TAR as completed but not received by the facility. - 8/8/23: Skin intact, completed by previous DON. No alterations were noted as pre-existing or new. - 8/15/23: Skin intact. No alterations were noted as pre-existing or new. - 8/22/23: Skin intact. No alterations were noted as pre-existing or new. The July MAR and/or TAR did not include an order for weekly skin evaluations. A request to the facility was made for documentation of all weekly skin evaluations, the above were received. The resident had not received weekly skin evaluations on 7/21 or 7/28/23. The Wound Care (NP) Assessment Reports, dated 8/1/23, identified Resident #1's right and left heel wounds were acquired on 7/27/23 and the report, dated 8/23/23, regarding the resident's right great toe did not include an acquired wound date. The review of progress notes made on 7/27/23 for Resident #1 did not include documentation of the right or left heel wounds, or if the physician and/or family had been notified of the wounds development. A review of Weekly Non-Pressure Wound Evaluations, dated 8/8 and 8/15/23 regarding Resident #1's right and left Diabetic wounds identified the wounds were acquired on 7/14/23 (resident was admitted on [DATE]). The review of Resident #1's July MAR and TAR did not identify the resident had received wound care to the right and/or left heels. The care plan for Resident #1 included the following: - At risk for skin breakdown related to (r/t) Anemia, Chronic Obstructive Pulmonary Disease (COPD), Diabetes, History of Pressure Ulcers, (and) Impaired mobility. The interventions instructed staff to complete weekly skin evaluation. The focus and intervention was initiated on 7/14/23. - Has diagnosis of diabetes and is at risk for hype/hypo glycemia. The interventions instructed staff to complete Weekly skin checks and Observe for and report as needed (PRN) any signs/symptoms (s/sx) of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Monitor for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 5 of 12 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 10/25/2023 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 0684 reports of changes to the eye and report to MD, initiated 7/14/23. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 10/25/23 at 1:37 pm, with the Nursing Home Administrator (NHA). The NHA stated on 8/29/23 the Wound Nurse Practitioner (NP) had reported to the (previous) DON and NHA that an assessment was done on Resident #1's wound and it looked worse from the previous week and labs, an ultrasound and X-ray had been ordered to be completed the week before. The NP noted the wound was worsening, the above orders had not been put in (the computer), and Resident #1 needed to go to hospital due to the worsening wound. The NP had reported to the facility the orders had been given to the facility's previous Wound Care Nurse (WCN). The NHA reported the previous WCN stated she hadn't had time to do orders, had asked nurse manager for assistance and did not receive any. The NHA stated the Staff Development Coordinator and DON reported the WCN had not asked for help. The NHA reported the facility did substantiate the incident due to orders were not implemented and the wound deteriorating. The NHA stated Resident #1's wound to right and left heel had been acquired on 7/27/23 and the right great toe had been evaluated on 8/29/23, and the lack of treatment orders for the right great toe had not been addressed during the facility investigation. The NHA stated the expectation would be weekly skin evaluations be done accurately, unaware if primary care physician had been notified of wounds, and staff should have documented when the wounds had been acquired. Residents Affected - Few The policy - Medication Orders, reviewed/revised on 10/23, identified This facility shall use uniform guidelines for the ordering of medication. The policy's Explanation and Compliance Guidelines identified the following: Verbal orders should be received only by licensed nurses or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. Documentation of the medication orders included: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the medication administration record (MAR). d. If using electronic medication records, input the medication order according to the electronic health record (HER) instructions and facility policy. h. Enter the new order on the MAR or ensure the new order is in the electronic MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 6 of 12 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 10/25/2023 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 0684 i. Level of Harm - Minimal harm or potential for actual harm Notify resident sponsor slash family of the new order. Residents Affected - Few The policy - Consulting Physician/Practitioner Orders, reviewed/revised 10/2023, The attending physician shall authenticate orders for the care and treatment of assigned residents. The policy Explanation and Compliance Guidelines included the following: 1. Consulting physician/practitioner orders are those orders provided to the facility by a physician/ practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's: a. Surgeon b. Dialysis physician/nephrologist c. Wound care physician d. Specialist such as urologist, cardiologist, gastroenterologist, dentist, ophthalmologist, OB/GYN e. Nurse practitioner, clinical nurse specialist, or physician assistant to any of the above physicians. 2. For a consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order. b. Document the verification order by entering the order and the time, date, and signature on the physician order sheet. c. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 7 of 12 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 10/25/2023 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 0684 transcribing to medication or treatment administration record. Level of Harm - Minimal harm or potential for actual harm The policy - Skin Assessment, reviewed/revised 10/1/2022, revealed It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. The policy Explanation and Compliance Guidelines instructed the following: Residents Affected - Few 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedures, etcetera). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 8 of 12 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 10/25/2023 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, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-one medication administration opportunities were observed and seventeen (17) errors were identified for three (#6, #7, and #8) of three residents observed. These errors constituted a 77.27% medication error rate. Residents Affected - Few Findings included: 1. On 10/24/23 at 9:31 am, an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #6. Staff A was observed dispensing the following medications: - Amlodipine 5 milligram (mg) tablet - Iron 325 mg over-the counter (otc) tablet The staff member placed a blood pressure wrist cuff on Resident #6's left wrist while it lie in the residents lap and obtained a blood pressure of 138/80 and pulse of 62. - Zyprexa 2.5 mg tablet - Briviact 50 mg tablet - Clonazepam 0.5 mg tablet Staff A confirmed 5 tablets had been dispensed for Resident #6 and administered the medications to the resident while in the hallway. A review of Resident #6's Medication Administration Record (MAR) identified Staff A had documented one 50 mg tablet of Metoprolol Succinate Extended Release (ER), due at 9:00 am, had been administered. An interview was conducted on 10/24/23 at 3:22 pm, Staff A confirmed dispensing and confirming 5 medications during the medication observation and not going back to Resident #6 to give Metoprolol. The staff member said the documentation of administering Metoprolol would be struck out. Review of Resident #6's did identify Staff A had struck out Metoprolol and entered code 9 which identified Other/See Progress Notes. The progress note, entered at 3:22 pm on 10/24/23 and reviewed on 10/25/23 at 9:52 am, identified the resident's Metoprolol not given but did not reveal the physician had been notified. 2. On 10/24/23 at 10:20 am, an observation of medication administration with Staff B, Agency LPN was conducted with Resident #7. Resident #7's medication profile was colored red, along with 7 others, identifying the medications were late. Staff B was observed dispensing the following medications: - Metoprolol 50 mg tablet - Bupropion 75 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 9 of 12 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 10/25/2023 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 - Aspirin chewable 81 mg tablet Level of Harm - Minimal harm or potential for actual harm - Symbicort inhaler Residents Affected - Few Staff B confirmed 3 tablets had been dispensed prior to entering Resident #7's room. The staff member placed a blood pressure wrist cuff on the resident's left wrist, which laid beside the residents left hip, and obtained a blood presssure of 115/64 and pulse of 70. Staff B administered the oral medications and resident refused the Symbicort. Staff B stated the resident was due to receive the probiotic, Saccharomyces boulardii, but it was not on the cart. The staff member moved the medication cart to the nursing station and asked another nurse about the Saccharomyces. The other nurse informed Staff B to call pharmacy to send it. Staff B attempted to call the physician, at 10:37 am, leaving message with answering service. Review of Resident #7's Medication Administration Record (MAR) identified the residents Metoprolol Tartrate was scheduled for every 12 hours - 9:00 am and 9:00 pm, Bupropion was scheduled for twice daily at 9:00 am and 5:00 pm, Aspirin was scheduled daily at 9:00 am, Symbicort was scheduled every 12 hours at 9:00 am and 9:00 pm, and Saccharomyces boulardii was scheduled three times a day at 9:00 am, 1:00 pm, and 5:00 pm. Review of Resident #7's Medication Admin Audit Report identified the resident was administered Metoprolol, Bupropion, and Aspirin at 10:24 am on 10/24/23, one hour and twenty-four minutes after their scheduled time. The Audit Report identified the resident received one capsule of Saccharomyces on 10/24/23 at 11:39 am, 2 hours and 39 minutes after the scheduled time. The progress notes for Resident #7, which were reviewed on 10/25/23 at 9:49 am, revealed the resident refused Symbicort but did not identify the physician had been notified of the resident's late medications and instructions for other doses. 3. On 10/24/23 at 10:45 am, an observation of medication administration with Staff B, Agency LPN was conducted with Resident #8. Resident #8's medication profile was colored red, identifying the resident's medications were late. Staff B was observed dispensing the following medications: - Carvedilol 12.5 mg tablet - Losartan Potassium 50 mg tablet - Metformin 500 mg tablet - Furosemide 20 mg tablet - Diltiazem 180 mg ER tablet - Sertraline 50 mg tablet - Lyrica 50 mg tablet - Percocet 10-325 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 10 of 12 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 10/25/2023 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 Staff B reported the medication cart did not have the resident's Vitamin D, Aspirin capsule, or Hydralazine and confirmed dispensing 8 tablets prior to administering the available medications. The above medications were administered 1 hour and 45 minutes after the scheduled times. Review of Resident #8's Medication Administration Record (MAR) revealed the scheduled times for the observed and unavailable medications: - Carvedilol scheduled twice daily at 9:00 am and 5:00 pm for high blood pressure - Losartan Potassium scheduled twice daily at 9:00 am and 5:00 pm for high blood pressure - Metformin scheduled twice daily at 9:00 am and 5:00 pm for diabetes - Furosemide scheduled daily at 9:00 am for swelling/edema - Diltiazem scheduled daily at 9:00 am for high blood pressure - Sertraline scheduled daily at 9:00 am for depression - Lyrica scheduled twice daily at 9:00 am and 5:00 pm for pain - Percocet scheduled every 8 hours at 1:00 am, 9:00 am, and 5:00 pm for pain - Vitamin D 2000 international unit (iu) daily for Vitamin deficiency, scheduled for 9:00 am - documented as administered. - Aspirin 81 mg capsule daily for acute pain, scheduled for 9:00 am - documented to see progress notes. - Hydralazine 50 mg tablet three times a day for hypertension, scheduled for 9:00 am, 1:00 pm, and 5:00 pm - documented as administered. Review of Resident #8's progress notes, on 10/25/23 at 9:50 am, identified the facility had received a physician order to change the resident's order for a 81 mg capsule of Aspirin to 81 mg chewable tablet of Aspirin. The MAR revealed the resident had not received a dosage of low-dose Aspirin on 10/24/23. The MAR identified the resident had been receiving the capsule form of 81 mg Aspirin. The progress notes did not reveal the physician had been notified of late medications and instructions for future doses. On 10/25/23 at 9:45 am, the Director of Nursing stated it depended on the medication if the physician was notified before or after administering late medications. The DON reviewed Resident #7's progress notes and confirmed the physician had not been notified of late medications. Review of the policy - Medication Administration, revised 10/23, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy is explanation and compliance guidelines identified the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 11 of 12 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 10/25/2023 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 - Compare medication source (bubble pack, vial pack etc.) with MAR to verify resident name, medication name, form, dose, route, and time. -- b. Administer within 60 minutes prior to or after scheduled time and left authorized ordered by physician. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 12 of 12