Inspection·February 20, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview, and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for six of six months reviewed and one (Resident #65) of three residents sampled. Findings included: A review of the Grievance Logs from August 2023 to January 2024, revealed an absence of grievance issue concern. Eight grievances were randomly chosen for review from September 2023 to January 2024. Review of a grievances dated 1/16/2024, 1/28/2024, and 1/31/2024, for Resident #65, revealed the grievance was filed by the resident related to not receiving medications as ordered and staff assistance. The investigative section and the date the grievance was resolved was blank. Review of the Resident Council Minutes dated September 2023, revealed Old Business concern relating to staff being on their phones and wearing ear buds while providing care. Under the section New Business: ongoing issues of cell phone/ear bud usage. Review of the Resident Council Minutes dated October 2023 revealed Old Business concern relating to staff hiding out in rooms on 3-11/11-7 (shifts) and dayrooms and call lights are on for a long time. Under the section New Business: ongoing issues of cell phone/ear bud usage and call lights. Review of the Resident Council Minutes dated December 2023 revealed the section New Business: ongoing issues of cell phone/ear bud usage; Certified Nursing Assistants (CNAs) not making beds when requested and call lights when staff are sitting at the nurses station. Review of the Resident Council Minutes dated January 2024 revealed the section New Business: CNAs continue to not make beds for residents when they request. During an interview on 2/8/2024 at 10:28 AM, the Social Service Director (SSD) reviewed the grievance process. The SSD said, Once the grievance is received, it is logged in by social services. I take the grievance to our morning meeting for discussion, at which all managers are in attendance. We decide who is responsible for investigating the grievance and that manager takes the grievance to complete the investigation, determine resolution and follow up with the resident/responsible party. Once completed, the grievance form is returned to social services. The SSD stated, we like to get them back in three to five days. The SSD stated the Administrator (NHA) and SSD meet weekly to discuss grievances. The SSD stated that the log did not track the type of concern and did not know if there were any trends. The NHA determined if there were trends based on our weekly meetings. The SSD stated most of the grievances got resolved, some were repeating. The SSD stated call lights seemed like it might repeat. The SSD stated, the call light does not get answered because the staff don't answer another staffs call light. Meaning the staff do not usually answer call lights that were not in their assigned rooms for coverage. The SSD confirmed the grievances for Residents #65 were incomplete and had not heard any further discussions regarding them. During an interview on 2/8/2024 at 12:55 PM, the NHA stated follow through on grievances should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 2 of 41 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 02/20/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm to have them wrapped up in approximately 72 hours. The NHA stated she did not have any information regarding the grievances. The NHA stated the SSD did a trending of grievances and that she (NHA) did not. During an interview on 2/7/2024 at 12:15 PM, Resident #65 stated recollection of the grievance. Resident #65 stated nothing had changed, they (the facility) may come and speak to you, but nothing ever changes. Residents Affected - Few During an interview on 2/8/2024 at 9:55 AM with the Resident Council President. The Resident Council President stated the concerns regarding: call lights, staff sitting around (hiding), and talking on their phones with ear buds on continued to be an ongoing issue. Review of the facility's policies and procedures titled Complaint/Grievance, with a revision date of 10/24/2022 revealed Policy: the center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. Grievances will be reviewed by the quality assurance performance improvement committee. the center will inform residents of the right to file grievance orally and in writing, the right to file grievances anonymously, the contact information of the grievance officer, a reasonable time frame for completing the review of the grievance, the right to obtain written decision regarding the grievance, and contact information of independent entities with whom grievances may be filed . Procedure: . 4. The follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the complaint/grievance form. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 3 of 41 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 02/20/2024 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 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. Based on interviews, records, and policy review, the facility failed to ensure the admission Procedure was implemented for five (Residents #247, #245, #343, #143, and #144) of five residents who were reviewed for admission paperwork. Findings included: During an interview on 2/6/2024 at 10:30 AM, the Admissions Director (AD) stated no residents had been signed in since 1/1/2024. The AD stated she had not had time to get the paperwork completed by the resident or the resident representative. The AD continued to state there had been 32 admissions to date. admission documentation for Residents #247, #245, #343, #143, and #144 were requested from the AD. The AD stated she did not have the admission Packet completed for any of those residents. An interview was conducted with the Administrator (NHA) on 2/8/2024 at 12:55 PM. The NHA stated the AD had not mentioned the paperwork not being completed until after the AD met with the surveyor. The NHA confirmed the AD was the same as the Business Development Coordinator (BDC). Review of the facility's policies and procedures with the subject of Admissions Procedure, dated 8/19/2018 showed Policy: Every admission will be processed by the Business Development Coordinator (BDC) at the time of or prior to admission. BDC will attempt to obtain paperwork prior to admission. Appropriate paperwork will be reviewed with each resident and/or responsible party to ensure financial information is obtained, and the resident and/or the responsible party is informed as to their obligations, rights and responsibilities. The company will give equal consideration and access for admission of all referrals regardless of race, color, national origin, sex, age, disability, religion, or payer source. Procedure: The BDC will print out the admission packet for each patient with documents contained in the admission checklist in sufficient quantity to ensure availability, or in the event the computer system is unavailable. The BDC will: . obtain information via an interview with the resident and/or responsible party to complete the admission portion of the packet. Review the admission portion with the resident and/or responsible party. Obtain consent to photograph/publish. In the event the resident is their own responsible party yet chooses to delegate the signing of the admission paperwork to a member of their family, the resident must sign the Resident Delegation of admission Form. The Resident Delegation of admission Form must be completed and signed by the resident before the admission Agreement packet is signed. complete all documents listed on the admission checklist including any state specific forms not listed. Provide information handbook and copies of all signed documents to the resident and or responsible party. The completed facility admission packet is then given to the business office no later than the next business day Review resident rights, responsibilities, and Advanced Directives with the resident and/or responsible party. Introduce the resident and their family to the social worker for further information on Advanced Directives. Introduce the resident and their family to the business office manager for further information on fiscal responsibility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 4 of 41 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 02/20/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) for 1 of 3 (#1) sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and later identified. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder . Review of Resident #1's PASARR Level I assessment dated [DATE] revealed a qualifying diagnosis of Depressive Disorder and that no PASARR Level II was required. Review of Resident #1's Diagnosis Report revealed additional qualifying diagnosis as follows: -Bipolar Disorder with date of onset 12/31/21 -Major Depressive Disorder with date of onset 12/31/21 -Dx Unspecified Dementia with date of onset 4/12/22 -Schizoaffective disorder with date of onset 1/12/23 -Generalized anxiety disorder with date of onset 1/12/23 -Parkinson's disease with date of onset 10/1/23 Review of the residents medical record revealed that the resident was not assessed for PASARR Level II as the resident acquired additional qualifying diagnosis. Interview on 02/08/24 at 10:41 AM with the Admissions Director revealed that her responsibility is to make sure that they get the PASARR forms from the hospital prior to admission and that she reviews for accuracy. She reported that she checks to see that the forms are signed, dated, and that she checks for diagnosis from the hospital transfer form (3008) or History and Physical. She reported that if the form is not accurate that she would check with the Minimum Data Set (MDS) staff, usually after admission. The Admissions Director reported that nursing staff or MDS would follow-up if there are new diagnosis. Interview on 02/08/24 at 10:56 AM with Staff J, Licensed Practical Nurse (LPN), MDS Coordinator, Staff C, LPN, MDS Coordinator, and the Social Service Director revealed that they get the PASARR's from admissions prior to resident arriving, and if they are not correct they would let admissions know. Staff J and Staff C reported that after reviewing the forms, that if they are incorrect they would notify the Social Service Director the resident/form would be reviewed during the morning meeting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 5 of 41 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 02/20/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff J and Staff C reported that during the morning meeting the resident/form would be where new diagnosis would be discussed, but that they do not know who would be responsible for re-doing the PASARR. Continued interview at this time revealed that the Social Service Director reported that Admissions would be responsible for the accuracy of the PASARR prior to admission and that MDS staff and the Social Service Director would be responsible for the PASARR if there are new diagnosis. Staff C, LPN, MDS Coordinator, reported that based on the documentation in the record there should have been a new PASARR completed to reflect the new diagnosis for Resident #1. Review of the facility policy titled Preadmission Screening and Resident Review (PASRR) with an original date of 11/08/2021 and a revision date of 11/08/2021 revealed the following: 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 6 of 41 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 02/20/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for two (Residents #41 and #50) of nineteen residents sampled for PASRR. Residents Affected - Few Findings included: 1. Review of the admission Record showed Resident #41 had an original admission date on 09/13/22 with diagnoses that included but was not limited to unspecified Dementia, other specified anxiety orders, Major depressive disorder, recurrent, moderate, other specified persistent mood disorders and post-traumatic stress disorder (PTSD). A review of Resident #41's PASRR assessment, dated 09/13/22 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), none of the checkboxes were checked. Review of Resident #41's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #41 had diagnoses of Anxiety Disorder, Depression and Post Traumatic Stress Disorder. During an interview on 02/08/24 at 2:00 p.m., the Director of Nursing (DON) stated that when a new Resident was admitted to the facility a team of staff reviewed all PASRRs after the morning meeting to ensure the PASRR was correct. The DON stated if the team of staff found a PASRR to be inaccurate the facility would request for a new PASRR to be completed. The DON reviewed Resident #41's Level I PASRR and admitting diagnoses and stated the Level I PASRR was incorrect but was never corrected. 2. Review of admission records for Resident #50 showed he was admitted on [DATE] with diagnoses including dementia and major depressive disorder. The diagnoses of anxiety disorder and psychotic disorder were added on 1/3/24. Review of Resident #50's Preadmission Screening and Resident Review (PASRR) Level I screen, completed at the hospital on [DATE], showed the resident had anxiety disorder and depressive disorder. Section II #5 of the PASRR indicated Resident #50 had a primary diagnosis of Dementia. Question #7 said the individual had validating documentation to support dementia or related neurocognitive disorder. At the bottom of section II the PASRR screen showed, A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. Section IV: PASRR Screen Completion showed No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of medical records for Resident #50 did not show a PASRR Level II had been completed. An interview was conducted on 2/7/24 at 5:53 p.m. with the Director of Nursing (DON). She confirmed there was no PASRR Level II completed for Resident #50. After reviewing the resident's Level I screen, the DON said It appears a Level II should have been completed. The DON said the admissions office reviewed the PASRR Level I screen then nursing management reviewed them as part of the admission process. When asked if the staff were just looking at Section IV that said no Level II required versus reviewing the entire screening, she said, it appears to be that way. The DON said Resident #50 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 7 of 41 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 02/20/2024 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 0645 should have a PASRR Level II. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 2/8/24 at 10:41 a.m. with the admission Director. She said when they received a PASRR from the hospital, they checked to make sure the Level I screen was in the record. She said they verified it was signed and dated. When asked if that was all they checked she said, pretty much so, When asked if they checked for accuracy of the Level I screening she said yes, especially if we get them from certain hospitals. The admission Director said they would compare the diagnoses from the hospital to make sure it was correct, then the PASRR was given to the nurses to review in their clinical meeting. She said if she noticed something was not correct, she would give it to the Minimum Data Set (MDS) Coordinator so they could put the codes in. She said if a resident needed a PASRR Level II she gave it to the Social Services Director (SSD) and MDS Coordinator and they took care of it. Regarding Resident #50, the admission Director said one part said he needed a Level II and one part said he did not. She said she was not sure what should have been done in that case. She said she believed Resident #50's PASRR Level I screening should have gone to the MDS Coordinator, but she did no know if it did. Residents Affected - Few An interview was conducted on 2/8/24 at 10:56 a.m. with Staff C, MDS Coordinator and the Social Services Director. Staff C said they received an admission email with the PASRR before the residents arrived, if they were incorrect, she would let admissions know because that part was prior to the resident arriving in the facility. The SSD said admission was responsible for new admission PASRRS and them being correct when the residents came in. The SSD said no one particular was in charge of making sure the PASRRs were correct and they were going to change the process so no one else fell through the cracks. Review of a facility policy titled Preadmission Screening and Resident Review (PASRR), dated 11/8/21, showed the following: Policy The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) resident receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the residents' records. #2 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 8 of 41 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 02/20/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure care plans were developed to address identified needs for five (Residents #50, #67, #69, #71, #247) of 31 sampled residents. Findings included: 1. Resident #71 was admitted to the facility on [DATE] and re-admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) dated 11/17/23. In an interview with Resident #71 on 02/05/24 at 12:30 p.m., she revealed she was having difficulty hearing and verbalized she needed hearing aids and had been waiting for them since before Christmas. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed under the heading of Hearing the following was documented: -Moderate difficulty -Hearing aid Yes A review of the resident's record revealed no documentation related to the resident having difficulty with hearing aids and no documentation that would indicate there had been communication with a vendor related to Resident #71's hearing aids. A review of the residents care plans revealed no documentation that would indicate the facility developed a care plan for Resident #71 to address her hearing loss, the need for hearing aids, or the use of hearing aids. In an interview on 02/08/24 at 9:00 a.m., the Social Service Director revealed the resident's hearing aids were not working properly, that a vendor came in during the month of December and he took one of the hearing aids for repair and they were waiting for the hearing aid to come back. The Social Service Director reported the resident reached out to her insurance and was told that she was not due for a new set of hearing aids until August, so they were waiting for the repairs. The Social Service Director was unable to verbalize the name of the vendor or provide any documentation that would determine the status of Resident #71's hearing aids. An interview on 02/08/24 at 09:34 a.m. with Staff C, Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Coordinator, revealed Resident #71 did not have a care plan in place to address her hearing loss, the need for hearing aids, or the use of hearing aids. Staff C said, I must have missed it, oversight on my part. Staff C said if someone required the use of hearing aids, typically a care plan was created to address this area of concern. 2. A review of admission records showed Resident #247 was admitted on [DATE] with diagnoses including fracture of part of neck of right femur, malignant neoplasm of prostate, and secondary malignant neoplasm of bone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 9 of 41 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 02/20/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #247's physician orders showed an order, dated 1/23/24 for Hospice admitting diagnosis: Malignant Neoplasm Prostate. A review of Resident #247's medical records did not reveal any care plans for hospice services. An interview was conducted on 2/8/24 at 9:41 a.m. with Staff C, Minimum Data Set (MDS) Coordinator. She said when Resident #247 came to the facility there were questions if the resident was going to be hospice or not. She said these kinds of things were discussed at the morning meeting, then the orders and care plans were put into the resident's record. Staff C said she did not remember hearing the final decision if Resident #247 was going to be hospice. She said there was no excuse, the resident should have had a hospice care plan in place. A review of admission records showed Resident #50 was admitted on [DATE] with diagnoses including dementia, type II diabetes mellitus, chronic pulmonary edema, brief psychotic disorder, and major depressive disorder. A review of Resident #50's physician orders showed an order, dated 1/29/24, for Hospice Order: [Company] admitting diagnosis Senial [sic] Degeneration of brain. A review of Resident #50's medical records did not reveal any care plans for hospice services. An interview was conducted on 2/7/24 at 4:24 p.m. with the DON. She confirmed Resident #50 began hospices services on 1/29/24. She reviewed the resident's medical record and confirmed there was no hospice care plan. The DON said this should have been reviewed in morning meetings, where the MDS Coordinators were present. They were then tasked with adding the care plans. 3. During an interview on 02/05/24 at 12:35 p.m., Resident #67 stated he has had a seizure disorder for a long while. Resident #67 stated he had been on medication for his seizures with no seizure activity for 20 years, however since tapering him off his original seizure medication he has had three seizures since being in the facility. A review of the admission Record showed Resident #67 had an original admission date on 03/21/23 with diagnoses that included but was not limited to hypertensive disease with heart failure, chronic pulmonary embolism, chronic pulmonary disease, and seizures. A review of the Order Summary Report showed, Resident #67 had a current order dated 01/30/24 for Levetiracetam oral tablet 500 [milligrams] MG give 4 tablets by mouth at bedtime for anticonvulsant. A review of Resident #67's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #67 had a diagnosis of Seizure Disorder. Section C- Cognitive Patterns showed Resident #67 had a brief interview for mental status (BIMS) of 15 (cognitively intact). A review of a progress note dated 12/21/23 showed Resident #67 had a change of condition related to seizure with a new seizure medication recommended. An additional progress note dated 01/27/24 showed Resident #67 had a change of condition related to a seizure with a recommendation for the Resident #67 to be sent to the hospital for evaluation. A review of Resident #67's care plan showed no area of focus related to Resident #67's seizure disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 10 of 41 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 02/20/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/18/24 at 2:05 p.m., the Director of Nursing stated there should have been a care plan in place for Resident 67's seizure disorder. The DON stated, I think what I did here. I searched for seizure and the other care plan that mentioned seizure came up, so I thought he had one. He is getting one now. He should have had a seizure care plan. A review of the admission Record showed Resident #69 had an original admission date on 06/20/23 with diagnoses that included but was not limited to Depression, acquired absence of left leg above the knee, bipolar disorder, current episode mixed, unspecified, unspecified mood [Affective] disorder and anxiety disorder unspecified. Review of the Order Summary Report and February 2024 Medication Administration Record (MAR) showed, Resident #69 had the following medication orders: Sertraline HCl Oral Tablet 100 MG (Sertraline HCl)- Give 1 tablet by mouth in the morning for depression dated 12/06/23. Xanax Oral Tablet 0.5 MG (Alprazolam) *Controlled Drug*- Give 1 tablet by mouth two times a day for anxiety dated 12/18/23. Mirtazapine Oral Tablet (Mirtazapine)- Give 7.5 mg by mouth at bedtime for depression dated 12/06/23. A review of Resident #69's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #69 had diagnoses of Anxiety Disorder, Depression and Bipolar Disorder. Section CCognitive Patterns showed Resident #69 had a brief interview for mental status (BIMS) of 15 (cognitively intact). A review of Resident #69's care plan showed no area of focus related to Depression, Anxiety, Bipolar or the use of psychotropic medications. During an interview on 02/08/24 at 2:05 p.m., the Director of Nursing stated there should have been care plans for his medications. The DON stated, I absolutely thought for sure we worked together to put in a care plan for his antidepressant, antipsychotic, and antianxiety. The DON stated the facility was on top of the drug changes, and we do that right at the time it is discussed. The DON stated, wonder when the facility changed companies some of the care plans went away? The DON confirmed the diagnoses and medications were not on the care plan and should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 11 of 41 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 02/20/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care plans were revised to reflect two (Residents #10 and #41) out of 19 sampled residents current needs, preferences and changing goals. Findings included: 1. A review of the facility's current smokers list showed Resident #41 was a current smoker in the facility. A review of the admission Record showed Resident #41 had an original admission date on 09/13/22 with diagnoses that included but was not limited to unspecified Dementia, other specified anxiety orders, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation and anxiety disorder. A review of the Order Summary Report 02/07/24 showed no current physician order for smoking. A review of Resident #41's Quarterly Minimum Data Set (MDS) dated [DATE], Section C- Cognitive Patterns showed Resident #41 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact). A review of a Smoking Evaluation dated 06/27/23 showed Resident #41 was not a current smoker in the facility. An additional Smoking Evaluation dated 06/01/23 showed Resident #41 was a current smoker in the facility and smoked 3-4 times a day. Further review of a Smoking Evaluation dated 05/07/23 showed Resident #41 was not a current smoker in the facility. An additional Smoking Evaluation dated 01/29/23 showed Resident #41 was not a current smoker in the facility. Further review of a Smoking Evaluation dated 09/13/22 showed Resident #41 was not a current smoker in the facility. Review of the care plan showed, Resident must smoke with supervision. A care plan goal showed, Resident will smoke safely with supervision throughout next review . The care plan interventions included: - Monitor for changes in / development of signs & symptoms of breathing difficulty and report to nurse if noted: SOB Cough (productive or non-productive) Fever Chills Difficulty speaking Bluish skin color Changes in cognition - Monitor oral hygiene - Notify charge nurse if it is suspected resident has violated facility smoking policy - Remind resident not to share smoking materials with other Resident who may be unsafe - Remind that it is an infection control hazard to smoke Butts from ashtray or ground - Resident oriented to smoking procedures and areas - Resident will demonstrate ability to physically hold the smoking device while smoking - Resident will demonstrate safe technique for putting out matches or lighter and disposing of ash (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 12 of 41 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 02/20/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas. During an interview on 02/07/24 at 5:26 p.m., Staff M Restorative Aid (RA) stated that she was the regular smoking aid and confirmed, Resident #41 was not a smoker. Staff M stated Resident #41 had never smoked. During an interview on 02/07/24 at 5:29 p.m., Resident #41 stated, I do not smoke. During an interview on 02/08/24 at 2:05 p.m., the Director of Nursing stated she had never seen Resident #41 outside smoking. The DON confirmed Resident #41 was on the facility's list of current smokers. The DON stated she would have expected the care plan to have been updated after last assessment. 2. On 2/5/2024 at 9:30 a.m., Resident #10 was observed lying in her bed with the covers over her sleeping. Resident #10 had an Enhanced Barrier Precaution Sign on the door to her room. A review of Resident #10's admission Record showed an admission date of 12/9/2023 and a re-admission of 1/25/2024. Resident #10 had diagnoses of: Sepsis, Pneumonia, Dementia and other co-morbidities. A review of Resident #10's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008, dated 1/17/2024 showed the resident had C. Auris and C. Diff. A review of Resident #10's Order Summary with an active date of 2/7/2024 showed no order for isolation. A review of Resident #10's Medication Administration Record (MAR) for February 2024 showed the resident was receiving treatment for C-Diff for 7 days. Start date was 1/26/204 to 2/2/2024. A review of Resident #10's Care Plan revealed a care plan with a focus of [Resident #10] has active infection in stool: C. Diff date initiated 1/26/2024. An interview was conducted with Staff C, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator on 2/8/2024 at 9:34 AM. Staff C, LPN confirmed she was responsible for updating and developing care plans along with the MDS for each resident. Staff C, LPN stated the care plan for Resident #10 should have been resolved for the C. Diff on 2/3/2024. Staff C, LPN continued to state Resident #10 should have a care plan for the C. Auris. Review of the facility's policies and procedures with the subject of Plans of Care dated 9/25/2017. Policy: an individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representatives to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: . develop and implement an individualized person-centered comprehensive plan of care by the interdisciplinary team that includes but is not limited - to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the residents needs or as requested by the resident, and, to the extent practicable, the participation of the resident and the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 13 of 41 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 02/20/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm representatives within seven days after completion of the comprehensive assessment (MDS). Review update and or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS (except discharge assessments), and as needed Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 14 of 41 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 02/20/2024 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide the appropriate treatment and assistive device to maintain residents hearing abilities for 1 of 31 (#71) total sampled residents. Residents Affected - Few Findings included: Resident #71 was admitted to the facility on [DATE] and re-admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) dated 11/17/23. Interview with Resident #71 on 02/05/24 at 12:30 PM the resident revealed that she was having difficulty hearing and verbalized that she needs hearing aids and has been waiting for them since before Christmas. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that under the heading of Hearing the following was documented: -Moderate difficulty -Hearing aid Yes Review of the residents record revealed no documentation related to the resident having difficulty with hearing aids and no documentation that would indicate that there had been communication with a vendor related to Resident #71's hearing aids. Review of the residents care plans revealed no documentation that would indicate that the facility developed a care plan for Resident #71 to address her hearing loss, the need for hearing aids, and the use of hearing aids. Interview on 02/08/24 at 09:00 AM with the Social Service Director revealed that the residents hearing aids were not working properly, that a vendor came in during the month of December and he took one of the hearing aids for repair and that they were waiting for the hearing aid to come back. The Social Service Director reported that the resident reached out to her insurance and was told that she is not due for a new set of hearing aids until August, so they are waiting for the repairs. The Social Service Director was unable to verbalize the name of the vendor or provide any documentation that would determine the status of Resident #71's hearing aids. Interview on 02/08/24 at 09:34 AM with Staff C, Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Coordinator, revealed that Resident #71 does not have a care plan in place to address her hearing loss, the need for hearing aids, and the use of hearing aids. Staff C reported that I must have missed it, oversight on my part. Staff C reported that if someone requires the use of hearing aids that they would typically create a care plan to address this area of concern. Review of the facilities policy titled Care of Hearing Aid with an effective date of 11/30/2014 and a revision date of 9/1/17 revealed that the facility is to Contact service agency if hearing aid fails to function properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 15 of 41 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 02/20/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure appropriate services and equipment related to splint application for one (Resident #64) of two sampled residents. Findings included: Multiple observations were conducted of Resident #64, from 2/5/2024 at 9:58 a.m. to 2/8/2024 at 10:00 a.m. Resident #64 was observed in bed, with the head of the bed slightly raised without any splints or braces on the upper body or hands. Both of the hands of Resident #64 were closed, fingers bent touching the palms, wrists were curved under toward the forearms. A review of the medical record for Resident #64 was conducted. The admission Record revealed Resident #64 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Acute Respiratory Failure with Hypoxia, Tracheostomy status, Gastrostomy Status, Contracture of Right Hand, Contracture of Left Hand, Persistent Vegetative State and other co-morbidities. The Minimum Data Set (MDS) assessment dated [DATE] revealed in Section G the upper extremities had impairment on both sides and the lower extremities had no impairment (bilaterally). The MDS revealed Resident #64 required total assistance with all activities of daily living (ADL) performance. The MDS dated [DATE] showed Section GG to have impairments on upper and lower extremities and did not have a restorative program marked. The physician's orders for Resident #64 showed an order initiated on 1/15/2024 for splints to bilateral hands to prevent contractures and increase range of motion daily per patient tolerance. The care plan for Resident #64 revealed a focus area for: [Resident #64] is at risk for alteration in comfort related to areas of impaired skin integrity, decreased range of motion to bilateral hands. 8/4/2022 impaired range of motion to the right elbow. 10/9/2022 impaired range of motion to the right elbow date initiated on 7/6/2022 and revised on 10/12/2022. Interventions to include: bilateral hand splints as ordered per Medical Doctor (MD). Date initiated on 9/14/2022 revised on 1/9/2024. Provide passive range of motion to bilateral upper extremities and bilateral lower extremities daily during ADL tasks. Date initiated 7/6/2022 revised on 1/9/2024. An interview was conducted with Staff W, Certified Nursing Assistant (CNA) on 2/7/2024 at 1:45 p.m. Staff W confirmed working with Resident #64 on a regular basis. Staff W, CNA stated, No, I do not do ROM for [Resident #64], Restorative does. An interview was conducted with Staff X, Occupational Therapy Assistant (OTA) on 2/7/2024 at 3:25 PM. Staff X confirmed filling in for the Director of Rehabilitation and stated the therapy department recommended residents for the Restorative Nursing Program if needed. When records were requested in regards to Resident #64, Staff X stated the rehabilitation department did not have any records for residents prior to November 2023. When the company was bought out (changed) the facility lost the ability to access the prior records. An interview was conducted with Staff Y, Occupational Therapist (OT) on 2/7/2024 at 3:30 PM. Staff Y stated there were no documents in the computer in regard to Resident #64. Staff Y stated this would mean Resident #64 was not on a Restorative Nursing Program for range of motion. An interview was conducted with Staff Z, CNA on 2/7/2024 at 3:45 p.m. Staff Z, CNA confirmed one of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 16 of 41 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 02/20/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the responsibilities assigned to her was restorative. Staff Z stated I don't see [Resident #64] anymore, I am not sure why. [Resident #64] needs splints for the hands. [Resident #64] does not have splints. I have told therapy. I think they are supposed to order them. An interview was conducted with Staff H, Registered Nurse (RN) on 2/7/2024 at 5:00 p.m. Staff H stated the Restorative Certified Nursing Assistant was the only staff who completed Range of Motion (ROM) for Resident #64. An interview was conducted with the Director of Nursing on 2/8/2024 at 9:45 a.m. The DON stated the expectation was for the physician order to be followed, the splints should be worn as ordered. The CNAs are all responsible for ROM not just restorative. An interview was conducted with the Regional Nurse Consultant on 2/7/2024 at 12:35 p.m. The Regional Nurse Consultant stated that a Policy and Procedure for Range of Motion did not exist. The facility followed standards of Care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 17 of 41 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 02/20/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services for two (Residents #245 and #45) of five residents reviewed for timely medication administration. They also failed to ensure sufficient staffing to provide call light assistance for residents based on Resident Council Meeting Minutes for two of six months reviewed. Findings included: 1. An interview was conducted on 2/6/24 at 10:57 a.m. with Resident #245. The resident stated he had not yet received his 9:00 a.m. medication. An interview was conducted on 2/6/24 at 10:58 a.m. with Staff G, LPN. Staff G confirmed 9:00 a.m. medications had not been administered to all residents in room [ROOM NUMBER]-111, including Resident #245. Staff G said she was doing her best, but she was assigned 30 residents; two of which had a wound vacuum, 3 or 4 were on IV medications, some with fall risks, some new admissions, and some residents with aphasia. She said staffing is not done based on acuity of residents; it is only based on numbers. Staff G said she was also having to share a medication cart with other nurses due to the way the assignment was divided because there are only 3 nurses working on the floor and she was just given the keys to the medication cart. An observation was conducted on 2/6/24 at 11:19 a.m. of Staff G, LPN preparing and administering medication for Resident #45. Staff G prepared Bupropion, Spironolactone, and Eliquis. The resident refused Bupropion and was administered Spironolactone and Eliquis. Reconciliation with physician orders showed all three medications were scheduled to be administered at 9:00 a.m., they were administered two hours and 19 minutes late. An interview was conducted on 2/6/24 at 12:35 p.m. with Staff H, RN. She said, It's a lot. We don't have enough nurses. Staff H confirmed staff could not get all medication and care done when it was scheduled. An interview was conducted on 2/7/24 at 2:01 p.m. with the DON. She said she knew they needed more nurses on the floor, and she was trying to get approval for another nurse. An interview was conducted on 2/8/24 at 12:37 p.m. with Staff B, LPN. She said there definitely isn't time to get everything done and they need more staff to help. Staff B said medication was regularly late. She said she was working the split assignment (assigned residents from both units) and when she was on one unit, she could not keep her eyes on the residents she had on the other unit. She said if a resident were to yell out, she would not be able to hear them. Staff B also said call bells were not answered timely by The Certified Nursing Assistance (CNA)s because they were running themselves to death and can't get to everything. An interview was conducted on 2/8/24 at 12:43 p.m. with Staff D, CNA. She said she was not able to get all of her job done, not in a timely manner anyway. She said it was hard especially when a nurse was working on the assignment split between the two units. She said the nurse would be on one unit and the CNA on the other and residents were asking for medications. Staff D confirmed it took a while for CNAs to answer call bells for residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 18 of 41 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 02/20/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) As for late medication, the DON said, I know nurses don't have time to get all the medication administered on time. She said there had been complaints and concerns from family members and the facility needed four nurses working on the medication carts. On 2/8/24 the Nursing Home Administrator (NHA) and DON confirmed there was no policy related to staffing. 2. Review of the Resident Council Minutes dated October 2023 reveals Old Business concern relating to staff hiding out in rooms on 3-11/11-7 (shifts) and dayrooms and call lights are on for a long time. Under the section New Business: ongoing issues of cell phone/ear bud usage and call lights. Review of the Resident Council Minutes dated December 2023 reveals the section New Business: ongoing issues of cell phone/ear bud usage; Certified Nursing Assistants (CNAs) not making beds when requested and call lights when staff are sitting at the nurses station. Review of the Resident Council Minutes dated January 2024 reveals the section New Business: CNAs continue to not make beds for residents when they request. During an interview on 2/8/2024 at 9:55 AM with the Resident Council President. The Resident Council President stated the concerns regarding: call lights, staff sitting around (hiding), and talking on their phones with ear buds on continues to be an ongoing issue. Review of the grievances log for January 2024 revealed nine grievances related to call lights taking longer than 20 minutes to answer, and four related to medication administration times being late. During an interview on 2/8/2024 at 12:55 PM with the NHA. The NHA stated the facility strictly staffs based on number of residents, not acuity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 19 of 41 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 02/20/2024 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 did not ensure the medication error rate was below 5% for three (Residents #79, #48, #45) out of five sampled residents who were administered medications. This resulted in seven errors from 27 medication administration opportunities for a medication error rate of 25.93%. Residents Affected - Few Findings Included: An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #79. The nurse administered the following medications: -Midodrine 2.5 mg x 1 tablet -Folic acid x 1 tablet -Glipizide XL Extended Release (ER) 5 mg x 2 tablets -Loratadine 10 mg x 1 tablet -Metoprolol 25 mg x 1 tablet Staff F, LPN did not take Resident #79's blood pressure before administering these medications. Review of Resident #79's physician orders showed an order for a multivitamin-minerals tablet to be administered at 9:00 a.m. Review of the Medication Administration Record (MAR) showed the medication was signed off but was not observed to be administered. There was a physician order, dated 12/26/23, for Metoprolol Tartrate 25 mg, 1 tablet given every 12 hours for hypertension and an order, dated 1/16/24, for Midodrine 2.5 mg, 1 tablet three times a day for hypotension; hold if systolic blood pressure is greater than 110. Staff F, LPN did not take Resident #79's blood pressure prior to administering the blood pressure medications. The resident was administered Midodrine for hypotension and Metoprolol for hypertension simultaneously. After administration Staff F, LPN asked another staff member to go take the resident's blood pressure because she was unable to check off the medication in the computer as administered without entering a blood pressure. Review of Resident #79's Weights and Vitals Summary show his blood pressure was taken at 9:31 a.m. on 2/6/24 and had a reading of 128/78, meaning the Midodrine should have been held due to the systolic blood pressure being 128 (greater than 110.) The Weights and Vitals Summary also showed the resident's blood pressure was not being taken before each administration of Midodrine to ensure the reading was within the physician outlined parameters and when it was taken his systolic blood pressure was greater than 110 from 2/1/24 through 2/7/24. Review of the MAR showed Midodrine had being administered to Resident #79 three times a day from 2/1/24-2/7/24. An observation was conducted on 2/6/24 at 9:15 a.m. of Staff F, LPN preparing and administering medication for Resident #48. The nurse administered the following medications: -Atenolol 50 mg x 2 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 20 of 41 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 02/20/2024 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 -Gemtesa 75 mg x 1 tablet Level of Harm - Minimal harm or potential for actual harm -Apixaban 5 mg x 1 tablet -Iron 325 mg x 1 tablet Residents Affected - Few -Keppra 100 mg/ml x 5 ml. -Magnesium oxide (not in the cart. Nurse said she will get a new bottle then administer) All medications were crushed and administered in pudding. Review of Resident #48's physician orders showed an order, dated 10/6/23, for Gemtesa 75 mg x 1 tablet via gastrostomy tube (g-tube) one time a day for overactive bladder and an order, dated 10/6/23, for Iron supplement oral elixir. Give alternating dose of 220 ml/5 ml via g-tube 5 ml two times a day for anemia. Staff F, LPN was observed to administer Gemtesa and Iron to Resident #48 by mouth. An interview was conducted on 2/6/24 at 4:50 p.m. with Staff F, LPN. She said Resident #48 takes medications by mouth and her g-tube and she thought that was a recent change. Staff F, LPN said she should have called the doctor to see if he wanted all the medications changed to oral. An observation was conducted on 1/6/24 at 11:19 a.m. of Staff G, LPN preparing and administering medication for Resident #45. The nurse administered the following medications: -Bupropion 75 mg x 1 tablet (resident refused) -Spironolactone 100 mg x 1 tablet -Apixaban 5 mg x 1 tablet Review of physician orders and the MAR showed these medications were scheduled to be administered at 9:00 a.m. They were administered at 11:19 a.m., 2 hours and 19 minutes after their scheduled time. The Bupropion 75 mg tablet was signed off on the MAR as given when the resident refused the medication. An interview was conducted with Staff G, LPN at the time of administration. She said she just received the keys to the medication cart due to two nurses sharing the cart and her having an assignment split between two units. The nurse said she had 30 residents assigned to her and she was not able to do her best work with that many residents. An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) She said nurses had all recently been educated on medication administration. Regarding Resident #48 she said it seemed like the nurse did not check the route of administration and the nurse should have called the physician to see if it was ok to give the medication orally. As for late medication, the DON said, I know nurses don't have time to get all the medication administered on time. She said there have been complaints and concerns from family members and the facility needs four nurses working on the medication carts. Review of a facility policy titled Medication Administration-General Guidelines, dated April 2018, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 21 of 41 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 02/20/2024 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 showed the following: Level of Harm - Minimal harm or potential for actual harm Policy Residents Affected - Few Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so, Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration.) The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures A. Preparation . 4. FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just aft the dose is prepared and the medication put away. 5. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the residence medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. . B. Administration . 2. Medications are administered in accordance with written orders of the prescriber. . 11. A schedule of routine dose administration times is established by the facility and utilized on the administration records. 12. Medications are administered within 60 minutes of scheduled time, except before, with, or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 22 of 41 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 02/20/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 23 of 41 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 02/20/2024 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interview, and policy review, the facility failed to ensure medications were stored as required for two (Residents #247 and #70) of two residents, two of two units, three of four medication carts, one of one treatment cart, and one of two medication storage rooms. Finding included: 1. An observation was conducted on 2/5/24 at 10:07 a.m. of a treatment cart on the South unit being unlocked with a resident sitting directly beside the cart. There were no nurses in view of the cart. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 10:16 a.m. of two bottles of Immune Support Supplements sitting on the bedside tray table of Resident #247. An interview was conducted with Resident #247 at that time. He said he bought the immune supplements and no staff member had ever said anything to him about them being in his room and he had not been offered somewhere to lock them up. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 10:45 a.m. of Resident #70 lying in bed. The over the bed table was half over the resident's waist, a small plastic cup was sitting on the over the bed table. In the cup was 6 pills (5 white of various shapes and sizes and one round red pill). Resident #70 stated, the nurse left them with me to take when I wanted. (Photographic Evidence Obtained) Review of Resident #70's active order summary for February 2024 revealed a no order for self-administration of medication. An observation was conducted on 2/5/24 at 4:50 p.m. of a medication cart unlocked on a resident hall on the South unit. No nurses were in view of the medication cart. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 4:52 p.m. of a medication cart unlocked in the hall next to the nurses' station on the North unit. No nurses were in view of the cart. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medications in a resident hall on the North unit. Staff F was observed dropping a medication tablet on the floor while preparing medications. She commented about dropping it but did not pick the medication up. Staff F continued down the hall completing her medication administration. The medication tablet remained on the floor outside of a resident room at 9:20 a.m. (Photographic evidence obtained.) An interview was conducted on 2/6/24 at 10:58 a.m. with Staff G, LPN. She said there were currently three nurses on the floor working and she was working an assignment split between the north and south unit. Staff G said the way the assignment was she had to share a medication cart for half of her residents with one nurse and share another medication cart with the other half of her residents with another nurse. She confirmed each cart only had one narcotic box inside and the nurses were sharing the narcotic box. Staff G said you have to have a lot of trust in your coworkers because you both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 24 of 41 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 02/20/2024 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 - Some have access to the same narcotics and narcotics counts were not done every time they each access the cart. An interview was conducted on 2/6/24 12.35 p.m. with Staff H, RN. She said nurses share a medication cart and narcotics box. She said they both use the cart during the shift and narcotics counts were only completed at the beginning and end of each shift. An observation was conducted on 2/6/24 at 1:52 p.m. of a treatment cart unlocked in a resident hall on the North unit. The cart remained unlocked at 2:23 p.m. and no nurses were in view of the cart. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 1:57 p.m. on the North unit of a medication cart unlocked near the nurses' station. At 1:59 p.m. a confused resident rolled up to the unlocked cart in his wheelchair and began messing with the cart and the trash can attached to the cart. No nurses were in view of the cart and no staff were monitoring the resident. At 2:08 p.m. the cart remained unlocked. This same resident was observed going to a medication cart that was locked and pulling on the drawers trying to open them. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 2:15 p.m. of the North unit medication storage room door propped open with a trash can blocking it from closing. No staff were at the nurses' station or in the medication storage room. Medications were observed to be in the cabinets and in the refrigerator in the medication storage room with no additional locks present. Staff F, LPN came down the hall and was interviewed about the medication storage room. She confirmed she had keys and was working on the North unit but said she did not know why the door was propped open and it should not be. (Photographic evidence obtained.) An audit was conducted on 2/6/24 at 4:33 p.m. of a north unit mediation cart shared by Staff F, LPN and Staff G, LPN. The medication cart had two loose pills in the top drawer of the cart and there were loose pills and debris under the bottom drawer of the medication cart. There was also a drawer on the cart that contained cigarettes, eyeglasses, a phone charger, and a bag with keys and miscellaneous items with the medication. The narcotics drawer contained a medication cup with pills inside, not labeled. Staff G, LPN was interviewed at that time. She said the nurses all keep the carts clean. She confirmed there should be no loose medication or items besides medication in the cart and she did not know why people used it for storage of other items. Staff G confirmed the pills in the medication cup were narcotics. She said Staff F, LPN inadvertently signed off narcotics on one of Staff G's resident's narcotic count sheet. Staff G said she is now waiting on Staff F so they can correct the error and dispose of the narcotic together. Staff G said, that is the joy of sharing a cart. (Photographic evidence obtained.) An interview was conducted on 2/6/24 at 4:3 p.m. with Staff F, LPN. She said, you've got to have a lot of faith in other nurses when sharing a narcotics box. An interview was conducted on 2/7/24 at 2:01 p.m. with the Director of Nursing (DON.) The DON said the facility had previous issues with unlocked medication carts and she still did audits. The DON said, I find the problem more than I would like to. The DON said medications should not be left in resident rooms and the nurses know better. She said the medication and treatment carts should always be locked when not in use if they had medication in them. The DON said narcotics should be counted every time the keys to the narcotics box change hands. She said when the nurses are sharing a narcotics box, both nurses need to be aware when someone pulls a narcotic out or one nurse needs to pull it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 25 of 41 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 02/20/2024 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 - Some out for the other one. The DON said she was calling the pharmacy to see about re-keying a medication cart with two narcotic drawers. She said it would be a nightmare if a drug diversion happened right now. 2. During observations on 02/05/24 at 12:40 p.m. while walking down the 200 hall towards the south wing nurses station, a resident was observed rummaging through the top drawer of a cart. Staff F, Licensed Practical Nurse (LPN) was noted to be behind the nurse's station and asked the resident what he wanted. The resident continued rummaging through the cart and said, I want a stirrer, where are all the stirrers I need one. The cart was noted to have the lock fully extended out and observation of the top drawer revealed tubes of topical creams. Staff F then proceeded to come around from behind the desk, told the resident that he could not be in the cart and then closed the top drawer and locked the cart. (Photographic evidence obtained). A interview on 02/05/24 at 12:45 p.m. with Staff F revealed she was assigned to the South wing and the cart was a treatment cart, and it was typically kept locked. She reported the facility had a treatment nurse and that she was not sure why the treatment cart was left unlocked. Observations on 02/07/24 at 11:46 a.m. of the south hall by the nurse's station revealed a treatment cart stored in the hallway in front of the nurse's station. The treatment cart was noted to have the lock open and fully extended and the second drawer down was noted to be held open with a box of sterile gauze. Topical ointments were noted to be stored in the treatment cart. Closer observation revealed a resident was seated in his wheelchair directly next to the cart. An unsuccessful attempt was made to locate a nurse on the south unit. A Certified Nursing Assistant (CNA) left the unit to find a nurse. (Photographic evidence obtained) An interview on 02/07/24 at 11:58 a.m. with Staff F revealed she had no idea why the cart was open But I can close it. She reported that she did not have keys to the treatment cart and that the treatment nurse had the key and might have left it open. An interview on 02/07/24 at 1:57 p.m. with the Director of Nursing (DON) revealed the treatment cart could be unlocked if empty, but that it should be secured if not empty. She reported staff had been trained to secure the medication and treatment carts. The DON reported she found the medication and treatment carts unsecured more than she would like to. Observations on 02/07/24 at 2:18 p.m. revealed a medication cart on South unit was noted to be unlocked. A successful attempt was made at opening the cart drawers. All drawers on the medication side were accessible. Closer observations at this time revealed a resident was mobile in his wheelchair and in close proximity to the cart. (Photographic evidence obtained) An interview on 02/07/24 at 2:22 p.m. with Staff B, LPN revealed she was assigned to the other cart on the unit and Staff F, LPN was assigned to this cart. She reported she saw Staff F leave the unit, but it was not communicated to her that she was leaving or as to where she went. She reported that the medication cart should never be left unlocked. Observations on 02/07/24 at 2:27 p.m. revealed Staff F had returned to the unit. At this time during an interview with Staff F she said, I probably forgot to close and lock it. She reported that every time you walk away from the cart it should be locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 26 of 41 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 02/20/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper diet, free of allergens, was served to one (Resident #42) of three reviewed for dietary restrictions. Findings included: An interview was conducted on 2/5/24 at 11:35 a.m. with a family member of Resident #42. The family member said Resident #42 was lactose intolerant and could not have dairy products and the facility continued to serve them to the resident. They said the resident had diarrhea when she consumed lactose products. The resident was observed to have a lunch tray with a grilled cheese sandwich. The family said they notified staff and asked them to send a different lunch for the resident. The family said they do not feel like dietary staff know what lactose is. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 11:50 a.m. of Resident #42's replacement lunch tray. The resident was sitting in a chair at her bedside eating her new lunch tray. The lunch consisted of chicken, broccoli, mashed potatoes, bread, and macaroni and cheese. The resident had eaten about half of the macaroni and cheese. She was asked if she knew what it was, and she said she didn't know. (Photographic evidence obtained.) A review of admission records showed Resident #42 was admitted on [DATE] with diagnoses including Type II Diabetes Mellitus, Protein-Calorie Malnutrition, Anemia, dysphagia, Vitamin D deficiency, and cognitive communication deficit. Resident #42's allergies included lactose intolerant. A review of medical records for Resident #42 revealed a care plan in place for Malnutrition r/t [related to] dysphagia, revised 10/11/23. Interventions included honor food preferences within meal plan and provide diet as ordered. A review of the facility's Allergy Report listed Resident #42 as being lactose intolerant at a moderate severity with the reaction listed as loose stools. A review of physician orders for Resident #42 showed an order, dated 12/29/23, for regular diet, regular texture. An interview was conducted on 2/5/24 at 4:45 p.m. with Resident #42 as she was leaving the dining room. The resident was asked what she had for dinner, and she said she had pizza. An unknown aide was walking by and confirmed the resident had eaten cheese pizza with no additional toppings. The resident nodded in agreement. An observation was conducted on 2/7/24 at 8:40 a.m. of Resident #42 finishing her breakfast. The resident was sitting in a chair at her bedside with her breakfast tray in front of her. Her plate was observed to have remnants of eggs and cheese. Her tray card showed MILK Lactaid and her diet was noted as Regular with Lactate* underneath. The tray card did not note lactose intolerance or no dairy products. For the days breakfast it said, No sub found for Cheese Omelet. (Photographic evidence obtained.) An interview was conducted on 2/7/24 at 11:38 a.m. with the Certified Dietary Manager. He said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 27 of 41 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 02/20/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents that were lactose intolerant should not get cheese on their eggs, they should only receive plain eggs. Additionally, he said if something like macaroni and cheese was being served the resident would be served an alternate item. An interview was conducted on 2/8/24 at 12:55 p.m. with Staff K, Cook. He said he served food on the serving line. He said for residents with allergies, the person working at the front of the line told him what allergies the residents had or diets they were on. He said from his understanding the person at the end of the line checked the tray cards and made sure the food was correct before putting the lid on the plate and placing the tray on the carts to be delivered. Staff K said, they are the last line of defense in the kitchen. He said they had a new company with different tray cards and the information the cards gave was pretty basic. An interview was conducted on 2/8/24 at 1:03 p.m. with Staff L, Interim Dietary Director. Staff L said the person at the front of the serving line should be letting the cook know what items residents could and could not have. Staff L reviewed Resident #42's tray card and noted it said Lactaid. He said staff should know that Lactaid meant the resident could not have milk products, but he was going to add more details to the tray card. Staff L was very surprised to hear Resident #42 had received dairy products multiple times in the last few days. He said this must have slipped through. An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) The DON said meal trays should be checked when they were loaded in the kitchen, but staff should also be verifying the diets when trays were passed to residents. She said the only reason a diet could vary was if a resident was competent and requested something. She said that was not the case with Resident #42. She said she would work with dietary to ensure they knew what someone with lactose intolerance could and could not have. Review of a facility policy titled Food Likes and Dislikes, undated, showed the following: Policy: The food likes, dislikes, allergies and intolerances of each resident are determined through a dietary assessment. Procedure: 1. A record shall be maintained of the resident's likes, dislikes, allergies, and intolerances. Such record will include how the resident prefers his/her food to be served. (i.e., cut, chopped, or ground.) 2. Residents shall be visited periodically to determine if any changes need to be made in order to meet the resident's needs. 3. Electronic database will be updated each time changes are made to the resident's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 28 of 41 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 02/20/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview and record review the facility failed to ensure that staff appropriately utilized hair restraints when preparing, distributing resident food. for 2 of 4 (Staff K, Staff M) staff working on the food tray-line. Findings included: On 02/07/24 at 11:20 AM at the time of the Comprehensive Tour of the kitchen and Tray line observations Staff N, Interim Dietary Manager approached Staff K, cook and whispered to him. The cook was observed to have facial hair around his mouth and chin with no hair restraint in place. The cook left the tray-line and returned after 3 minutes with a hair restraint covering his mouth and chin. Interview at this time with Staff K, [NAME] revealed that his face was uncovered and that he was directed by the dietary manager to cover the hair on his face. The staff person reported that he was not aware that he was supposed to keep his facial hair covered. Observations on 02/07/24 at 11:28 AM revealed that Staff M, Dietary Aide entered the kitchen and was noted with a hair net covering her head. Closer observations revealed that Staff M had a braided ponytail that extended down below her buttocks, which was not covered by the hair net on the top of her hair. Interview with the Dietary Manager revealed that all her hair should be up in the hair net, and should not be exposed. At this time the Dietary Manager directed Staff M to cover her hair. The aide was observed to place the ponytail up in a bun and then cover her head with the hairnet. Review of the facilities undated policy titled Hair Restraints/Jewelry/Nail Polish revealed the following: Food & nutrition services employees shall wear hair restraints and beard guards. Hairnet, hat or hair restraint will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 29 of 41 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 02/20/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and interview, the facility failed to dispose of garbage appropriately for two of two (In front of kitchen door, to the right of kitchen door) outside dumpster areas. Residents Affected - Many Findings included: Observations on 02/05/24 at 10:11 a.m., during the initial tour of the kitchen, an inspection of the dumpster area was conducted and the following was noted. -A green dumpster was noted in the rear parking area directly in front of the kitchen door. The dumpster lip was noted to be partially open and exposing the garbage inside, additionally there were crates and debris noted to be stored on the side and back of the dumpster wall. (Photographic evidence obtained) -A blue dumpster was noted in the far right corner of the rear parking lot. It was noted that there were two mattresses stored next to the dumpster. Additionally debris was noted on the ground in front of the dumpster. At this time, an interview with the Staff N, Interim Dietary Manager revealed these dumpster areas were used by the entire building and the area should be kept clean. (Photographic evidence obtained) Review of the undated facility policy titled Trash Handling revealed the following: -5. Outside dumpsters and the surrounding area are to kept clean and free of debris. -6. Dumpster doors should remain closed. This includes the dumpster and enclosed dumpster area doors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 30 of 41 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 02/20/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, facility did not ensure there was a communication plan between hospice providers and the facility for two (Residents #50 and #247) of three reviewed for hospice services. Finding included: A review of admission records showed Resident #50 was admitted on [DATE] with diagnoses including Dementia, Type II Diabetes Mellitus, chronic pulmonary edema, brief psychotic disorder, and major depressive disorder. A review of Resident #50's physician orders showed an order, dated 1/29/24, for Hospice Order: [Company] admitting diagnosis Senial [sic] Degeneration of brain. An interview was conducted on 2/7/24 with the Director of Nursing (DON). She stated Resident #50 was currently receiving hospice services. An interview was conducted on 2/7/24 at 4:20 p.m. with Staff B, Licensed Practical Nurse (LPN) after not being able to locate a hospice communication book for Resident #50. Staff B said she was the nurse assigned to Resident #50 and he was not on hospice services. The Assistant Director of Nursing (ADON) joined the interview and stated she did not believe Resident #50 was on hospice services. The ADON checked the hospice binder where she said all hospice communication was kept, and there was no paperwork for Resident #50. The ADON reviewed Resident #50's electronic medical record and confirmed there was a hospice order in place. The ADON said she did not see any notes in the computer regarding hospice and they should be there. Staff were unable to locate a hospice care plan, hospice communication sheets, hospice team contact information, or a hospice care plan for Resident #50. An interview was conducted on 2/7/24 at 4:25 p.m. with the DON. She said generally items like hospice were discussed at the morning meetings. The DON reviewed Resident #50's medical record and confirmed the order for hospice was in place, but she did not know where it came from. She determined Staff I, Registered Nurse (RN)/Unit Manager (UM) put the order in the computer. An interview was conducted on 2/7/24 at 4:34 p.m. with Staff I, RN/UM. Staff I said Resident #50's wife had spoken to the resident's doctor because apparently the resident had been on hospice prior to being admitted to the facility. Staff I said the facility had been unaware because nothing from the hospital discharge paperwork noted the resident was receiving hospice services. After Staff I spoke with the wife and doctor, the order for hospice services was entered. She said hospice had been coming to see Resident #50, providing care and showers. Staff I said there should be hospice notes and a hospice care plan from the hospice providers. An interview was conducted on 2/7/24 at 4:49 p.m. with the ADON. She said she called and spoke to Resident #50's hospice nurse. The hospice nurse told the ADON she had emailed all of her notes to the email that had been provided to her, which was the business office email. The ADON said she gave the hospice nurse her email to send past and future notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 31 of 41 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 02/20/2024 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 0849 The business office manager was out and unavailable for interview. Level of Harm - Minimal harm or potential for actual harm A review of Hospice notes for Resident #50 showed hospice care began on 12/8/23. Residents Affected - Some A review of admission records showed Resident #247 was admitted on [DATE] with diagnoses including fracture of part of neck of right femur, malignant neoplasm of prostate, and secondary malignant neoplasm of bone. Review of Resident #247's physician orders showed an order, dated 1/23/24 for Hospice admitting diagnosis: Malignant Neoplasm Prostate. An interview was conducted on 2/7/24 at 1:26 p.m. with Staff B, LPN. She confirmed she was the nurse for Resident #247 and he did receive hospice services. When asked where the hospice notes and care plan were, Staff B said they should be in the hospice book at the nurses' station. She was observed looking for Resident #247's hospice information and was unable to find it. Staff B said she had no idea where the information was and she would have to ask the Unit Manager. An interview was conducted on 2/7/24 at 1:29 p.m. with Staff I, RN/UM. She reviewed Resident #247's medical record and said she did not see any hospice notes. She confirmed the facility should have the resident's hospice notes and care plan. Staff I then stated the hospice company did not give them a book and she would have to call them. Staff I was observed going to Staff C, Minimum Data Set (MDS) Coordinator and asking her where the hospice information would be and Staff C said she did not know. Staff C checked Resident #247's medical record and was unable to find any hospice notes. She said, that's not good, I will have to ask. Staff I and Staff C were observed proceeding to the admissions office and asking the Admissions Director where Resident #247's hospice paperwork would be and the Admissions Director stated she would call the hospice company. Staff I confirmed hospice had been seeing the resident and Staff C confirmed there were no hospice notes or care plan in the resident's medical record. An interview was conducted on 2/7/24 at 1:40 p.m. with the DON. She said sometimes hospice documentation is in the electronic record and sometimes in the hospice binder. She said she had not worked with Resident #247's hospice provider before and they had not asked her for computer access, therefore the documents should be in a binder at the nurses' station. A follow-up interview was conducted on 2/7/24 at 1:49 p.m. with Staff B, LPN. She said if something happened with Resident #247 she would not know which hospice team to contact or how to get ahold of them. She said, it is pretty important to be able to reach the hospice team if needed. An interview was conducted on 2/7/24 at 3:03 p.m. with Resident #247's hospice nurse. She said she did any paperwork the facility requested and they had not asked for anything. She said she had faxed her notes to the facility twice a week and had also sent them the resident's hospice care plan. The hospice nurse pulled up her computer records and showed her fax confirmation on 1/17/24 and 1/31/24. The hospice nurse said she knew she had the correct fax number, due to the facility receiving prescriptions she had faxed to the same number. The hospice nurse said when she came to see Resident #247 she would speak with the nurse assigned to the resident. She also said the resident had developed a rash two days prior and the facility did not notify her. She said had she known, she would have come and assessed the resident at that time. The hospice nurse said Resident #247 appeared to have shingles. She said she notified the facility to put him on precautions and treatment started. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 32 of 41 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 02/20/2024 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 0849 Review of a facility policy titled Hospice Care, revised 9/20/17, showed the following: Level of Harm - Minimal harm or potential for actual harm Policy Residents Affected - Some The center supports the patient/resident's rights to a dignified existence and self determination. The center will assist the patient/resident and/or legal representative in arranging hospice services. Procedure . When hospice are provided in the center, the center should meet the following: -The center will furnish 24 hour room and board, and meet the patient/resident's personal and nursing care needs in coordination with hospice based on the patient/resident's individual plan of care. . To ensure continuity of care between the center and the hospice provider, the Director of Nursing will designate a clinical member of the interdisciplinary team to work with the hospice including the following: -Coordination of care plan process between the hospice and the center -Communication with hospice representatives, hospice medical director and the patient/resident's attending physician to ensure coordination of care. -Ensure the following information is obtained from the hospice: -Most recent hospice plan of care -Hospice election form -Physician certification and recertification of the terminal illness. -Names and contact information for hospice personnel involved in the care of the patient/resident(s). -How to access hospice's 24 hour on call system. -Medication information for the patient/resident(s). -Hospice physician and attending physician orders for the patient/resident(s). -Provide education to the hospice staff on the center policies and procedures, including: resident rights, documentation and forms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 33 of 41 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 02/20/2024 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 0849 -The center will ensure the care plan includes the most current hospice plan of care and the center's plan to attain or maintain the patient/resident's highest practicable physical, mental and psychosocial well-being. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 34 of 41 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 02/20/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observations, interviews, record review, facility policy review, and plan of correction review, the facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a recertification and complaint survey conducted on 2/5/24 through 2/21/2024 and was cited F761. On 4/2/2024 the facility was recited F761. The facility had developed a Plan of Correction with a completion date 3/21/2024. Findings included: Review of the facility's plan of correction revealed: On 3-12-24 the Director of Nursing and/or Designee in-serviced licensed nursing staff on storage of medications and biologicals in medication carts, treatment carts, & medication rooms Any newly hired licensed nursing staff and/or any agency licensed nursing staff will be in-serviced on storage of medications and biologicals in medication carts, treatment carts, &medication rooms. The Director of nursing and/ or designee will complete an audit of the facilities medication/treatment carts, the medication rooms and resident rooms weekly for 4 weeks to ensure that medications and biologicals are stored in accordance to federal and state laws, then every other week until the QAPI [Quality Assurance Performance Improvement] committee determines that the facility is in substantial compliance with this regulation. 2. The findings of the audits will be reported in the monthly Quality Assurance Performance Improvement Committee meeting until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the QAPI committee. During the revisit survey on 4/2/24, the facility failed to ensure medications and biologicals were stored as required for three (100, 200, and 300) of four medication carts, and one (North Unit) of two medication storage rooms. A medication storage observation was conducted on 4/2/24 at 9:55 a.m. of the 100-hallway medication cart. The medication cart was observed to have 2 open insulin strip bottles in the top drawer and there was no open date labeled on the two insulin strip bottles. An interview was conducted at the time of the observation with Staff A Licensed Practical Nurse (LPN). She said the insulin strip bottles should be labeled with the open date on it because they are only good for 90 days after opening. A medication storage observation was conducted on 4/2/24 at 10:03 a.m. of the 200-hallway medication cart. The bottom drawer handles were observed to be rigid, with a rust-like color to them. There was one loose pink pill in the bottom drawer. The bottom two drawers of the medication cart were overflowing over the dividers with items such as, three glucometers, a sleeve of Styrofoam cups, a sleeve of plastic cups, earwax softener drops, ace wraps, three fingernail scrub brushes, nail clippers, nail file, three bags of resident labeled intravenous (IV) medications sitting inside a box of Safety Pen needles with intravenous medications tubing. In the same section as the three-resident labeled IV medication bags there was a drug buster bottle with a blackish brown substance along the side of the bottle and under the cap. In the same drawer, the divided section next to drug buster bottle there was a blackish, brownish substance covering the bottom of the drawer with a Styrofoam cup of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 35 of 41 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 02/20/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few individually packaged disposable syringes sitting on top of the substance. There was a plastic cup with a piece of folded cloth in it. An interview was conducted at the time of the observation with Staff B, LPN she said night shift is supposed to clean the medication carts. She said the glucometers in the bottom drawers were not being used and the medication cart should be cleaned, she was observed to discard items located in the bottom two drawers and when she discarded the plastic cup with the folded cloth in it, she said This looks like it's something for a wound dressing. She removed the loose pill and placed it in the drug buster bottle and said This looks like Eliquis. A medication storage observation was conducted on 4/2/24 at 10:34 a.m. of the 400-hallway medication cart. The top drawer of the medication cart was observed to have one Lantus insulin pen and one Basaglar insulin pen, both insulin pens were observed to be lying on top of a resident labeled pharmacy bag. An interview was conducted at the time of the observation with Staff C, Registered Nurse (RN). He confirmed the Basaglar insulin pen did not have a resident name or pharmacy drug label on it. He also said the Lantus insulin pen should be in the pharmacy labeled bag. He compared the pharmacy label located on the Lantus pen and the Lantus Pharmacy label on the bag, he confirmed it was for the same resident and the same medication, and placed the Lantus in the bag and discarded the Basaglar insulin pen. Staff C, RN said he received education recently that every medication is to be labeled with an open date and if it is a medication from the pharmacy and has a bag it should be stored in the pharmacy labeled bag. A medication storage observation was conducted on 4/2/24 at 10:25 a.m. of the North unit medication room. The side of the resident medication storage refrigerator was observed to have rigid and rust-like color to it, resident medication was observed to be in the refrigerator. In the bottom cabinet of the medication storage room, there was a full enteral nutrition bottle and a resident labeled medication bottle sitting next to a Ant & Roach spray bottle. An interview was conducted at the time of observation with Staff D, LPN. She was asked about the eternal nutritional bottle and the resident medication bottle being next to the Ant & Roach spray bottle and she said oh yeah. I don't know why that's there. then Staff D, LPN walked out of the medication room. An observation was conducted with the Director of Nursing (DON) on 4/2/24 at 1:06 p.m. of the 300-hallway medication cart handles. The handles of the medication cart were observed to be rigid and have a rust-like color to them. She confirmed the medication cart handles were worn and some of the handles felt rigid. An interview was conducted on 4/2/24 at 1:10 p.m. with the Director of Nursing (DON) she confirmed medications should be labeled and in the pharmacy labeled bag. She said the medication carts should be clean and items should be separated and not stacked on top of each other. She said the third shift is supposed to clean the medication carts but if something is spilled then that nurse should clean up the spill. An observation was conducted of the North unit medication room with the DON at this time. The DON observed the enteral nutrition bottle and a resident medication bottle next to the a Ant & Roach Spray bottle. The DON said the enteral nutritional bottle should not be in the medication room, it's not stored in this room. She also said she does not know where the ant and roach spray bottle came from. She discarded the enteral nutrition bottle, the resident medication, and the ant and roach spray bottle into the trash can. She also observed the refrigerator in the medication room, with resident medication in it and confirmed the refrigerator was rusted along the outside of it. An interview was conducted on 4/2/24 at 1:38 p.m. with the DON. She said all four medication carts needed new handles. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 36 of 41 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 02/20/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 4/2/24 at 4:42 p.m. with the DON. She said, IV medications should be stored in the medication rooms and the nurse should obtain the medication when it's time to administer it. She said the medication carts should be clean and there should not be miscellaneous items stored with resident medications. A phone interview was conducted on 4/2/24 at 4:04 p.m. with the facility's Pharmacy Consultant. She said, the purpose of a clean medication cart is contamination of medications so if the medication is in a bag or not directly touching miscellaneous items then it is not being contaminated. She said she would like to see the medication carts clean and organized but there is not a regulation for organization. She said insulin pens should be stored with the label. She said the unlabeled insulin pen was probably an emergency use pen and that was why it didn't have a label on it. But it should not be in the medication cart if there was no label. She said resident medications should not be stored with ant and roach spray. She said the pharmacy is ordering new handles for the medication carts and I'm not sure yet when they are coming but brand-new handles are being delivered. Review of the back of the insulin strip bottle revealed Use within 90 days (3 months) of first opening. Review of the facility's Medication Storage In the Facility policy dated April 2018, revealed: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: .C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. .G. Potentially harmful substances such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants are clearly identified and stored in a locked area separately from medications. .I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. .Infusion Therapy Storage and Labeling .E. Facility should assure that the infusion therapy product storage area is kept clean and free of clutter. .Expiration Dating (Beyond-use dating) .C. Certain medications or package types, such as .blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 37 of 41 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 02/20/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration .The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating . Review of the facility's Quality Assurance Performance Improvement Program (QAPI) revised on 10/24/22. Policy: The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Procedure: Program Design and Scope 1. The center's QAPI is on-going comprehensive review of care and services provided to residents. Including but not limited to: .d. Pharmacy Services .Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a) Implementation b) Identify priorities c) Ensures adequate resources d) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities e) Ensures corrective actions are implemented to address identified problems in systems f) Evaluates the effectiveness of actions g) Establishes expectations for safety, quality, rights and choice and respect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 38 of 41 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 02/20/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and policy review, the facility did not ensure proper infection control practices for two out of two units related to staff not using personal protective equipment (PPE), staff not knowing isolation precaution procedures, and uncovered oxygen equipment. Residents Affected - Many Findings included: An observation was conducted on 2/5/24 at 9:55 a.m. of multiple rooms on the 400 unit with Enhanced Barrier Precaution signs. Some rooms had contact and enhanced barrier signs. At that time, an interview was conducted with Staff Q, Registered Nurse (RN.) Staff Q said she did not know why some rooms had both signs. She said with enhanced barrier precautions, staff should wear a gown at all times, but no mask and with contact precautions, staff should wear gown, gloves, and mask. An observation was conducted on 2/5/24 at 9:58 a.m. of Staff S, Certified Nursing Assistant (CNA.) entering room [ROOM NUMBER], which had an enhanced barrier precaution sign on the door. Staff S had gloves on but no gown. She pulled the curtain around the resident's bed and proceeded to change the resident's colostomy bag. An interview was conducted with Staff S at that time. She said she felt like a lot of rooms had signs that do not need isolation precautions. She said staff see it so often and do not pay attention. Staff S confirmed she did not put on a gown to change the wafer on the resident's colostomy bag and added that she did not put on a gown for most of the rooms on the 400 unit. She said she did not believe they were really on isolation. An observation was conducted on 2/5/24 at 10:03 a.m. of a staff member providing care to a resident in room [ROOM NUMBER] with no PPE on. The room was posted as being on contact precautions. (Photographic evidence obtained.) An observation as conducted on 2/5/24 at 10:11 a.m. of Staff U, Housekeeper pushing a large gray trash can with a plastic liner enter room [ROOM NUMBER] with no gown or gloves. She opened and closed drawers in the room then exited without performing hand hygiene prior to entering room [ROOM NUMBER] with no gown or gloves. Staff U then entered room [ROOM NUMBER] without performing hand hygiene, opened and closed drawers then put gloves on and removed towels and placed them in a plastic bag in the gray trash can. She proceeded to remove her gloves and walk down the hall to dispose of them, went back to the gray trash can and pushed it to room [ROOM NUMBER] and entered the room without performing hand hygiene and began opening drawers. An interview was conducted with Staff U with help of an interpreter. Staff U said the signs on the doors meant staff needed to wear PPE. She confirmed she did not wear gloves in the rooms until she needed to remove towels from the one room. She said she used hand sanitizer in the rooms, but it dried quickly on her hands. An observation was conducted on 2/5/24 at 10:16 a.m. of a continuous positive airway pressure (CPAP) mask lying on a wheelchair uncovered in room [ROOM NUMBER]. The mask remained uncovered on 2/6 and 2/7/24. (Photographic evidence obtained.) An interview was conducted on 2/5/24 at 10:30 a.m. with Staff T, CNA regarding isolation precautions. She said enhanced barrier precautions meant staff should wear gloves all of the time and contact precautions means staff should wear a mask all of the time. An interview was conducted on 2/5/24 at 10:50 a.m. with Staff Q, RN. She said she just put a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 39 of 41 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 02/20/2024 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 - Many precaution sign up on room [ROOM NUMBER] due to the resident being COVID + and not having a sign on the door. She said the resident should have been on droplet precautions. An interview was conducted on 2/5/24 at 10:55 a.m. with Staff V, Licensed Practical Nurse (LPN). Staff V said enhanced barrier was just a fancy word for contact precautions and there was no real difference between the two. An observation was conducted on 2/5/24 at 11:51 a.m. of lunch trays being delivered to residents. Staff W, CNA was observed entering room [ROOM NUMBER] with a gown on but no gloves on to deliver a lunch tray. She moved the over bed table, uncovered the food, and opened the curtains. She then exited the room and walked across the hall to the trash bin where she removed her gown. Staff W then walked to the PPE cart, removed another gown, and put in on, picked up another tray and entered room [ROOM NUMBER] with no gloves on. She proceeded to move the table and set up the resident's tray, exited room and removed gown, then walked down the hall with the gown in her hand to dispose of it. She then used hand sanitizer. An interview was conducted with Staff W at that time. She said enhanced barrier precautions means you have to wear a gown but not gloves. Staff W said she used hand sanitizer when entering and exiting each room. An observation was conducted on 2/6/24 at 8:58 a.m. of a personal cell phone observed on top of a medication cart. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 9:01 a.m. of Staff O, Registered Nurse, (RN) entering room [ROOM NUMBER], which had a contact precaution sign on the door, without donning PPE. At 9:04 a.m. Staff P, Certified Nursing Assistance (CNA) entered the same room to pick up a food tray with no PPE on. An interview was conducted on 2/6/24 at 9:05 a.m. with Staff O, RN, Staff P, CNA and Staff F, Licensed Practical Nurse (LPN.) When asked if they knew the resident was on contact precautions, they all said they were aware. Staff F, LPN spoke up and said the reason the resident was on precautions was bacteria in the urine and since they had a catheter it was contained, and they did not need to wear PPE. Staff O, and Staff P agreed. When asked if the resident had an order for contact precautions, should it be followed and Staff F, LPN agreed it should. An interview was conducted on 2/6/24 at 10:00 a.m. with Staff F, LPN. Staff F said with contact precautions staff should wear a gown and gloves and with enhanced barrier precautions she thought staff might have to wear a face shield all the time. Staff F said she did not know why a room would have both contact and enhanced barrier precaution signs. An interview was conducted on 2/6/24 at 10:10 a.m. with the Director of Nursing (DON.) She said when staff were caring for a resident on enhanced barrier precautions, they should wear a gown and gloves, but if they are just going to drop something off in the room and not touch anything they do not have to wear any PPE. The DON said if there were multiple types of precaution signs on a room staff would go with the highest level of precautions posted. The DON said all staff had been educated on precautions and she would expect them to know the information. An observation was conducted on 2/7/24 at 9:30 a.m. of Staff AA, CNA entering room [ROOM NUMBER], with posted droplet precautions, with no gown or mask, only donning gloves. An interview was conducted with Staff AA at that time. He said, oh the sign is just up. Doesn't mean anything. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 40 of 41 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 02/20/2024 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 - Many An observation was conducted on 2/7/24 at 1:33 p.m. of a pudding cup, used for medication administration, sitting open and uncovered on the medication cart in the north unit. (Photographic evidence obtained.) An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) She said if a resident had a diagnosis that warranted isolation, they notified the doctor to get orders and implement isolation. She said the resident was care planned for isolation, so the aides were also aware. Then signage and PPE was placed at the resident's door. The DON said even if the sign was not on the door, the CNAs should have known from their task list. The DON said she knew there were infection control concerns. She said nurses knew not to keep personal items on the medication carts but they choose not to listen. The DON said all oxygen equipment such as CPAP masks should be stored in a plastic bag and not left uncovered. She said unfortunately I am aware this happens. Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions dated at the bottom of the page revised October 2018. Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; Arrives for admission with symptoms of an infection; Or has a laboratory confirmed infection; And is at risk of transmitting the infection to other residents. Policy interpretation and implementation: 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status 3. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions.5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart, so the personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precautions, instructions for use of personal protective equipment (PPE), and/or instructions to see a nurse before entering the room. b. Signs and notification comply with the residents right to confidentiality or privacy. Contact Precautions: . 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While caring for residents, staff will change gloves after having contact with infected material, (for example fecal material and wound drainage). b. Gloves will be removed, and hand hygiene performed before leaving the room. c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions: 3. Masks will be worn when entering the room. 4. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 41 of 41