Health inspection·September 30, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on with her patients. She said she is at the facility at least twice a week, and no one had informed her about the medication incident. On 09/30/2025 at 4:20 p.m., an interview was conducted with The Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). The RNC said they don't have a policy specific to medication errors and notification to the provider. She said notifications for medication errors are considered a change in condition and should fall under those guidelines. Review of the facility policy titled, Notification of Change in Condition, Revision Date 12/16/2020 revealed, Policy: The Center to promptly notify the patient/ resident, the attending physician, and the resident representative when there is a change in the status or condition. Event ID: Facility ID: 105644 If continuation sheet Page 2 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to the administration of Vancomycin. The facility failed to obtain and follow physician orders for Vancomycin laboratory services, and failed to report laboratory results to the physician and pharmacy for one resident (#2) of two residents sampled.Findings included: Resident #2 was admitted to the facility on [DATE] and discharged on 07/25/2025. Review of the admission Record showed diagnoses included but not limited to cellulitis of right lower limb and left lower limb, non-pressure chronic ulcer of left calf with fat layer exposed, non-pressure chronic ulcer right calf, diabetes, polyneuropathy, Chronic Obstructive Pulmonary Disease (COPD), muscle weakness, hypertension, encounter for therapeutic drug level monitoring, end stage renal disease (ESRD), anemia, edema, peripheral vascular disease (PVD), gastrostomy, myocardial infarction, and Methicillin-resistant Staphylococcus aureus (MRSA). Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, meaning cognitively intact. Section GG, Functional Abilities showed the resident required substantial/ maximal assistance for toileting and shower and bathing. Review of the physician orders showed the following orders:Vancomycin HCl in Normal Saline (NaCl) Intravenous Solution 1.25-0.9 GM (gram)/250ML (milliliter)-% every 18 hours for bilateral lower extremities (BLE) infected wound for 14 days as of 6/17/25 to 07/01/25Vancomycin HCl in NaCl Intravenous Solution 1.25-0.9 GM/250ML-% in the morning for BLE (bilateral lower extremity) Infected wound from 07/08/2025 starting 07/09/25Pharmacy to dose Vanco as of 06/18/25Pharmacy to dose Vanco as of 07/21/25Pharmacy to dose Vanco as of 07/09/25Complete Blood Count (CBC) with differential (diff), Comprehensive Panel (CMP) ordered on 06/18/25 for 06/18/25Basic Metabolic Panel (BMP), Vancomycin Pre-dose (trough), sed rate (Erythrocyte sedimentation rate which monitors inflammation and infection) for 06/18/25Vancomycin pre-dose (trough), BMP ordered 06/19/25 for 06/23/25Vancomycin pre-dose (trough), sed rate, CMP, CBC with diff, hemoglobin A1C ordered 06/18/25 for 06/26/25Vancomycin pre-dose (trough), sed rate, CMP, CBC with diff, A1C ordered 06/18/25 for 06/27/25Vancomycin pre-dose (trough), sed rate, CMP ordered on 06/18/25 for 07/03/25Vancomycin Random ordered 07/14/25 for 07/14/25CBC with diff, CMP, sed rate, CRP Quantitative, Vancomycin random ordered on 07/14/25CBC with diff, CMP, sed rate, CRP (C-reactive protein) Quantitative, Vancomycin random as of 07/21/25Vancomycin pre-dose (trough) ordered on 07/23/25 for 07/24/25Vancomycin Random ordered 07/24/25 for 07/25/25BMP for 07/24/25Ok to transfer to ER (emergency room) per Infectious Disease (ID) Medical Doctor (MD) on 07/25/25 Review of Inpatient consult to Care Management dated 06/10/25 showed to perform CBC, BMP every Monday and Thursday. Vancomycin trough every Monday. Review of a handwritten script from the ID physician dated 07/07/25 showed CBC, CMP, UT or VT, ESR, CRP on Mondays and CBC, BMP on Thursdays and fax results to ID physician. Review of the Medication Administration Record (MAR) for June 2025 showed:Vancomycin HCL in NaCL Intravenous Solution 1.25-0.9 gm/250 ml every 18 hours for LLE (left lower extremity) infected wound for 14 days as of 06/17/25 discontinued on 06/19/25 administered on 06/17/25 to 06/19/25.Vancomycin HCL in NaCL Intravenous Solution 1.25-0.9 gm/250 ml in the morning for BLE infected wound as of 06/20/25 until 07/01/25 administered 06/20/25 to 06/27/25; on hold for 06/28/25 and 06/29/25; administered on 06/30/25. Review of the Medication Administration Record (MAR) for July 2025 showed:Vancomycin HCL in NaCL Intravenous Solution 1.25-0.9 gm/250 ml in the morning for BLE infected wound as of 07/09/25 until 07/24/25 administered 07/09/25 through 07/16/25; 07/17/25 dose was not administered; administered 07/18/25 to 07/21/25; 07/22/25 dose was not administered and the 07/23/25 was administered. Review of Lab Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 3 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few results showed06/18/25 showed Vancomycin random was 14.7 (trough 10-20 ug/ml); (peak 18-40 ug/ml)06/19/25 showed Vancomycin trough was 27.8; sed rate of 82 (0-20)06/23/25 showed unable to obtain06/26/25 showed unable to obtain06/27/25 showed unable to obtain06/30/25 showed Vancomycin trough was 27.6; sed rate of 4607/03/25 showed vancomycin trough of 14.5; no sed rate; (after medications were stopped on 07/01/25)07/14/25 showed sed rate of 102 (Vanco trough not performed)07/21/25 showed sed rate of 121 (Vanco trough not performed)07/24/25 showed Vancomycin trough 33.907/25/25 showed Vancomycin random 32.6 Review of the physician and nursing progress notes showed:On 06/18/25, Resident new admit to facility, resident admitted on IV antibiotics Cefepime and Vancomycin until 07/01/25 for wound infection. Resident has history of ESBL (Extended - Spectrum Beta-Lactamase), active MRSA in right lower extremity (RLE) and positive for C. Auris. Resident educated on contact precautions and isolation.On 06/19/25, initial note Staff B, Nurse Practitioner (NP) showed his was a [AGE] year-old male with history of PAD (Peripheral Artery Disease) who presented with worsening wound on LE (lower extremity) to the hospital. Vascular surgery was consulted. Patient underwent excisional debridement of bilateral legs. Cultures done and grew gram-negative rod. ID consulted. Patient managed at the hospital with ABX (antibiotics), then once stable, was discharged to SNF (Skilled Nursing Facility) with IV Vancomycin, Cefepime and metronidazole. Now remains at SNF for continued IV ABX, wound care management and therapy services. Labs reviewed, 06/18/25 results.On 06/19/25 the Vanco trough: 27.l8, results relayed to the pharmacy, recommendations received to continue same dose of Vanco 1.25 at 6 a.m. q(every) 24 hrs (hours) instead of q18hrs, repeat Vanco trough on 6/23/25 30 mins prior to administration.On 06/21/25, Staff C, NP, initial note. An extensive chart review was completed and included a review of eh initial chief complaint, progress notes, vital signs, lab results, diagnostic results, therapy evaluation, consultations, and medication reconciliation. Pharmacy to dose (Vancomycin).On 06/23/25, The Vanco Though lab ( [SIC] trough) did not collect; the lab tech was not able to draw blood from the resident; writer and the nurse to try over again, it could not.On 06/24/25 late entry, Primary Provider MD note, history and physical. The patient is currently receiving wound care and antibiotic treatment, including Flagyl, cefepime, and Vancomycin, scheduled July 1, 2025, with weekly labs. Has a poor treatment adherence. Vancomycin level 27.8. Medications and labs reviewed. Pharmacy to dose Vancomycin. Obtain weekly labs.On 06/25/25, received call from ID office with follow-up appointment on 07/07/25.On 06/26/25 at 6:30 a.m., nursing note showed lab technician, DON (Director of Nursing) and writer tried to collect resident sample, but it was not possible. Lab will send another technician but at 8 a.m.On 06/26/25 late entry, Primary Provider MD note, Multiple complaints from staff about poor compliance with treatment. He refuses to elevate his lower extremities during the day and when not in therapy he was on the smoking patio. Tolerating IV antibiotics well. Wounds not improving. Plan: Medications reviewed. Pharmacy to dose Vancomycin. Weekly labs.On 06/27/25 nursing progress note showed, Vanco is on hold per MD order.On 06/27/25, Staff B, NP note showed patient seen today. No labs today. Pharmacy to dose.On 06/30/25, late entry, Primary Provider MD note, no acute changes in condition. He will complete antibiotics tomorrow and ID follow-up is scheduled for 07/07/25. Plan to continue current treatment.On 07/02/25 Primary Provider MD note, participating in therapy. Medications reviewed. Infectious disease follow-up on 07/07/25. Antibiotics completed.On 07/09/25, Infectious Disease by MD order to restart Vancomycin the same dose and start Zosyn 4.5 gm every 8 hours. CBC, CMP, UT, ESR, CRP every Monday and CBC, BMP every Thursday. Fax results to ID MD. Primary Provider MD notified.On 07/09/25, late entry, Primary Provider MD note, Patient came back from ID follow-up with new orders to continue antibiotics. He will be on Vancomycin 1. 25 grams daily and Zosyn 3.375 every 6 hours. No stop date given but he will need follow-up in 2 weeks. Weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 4 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few labs. Patient still poorly compliant with recommendations to elevate lower extremities. Instead, he spent all day on the patio in his wheelchair in high temperatures. Wounds not improving. Plan: medication reviewed. Vancomycin 1.25 g IV daily. Pharmacy to dose Vanco. Labs weekly and fax results to ID.On 07/09/2025 2:48 p.m. DON and Primary Provider MD present during wound care. Aware of wound condition.On 07/11/25, late entry - pharmacy follow up. Medications and labs reviewed. Vancomycin 1.25 g IV daily. We need a stop date from ID. Pharmacy to dose Vanco. Labs in a.m.On 07/22/25 at 6:34 a.m. on- call MD was notified that a new prescription for the antibiotic (Vancomycin 1.25 gram) was needed. She said she would call after 8 a.m. so the person on-call could send the prescription. She would follow up with the next shift.On 07/22/25 at 7:47 p.m. Staff B, NP progress note showed met with patient today. He continues treatment with Vancomycin for lower extremity cellulitis, with close monitoring of response. Continue Vancomycin IV in the morning. Pharmacy to dose Vanco. Next labs are pending. Continue Vancomycin. Pharmacy to dose Vanco.On 07/24/25 at 7:37 a.m., The pharmacy was calling. Resident was without a vancomycin dose for this morning. Pharmacist was informed medication was on hold due to vancomycin trough. They (pharmacy) stated they sent a fax on 07/17/25 because they don't have the results (Vanco trough). Vancomycin trough was drawn this morning. Oncoming nurse was informed about the situation. Pharmacy requested the result to send the medication back to the facility.On 07/24/25 Primary Provider MD note, showed I was notified by nurse about critical Vanco level 33.9. I gave orders to discontinue Vancomycin and wrote an order for BMP in am. Nurse called ID office. Vancomycin last day was 07/21/25 and he missed his follow up appointment (ID MD). New appointment for 07/29/25 was scheduled. Nurse also received orders from pharmacy for random Vanco level in a.m. and BMP.On 07/24/25 showed pharmacy & MD advised writer to discontinue Vanco. Vanco end date was 07/21/25. All labs were faxed to the ID office. The resident had an appointment with ID on 07/29/25. Resident's Vanco was Discontinued due to HIGH trough. Primary provider MD notified of situation.On 07/25/25, Primary Provider MD note, we received a call from ID earlier today with request to transfer patient to local hospital for continuation of care. Wounds seen by wound specialist and dressed this morning. Wounds continue to get worse. Transportation pending per patient request for a smoking break before he leaves. Vancomycin toxicity.On 07/25/25, Change in Condition showed send to ER.On 07/25/25, ID assistant called the writer and instructed the writer to send the resident to local hospital due to abnormal lab results. The resident was advised and sent to the ER. The resident's family was notified of the transfer and situation. Review of the care plans showedResident had infection of the BLE cellulitis, MRSA, Morganella, Enterobacter, C. Auris as of 06/18/2025. Interventions included but not limited to administer antibiotics as per MD orders.Resident had anemia as of 06/18/2025. Interventions included but not limited to obtain and monitor lab/diagnostic work as orders. Report results to MD and follow up as indicated.Resident was at risk for malnutrition related to cellulitis, diabetes, COPD, ESRD, anemia, anxiety, bipolar disorder, hypertension, altered skin integrity, and altered lab values. Interventions included but not limited to administer medications as ordered. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Resident has potential actual impairment to skin integrity related to BLE cellulitis, edema, fragile skin, impaired skin integrity, susceptible to bruising, medication and use, PAD / PVD, diabetes, chronic BLE ulcers as of 6/18/2025. interventions included but not limited to obtain blood work such as CBC with DIF, blood cultures and C and of any open wounds as ordered by physician. During an interview on 09/29/2025 at 1:12 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) they stated on 07/24/25 they noted a critical Vanco trough level. The Vanco trough lab was drawn on 07/24/25 and the results were 33.9. The DON stated at that time the ADON (Assistant) spoke with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 5 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Primary Provider MD. The ADON asked the Primary Provider MD if she wanted the resident transferred to the hospital due to the critical Vanco trough. Primary Provider MD said no. Primary Provider MD ordered a redraw of the Vanco trough on 07/25/25. The 07/25/25 redraw results were 32.6. The NHA and the DON stated on 07/25/25 the Infectious Disease (ID) received the 07/25/25 Vanco trough results and ID recommended sending the resident to the ER. Resident #2 was sent to the ER for evaluation. The NHA and the DON stated they started an investigation due to the ID sending the resident to the hospital. The NHA and the DON stated It was identified Resident #2's Vanco troughs were not obtained prior to administration of the Vanco, and it resulted in critical Vanco levels. The DON stated they initially schedule a Vanco trough level to be performed on either Mondays or Thursdays depending on when a resident was admitted to the facility. The DON stated from there it was determined by a physician's order when the Vanco troughs were to be performed for the duration of the IV antibiotic administration. The DON stated the physicians normally have the pharmacy dose the antibiotic depending on the Vanco troughs. The DON stated once the Monday or Thursday trough was obtained, they will get the orders from pharmacy for dosage. The DON stated the pharmacy gives the order to redraw the trough depending on the dosage. The DON stated there was not a set day of the week after the initial draw for the Vanco troughs to be performed. The DON verified the pharmacy had not received a Vanco trough since 07/08/25 based on documentation. The DON stated Resident #2's original order on admission was for the Vanco to be administered through 07/01/25. The DON stated that the Primary Provider MD wrote an order on admission, 06/18/2025, for Vanco troughs twice a week. The scheduled dates were 6/19/25, 6/23/25, and 6/27/25. On 06/23/25 and 06/27/25 the Vanco trough level showed, but the lab results showed unable to obtain The DON stated there was no documentation the physician or pharmacy was informed of the lack of Vanco trough results. The DON stated she would expect to see documentation informing both the Primary Provider MD and the pharmacy. The DON verified based on the MAR that the Vanco was not administered on 06/27/25, 06/28/25, nor 06/29/25. The DON stated the progress notes/documentation showed Vanco was on hold per MD order. The DON stated the nurse inputted the hold of the medication order under Primary Provider MD. The DON stated the Primary Provider MD inputted a late note from 06/26/25, and the note was inputted on 07/02/2025 which showed tolerating IV antibiotics well. The DON verified that on 06/27/25 an order to hold the Vanco for 2 days until 6/29 was from the Primary Provider MD due to lab issues. The due to lab issues was documented on the orders. The DON verified the Vanco restarted on 06/30/25 (after the hold). The DON stated Resident #2 was seen again on 06/30/25 by the Primary Provider MD and her note showed Resident #2 will complete IV antibiotics on tomorrow (07/01/25) and follow up with the ID MD on 07/07/25. The DON and the NHA stated the pharmacy did not question the lack of Vanco troughs nor did the nurses call the MD regarding lack of Vanco troughs. The DON stated the 07/03/25 Vanco trough order was originally ordered on 06/18/25 on admission to occur on 07/03/25 even though the Vanco was discontinued on 07/01/25. The nurses did not cancel the order for the Vanco trough. The Vanco level was 14.5. On 07/07/25 Resident #2 went to the ID MD. The DON stated the ID MD ordered to continue Vanco at the same dose and it was started again on 07/08/25. The order was handwritten from the ID MD as follows: CBC, CMP, UT or VT, ESR, CRP every Monday and CBC and BMP every Thursday. The DON stated the labs were not clarified with the ID MD, questioning a UT vs. VT as being a Vancomycin trough. The DON stated the order was entered as UT by the nurse. The DON stated the new orders would have been reviewed the following day in clinical / morning meeting. The DON stated it (UT vs. VT) was missed in morning meeting also. The DON stated the Primary Provider MD saw Resident #2 on 07/11/25 and documented in her note she had reviewed Resident #2's orders. The Primary Provider MD did not order a Vanco trough either (meds reviewed). The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 6 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the note showed the pharmacy was to dose and labs weekly and fax to ID per the Primary Provider MD. The DON stated the pharmacy sent a 3-day supply of Vanco on 07/14/25 even though they had not received a Vanco trough. The DON stated on 07/14/25 Resident #2 was seen by the Primary Provider MD, and she ordered a CBC, CMP, CRP, sed rate and Vanco random to be drawn. The DON stated the Primary Provider MD entered the order into the computer herself but entered the orders incorrectly. The orders were in a pending status. The orders did not get to the lab for collection. The orders did not come to the nursing dashboard either. The DON stated the labs the ID MD had ordered on 07/08/24 were performed on 07/14/25 but they did not contain a Vanco trough because a UT was ordered instead. The DON stated the documentation does not show the labs were sent to the ID MD. The DON stated the pharmacy told them they had suspended refills, and the last refill was on 07/14/25. The DON stated Resident #2 was seen by the Staff B, NP on 07/15/25. The DON verified the Vanco was not administered on 07/17/25 and no documentation in the progress notes. The DON stated there must have been doses here to administer. The DON stated she does not know why the nurse did not administer on 07/17/25. The NHA and the DON stated they are assuming there was Vanco doses here and the nurse administered them. The DON stated the Primary Provider MD saw Resident #2 on 07/21/25 but wrote the note late on 07/24/25. The DON stated the Primary Provider MD on 07/21/25 ordered a CBC, CMP, Vanco random, sed rate and CRP, and inputted the order herself. the Primary Provider MD reviewed the labs herself on 07/21/25. The DON stated after 07/24/25, but during the investigation it was found in the lab portal that the 07/21/25 labs had all been done but the Vanco random was not performed. The DON stated there was no explanation as to why the Vanco random was not done. The DON stated on 07/22/25, the Vanco was not available and so they called the on-call NP (Nurse Practitioner) for a new script. The DON stated on 07/22/25 the Vanco was missed, and the Primary Provider MD was notified. The DON stated on 07/23/25, the Vanco order was not placed on hold. The DON stated when they interviewed Staff E, Registered Nurse (RN), she stated she found Vanco for Resident #2 in the fridge and that was how she gave it on 07/23/25. The DON stated on 07/24/25, the pharmacy requested a Vanco trough. The Vanco trough level was given to the Primary Provider MD. The Nurse called the ID MD office also. The Primary Provider MD told them to discontinue the Vanco and fax labs to ID MD office. ID MD said to send the resident to the ER. The DON stated the pharmacy did not order labs nor did they communicate with the facility. The DON stated the pharmacy told them on 07/24/25 (during the investigation) that they (pharmacy) had sent a fax on 07/14/25 and 07/17/2025 regarding trough levels to be drawn and had not received a response. The DON stated the pharmacy told them they will not call the facility for follow-up, only fax. The NHA stated the pharmacy cannot show confirmation that they sent the faxes. The NHA stated the Primary Provider MD was interviewed on 07/29/25 by the DON and Regional Nurse Consultant, and the Primary Provider MD stated the pharmacy was to dose and the ID MD was following. The NHA stated the Medical Director was notified on 07/25/25 of the lack of Vanco levels. The NHA stated she asked the Medical Director to do a chart review. The NHA stated the Medical Director followed up with the NHA on 07/28/25. The Medical Director stated there was lack of oversight by the attending provider, pharmacy, and ID as well as in house nurse practitioner. A call was made to the ID MD's office on 09/29/2025 at 3:10 p.m. and received a return call from staff on 09/29/25 at 4:00 p.m. The Practice Administrator stated he read from the resident's notes and the resident was non-compliant at the facility and the ID MD suggested they bring him back to the hospital. The Practice Administrator stated the resident was in the hospital from [DATE] to 08/04/25. He stated he will speak with the doctor regarding any effects of the elevated vancomycin levels may have had and get back with surveyor. Did not receive a return call. During an interview on 09/30/25 at 12:15 p.m. with Staff D, Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 7 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Practical Nurse (LPN), Unit Manager (UM) and the NHA present, stated she inputted the lab order from the ID MD as UT. Staff D, LPN stated she remembered getting the script for labs from the ID MD. She stated she recalled it had a UT on it. Staff D stated she had never heard of a lab by that name but did not know all the labs out there. She stated she did not call the ID MD to clarify, because the orders were clear. Staff D, LPN stated Vanco troughs are normally done on a resident on Vanco, yes. She stated she does not recall seeing if he was on Vanco troughs or not. She stated she never gave him his medications. Staff D was the Unit Manager (UM) on the floor, on his floor. She stated she works Monday through Friday normally. Staff D stated she goes to the morning meetings. She stated she does not remember if the UT order was reviewed in morning meeting or not, she don't recall. She stated normally there are orders from the hospital for their Vanco. Staff D, LPN stated the orders are placed in the computer and the Vanco troughs are scheduled. She stated that our pharmacy does our (Vanco) dosing. Staff D stated the pharmacy decides when to do troughs and then the doctor reviews the orders from the pharmacy and the lab results. Staff D stated most of the doctors go into the system to review their own labs. She stated, You can see on the lab in computer that it has been reviewed. She stated if the lab was not reviewed then we will print it out and hand it to the doctor. Staff D state she checks labs daily. Staff D stated the UM would not have seen the labs the Primary Provider MD did if they had not been sent properly. She stated Resident #2 was being followed by ID MD and the Primary Provider MD. The NHA stated the care would be the Primary Provider MD due to primary care MD. Staff B, NP talks to the Primary Provider MD also. They all communicate with each other. During an interview on 09/30/25 at 12:30 p.m. Staff B, NP with NHA present stated she remembered the resident. She stated she was managing his chronic conditions that he came in with. She stated she would address any acute concerns that were brought to her attention. Staff B stated she alternates care with his Primary Provider MD. She stated so on the day she sees him; she would be involved in his care, and his Primary Provider MD would be on the alternate days. She stated on the day the resident was sent to the hospital it was brought to her attention a Vanco trough was not done. She verified her note on 06/18/25 it was documented she reviewed labs and addressed with staff/ pharmacy to dose and consult per protocol. She stated she saw him on 06/27/25 and her note showed labs were pending for the 06/30/25. She verified the note on 06/27/25 showed no labs were available. Staff B stated she saw him on 07/15/25. She stated she saw him on 07/22/25. She stated in the lab portal it will show who reviewed the labs. Staff B, NP stated If the Primary Provider comes in and addresses the labs then she would not address it again. During an interview on 09/30/2025 at 1:02 p.m. with pharmacy consultant stated a lot of the times the MD will order the Vancomycin trough. The trough was to be done 30 minutes to one hour before the fourth or fifth dose. The facility was to perform troughs continually. He stated the orders for the troughs were ordered by the prescriber. He stated the MD admitting or managing the Vanco gives the orders when the labs are to be done. He stated if the Vanco labs are drawn after the administration or not during the allotted time frame it may be incorrect. He stated sometime a consultation will be put in for the pharmacy to manage the dosing. If the Vanco trough was elevated, they will give the orders hold the Vanco. He stated if the trough was okay, they may increase the dosage as needed. The consultant stated the expectation would be for the troughs to be done as ordered and sent to the pharmacy. The consultant stated if he saw the troughs were not being done, he would put in a recommendation. He stated once the lab results are sent to the pharmacy, the pharmacy will give recommendation dosage. He stated if the resident was therapeutic for a while, they may do Vanco trough levels less. He stated the hospital will due Vanco randoms especially for dialysis residents. During an interview on 09/30 at 2:09 p.m. Staff E, Registered Nurse (RN) stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 8 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remembered the resident. She stated she found the last dose of Vancomycin in the fridge. She stated she called the pharmacy because it was the last dose. She stated the pharmacy said they will not send another dose because they (pharmacy) had sent a fax, they did not how many days ago, requesting a Vanco trough and they had not received the results yet. She stated the pharmacy sent a recommendation in the medication packet, the next day, with the request for a Vanco trough. She stated she was leaving after her evening shift and saw it. She stated she stayed and helped the day nurse put in the vancomycin trough order. Staff E stated she only worked with the resident that one day. During an interview on 09/30/25 at 2:42 p.m. the Medical Director stated she was asked to review the resident's chart. She stated there were a lot of people involved. She stated the facility was supposed to check the Vanco levels. The Medical Director stated there were orders placed and not done. She stated she spoke with both the Primary Provider MD and Staff B, NP about this. The Medical Director stated the nurses should be updating the orders. She stated the nurses should be looking at the lab results before giving the medication. She stated pharmacy should be checking the levels before dosing. The Medical Director stated there was nursing, NP and pharmacy involved. She stated a few people missed that meds were being given and not checking the (Vanco) levels. The Medical Director stated her expectation was for the labs to be checked and then give the meds. During an interview on 09/30/2025 at 3:08 p.m. the Primary Provider MD stated her expectations were for the Vanco troughs to be performed and receive the lab results. She stated the ID MD sends the order for the weekly labs. Primary Provider stated she prefers the pharmacy to dose the Vancomycin and keep track of the Vanco trough levels. She stated she had notified the UM that she had not seen levels (Vanco trough), and she asked for random Vanco levels. She stated the resident was usually on long term care labs 1-or-2-week. She stated she preferred the resident to be watched by the pharmacy. She stated they discussed this case. The Primary Provider MD stated the new way we order labs came in around this time. She started they were putting in orders into the electronic chart and then paper. She stated now it was automatically into the electronic chart. She stated that sometimes it was not automatically transmitted. She stated when she went into the order section of the electronic chart you would click on the labs and then it would give you another tab to click. This tab you would pick the diagnosis and date and time of the order and date and date and time to be performed. She stated the resident was getting the Vanco, but the pharmacy did not send any orders for Vanco levels. She stated the resident was at the facility for a couple of months. She stated he had a follow up with the ID MD and he put the resident back on the Vanco. She stated she ordered a couple of times to perform random Vanco levels. She stated she was seeing the Vanco levels in the lab portal and then stopped seeing the Vanco levels. When they did do a Vanco level it came back high. The Vanco levels were in the 30's. The labs were sent to the ID MD, and he wanted the resident to go back to the hospital. She stated the resident never returned to the facility. Primary Provider MD stated she was seeing the resident as well as the facility's NP. She saw him at least weekly and the NP 1-2 times per week. The Primary Provider MD stated she did not know what happened to the labs. She stated she did not hear from the pharmacy. She stated if the pharmacy had not been sent the labs, then they should not have kept sending the meds. She stated she did not hear from the facility the pharmacy was not sending the meds. She stated sometimes the resident would not come to the room for her to see him. She stated he was not getting his wound care done, he was refusing. He was not available at times. He was non-compliant. Review of the facility's policy, Laboratory, Diagnostic and X-ray, revised 06/21/2021 showed To provide guidance on ordering, obtaining, documenting and reporting laboratory, diagnostic and X-ray results. Procedure: Obtain a physician's order for laboratory work, diagnostic testing an X-ray Complete the required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 9 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete requisition forms Schedule laboratory work, diagnostic test and or X-ray as indicated Results of laboratory work, diagnostic tests, and X-ray to be sent to the center or electronically uploaded to the resident ERM Stat testing results are critical values to be called to the center The center to notify the ordering practitioner (or the covering physician if after hours) of values outside the reference range or per physician order Document any new orders Document notification of the practitioner and resident / resident representative of results Laboratory work, diagnostic testing and X-rays to be filed in the electronic medical record Review of the facility's policy, Physician Orders, revised 3/3/2021 showed The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure: admission ORDERS: information received from the referring facility for agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. ROUTINE ORDERS: A nurse may accept a telephone order from the physician, physician assistant or nurse practitioner. The order will be repeated back to the physician, PA or ARNP for his / her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR / eTAR). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date to order as soon as practicable after it is provided to maintain an accurate medical record. Review of the facility's policy, Administering Medications, revised April Event ID: Facility ID: 105644 If continuation sheet Page 10 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure residents were free from significant medication errors for three residents (#4, #5 and #6) of three sampled residents.Findings included: Residents Affected - Some 1. Resident #4 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. Review of the admission Record showed diagnoses included but were not limited to cerebrovascular disease, atrial fibrillation, diabetes, anemia in chronic kidney disease, neuromuscular dysfunction of bladder, stage IV chronic kidney disease, hypertension, stage III sacral pressure ulcer, stage III left heel pressure ulcer, and urine retention. Review of the quarterly, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 14 or cognitively intact. Review of the Section GG, Functional Abilities showed the resident was dependent for toileting, showering and bathing. Section J showed he had no pain for last 5 days. Review of the physician orders showed: Morphine Sulfate concentrate oral solution 20 mg (milligram) / ml (milliliter) give 0.25 ml by mouth every 3 hours as needed for pain as of [DATE] Do not resuscitate (DNR) Assess resident every shift for pain Terminal Diagnosis: the resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis of Sequelae of Cerebrovascular Disease. Hospice services provided Review of the [DATE] Medication Administration Record (MAR) showed Assess resident for pain every shift. [DATE], Pain assessed on days at a level of 0 [DATE], Pain assessed on evenings at a level of 0 Review of [DATE] MAR showed Morphine Sulfate concentrate oral solution 20 mg (milligram) / ml (milliliter) give 0.25 ml by mouth every 3 hours as needed for pain as of [DATE] [DATE] at 09:19 a.m. pain level of 7; given and effective; given by Staff G, Registered Nurse (RN) [DATE] at 1629 or 4:29 p.m. level of 8 given and effective; given by Staff G, RN [DATE] at 08:16 a.m. level of 7 given; given by Staff G, RN Review of Medical Provider and nursing progress notes revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 11 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 10:44 a.m. resident in hospice care. Resident noted with low blood pressure, 100/30, heart rate of 94, O2 (oxygen) saturation level was 80% with Oxygen at 2 Liters, respirations were 20. Resident appears weak and lethargic. Comfort measures provided by hospice protocol. Hospice nurse called. Staff H, Nurse Practitioner (NP) from insurance company was in facility. Primary Physician MD was aware and advised writer to stop regular medications on [DATE]. Residents Affected - Some On [DATE], Staff H, Nurse Practitioner (NP) from insurance company wrote resident was being seen visit to follow-up on chronic conditions. (Resident) Was seen lying in bed, chronically ill appearing, eyes closed, sleep, appears weak/fatigued. Minimal conversation. Drifts back to sleep. Denies chest pain, shortness of breath, fever, chills, cough/congestion. Per nursing this a.m., the blood pressure was 100/32, with oxygen saturation at 80% at 2 liters per minute. Rechecked by NP, blood pressure was 100/60, heart rate 51, respirations 20, oxygen saturation at 94% with 4 liters of oxygen via nasal cannula. Call placed to Hospice services, waiting on return call from Hospice MD to discuss. Discussed with Primary Provider MD in agreement to discontinue Atorvastatin, iron, GDR of Desvenlafaxine, defer work up of leukocytosis, presumptive UTI (Urinary Tract Infection) with chronic indwelling Foley/recurrent UTIs, Hospice status. Discussed Plan of Care with nursing requested nursing notify provider for any changes in status. On [DATE] at 8:00 a.m. Staff F, LPN (Licensed Practical Nurse) weekend supervisor wrote upon assessment this writer observed resident exhibiting signs of labored breathing, audible moaning, and involuntary twitching. Hospice was informed of change in condition. Awaiting call back from Hospice Nurse for estimated time of arrival. On [DATE] at 8:38 a.m. Staff F, LPN, weekend supervisor entered the resident's room, upon assessment the resident was noted with no pulse or respirations. His code status was verified with two nurses. The resident's code status was verified as Do Not Resuscitate. The DON (Director of Nursing) was notified. On [DATE] at 8:55 a.m. showed at 8:39 a.m., call received from Hospice Nurse, indicating an estimated time of arrival of 15 minutes. The resident expired at 8:42 a.m., and the Hospice Nurse arrived at 8:50 a.m., pronouncing the resident's death at 8:58 a.m. The family was notified at 9:00 a.m.: however, there was no answer, and a message was left. Resident's insurance company was notified at 9:02 a.m., and communication occurred with their staff. Staff H, Nurse Practitioner (NP) with insurance company was notified at 9:28 a.m. On [DATE] at 1:06 p.m., a Change in Condition (CIC) showed resident had expired. Resident pronounced dead by hospice nurse. Family and MD notified. Review of the care plans showed: Resident had a terminal prognosis related to Cerebrovascular disease and was receiving hospice services. Interventions included but not limited to observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Date Initiated: [DATE] Review of the Weights and Vitals Summary showed [DATE] at 12:35 a.m. blood pressure: 102/70 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 12 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 [DATE] at 4:26 p.m. blood pressure: 112/52 Level of Harm - Minimal harm or potential for actual harm [DATE] at 1:34 a.m. blood pressure: 123/55 Residents Affected - Some During an interview on [DATE] at 10:12 a.m. with the Nursing Home Administrator (NHA), Regional Registered Nurse (RN) and Director of Nursing (DON). The DON stated she was called in on [DATE] for what they identified as a discrepancy of the narcotic count. She stated she came in and reconciled all the medication carts with all the nurses at 7 p.m. At that time, she verified there was a discrepancy with Resident #4's liquid Morphine. Staff I, RN was working the day shift and was doing the medication pass from 7 a.m. to 7 p.m. Staff J LPN was coming on at 7 p.m. and found the discrepancy during narcotic reconciliation. Staff I, RN, was suspended due to possible drug diversion. The DON stated on [DATE] she came in and questioned Staff G, RN after looking at the inventory form and discovering she was the last person to administer the Morphine to Resident #4. The DON asked Staff G, RN how she administered the Morphine. Staff G picked up a medication cup and stated she administered it using the cup. Staff G was then pulled into office for a more in-depth interview. Staff G admitted to using the medication cup for measuring the morphine instead of a syringe. Staff G was asked to review the dosage she poured up of 2.5 ml to the actual order of 0.25 ml. Staff G, RN, was taken off the medication cart. The DON stated during the interview with Staff G, she disclosed she administered 2.5 ml of morphine for the three doses. The DON stated, once we calculated the 2.5 ml for three doses, that was what was removed or missing that we originally thought was a drug diversion. Staff G RN did a return demonstration of what she delivered. The DON asked Staff G why she gave the pain meds, and she stated that she guessed the pain level. The DON asked Staff G what the appropriate way would be to assess the pain level. Staff G stated using the PAINAD (Pain Assessment in Advance Dementia) scale. The DON stated Staff G was suspended at that time pending an investigation. On [DATE], Resident #4 received 2 doses and 1 dose on [DATE]. The NHA stated Staff G realized she made a medication error during her demonstration. The NHA stated it was documented on the Hospice note that the resident had a slow decline on the visit note of [DATE]. The NHA stated on [DATE] a note from Staff I, RN showed the resident was a hospice resident and was weak and lethargic, blood pressure of 100/30 (documented in a progress note). The NHA stated the progress note from Staff H, NP showed he was chronically ill, eyes closed, appears weak and fatigue, minimal conversation, back to sleep, blood pressure 100/32, oxygen saturation at 80% on 2 liters of oxygen. The NHA stated Staff H, NP documented she rechecked the blood pressure and it was 100/60, Oxygen saturation to 94% on 4 liters of oxygen. The note showed Staff H contacted hospice and was awaiting on return call. Staff H discussed the resident with his Primary Provider MD to discontinue medications and discounted plan of care with nurse. The NHA stated the Medical Director, and his Primary Provider could not say whether the added medication added to his (Resident #4's) decline or not. The NHA stated she interviewed Staff H, NP and she could not say whether the dosage caused anything or not. During an interview on [DATE] at 11:21 a.m. Staff H, NP with insurance company stated they specialize in long term care, and they work in conjunction with the Primary Provider MD. She stated they are another set of eyes and ears. She stated she was at the facility a couple days a week. She stated when she saw the resident she saw he was declining. Staff H stated she was not surprised that he had passed over the weekend. He had stage 4 chronic kidney disease. He had more than 9 lives due to kidneys and co-morbidities. She stated he was normally alert and awake, and he was not doing that on her last visit. He was in hospice. They were starting to cut medications. She stated she made numerous calls to the family trying to let them know he was declining. She confirmed with the nurse on [DATE] that he was on morphine and it had already been ordered. She stated he did not appear to be in any pain on [DATE] but she wanted it to be available to him. Staff H, NP stated she found out about the med error the following week. She stated they called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 13 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her to let her know he had passed. She stated later that week, she found out about the discrepancy in meds and a med error had been made. She stated she thinks death was imminent. She stated the pain medication helped with the comfort. She stated on [DATE] he looked like a limp rag. His vitals were abnormal. She stated she called the family and Hospice that he was rapidly declining. She stated she spoke with the Primary Provider MD about an antibiotic for possible UTI. He was on medication for anemia, but it was not helping. During an interview on [DATE] at 1:02 p.m. the pharmacy consultant stated he has a form he uses to audit narcotic counts and provide education. The nursing staff are to identify the resident, look for the medication in the narcotic logbook, use the MAR in the PCC, check to see if medication was scheduled or PRN (as needed), assess the pain level. The staff is supposed to use a medication cup on the cart, stable surface, eye level for pouring into. If using small doses should use a syringe to draw up. He stated to make sure the resident was sitting up and swallowed the medication completely. Ensure both logbook and the electronic chart or MAR are documented / signed. If order was less than 2- or 3-ml dosage, use a syringe to draw the medication up. He stated that reconciliation of medications should come after change of shift at a minimum. On 9/30 at 12:58 p.m. a telephone call was made to Staff G, RN. Staff G would not speak with this surveyor. During an interview on [DATE] at 1:51 p.m. Staff F, LPN, weekend supervisor stated she had just come on shift on a Saturday. She stated she overheard the night nurse give a report to the oncoming day nurse. The night nurse said Resident #4 had been actively dying. He was only opening his eyes. Staff F stated she went in and checked on him, he did not act like he normally does. She checked on him through the shift. She stated staff H, NP had followed up with hospice already. Staff F stated he was fine on Saturday, comfortable. Staff F stated we left Saturday night ([DATE]) and he was comfortable. She stated she checked on him Sunday morning ([DATE]) and he was twitching and moaning. She asked the evening nurse if she had given him anything throughout the night. Staff F stated she told Staff G, RN to give him some pain meds and she would call hospice. Staff F told hospice he was actively dying. Hospice placed her on hold to locate a nurse in the area. Hospice office told Staff F that they were sending a nurse over. Staff F reported to the Hospice office that the resident had an order for Morphine, but it had not been given yet. Staff F informed Hospice office the morphine was being given now. Staff F stated the Hospice nurse called her and stated she would be at the facility in 15 minutes. Staff F told the Hospice nurse she would wait to assess the resident until she (hospice nurse) got there. Staff F stated later the CNA (Certified Nursing Assistant) told her the resident was gone. Staff F stated she grabbed his chart and checked his code status. He was a DNR. She checked him and he had no pulse or respirations. Staff F stated she called the hospice nurse back and informed her of his passing. The hospice nurse was just coming into the building. Staff F walked the hospice nurse to the room. The hospice nurse pronounced him expired and she let the team know. Staff F stated she did not know about the medication (morphine) error until after the fact. Staff F stated that when drawing up morphine we are to use syringes for small doses. Staff F stated, We are to check the orders to the medication. Once the nurses check the medication and order they check the order again. Staff F stated they need to check the dose again to make sure it is correct. Stated they are to check it is the right resident, right time, right route. Staff F stated the oncoming shift does the narcotic count with the off going shift. The narcotic sheets are to be checked to the medication in the cart. Staff F stated, we even check the empty cards. Staff F stated she did not know anything about a medication error. She stated the nurses started having education on medication pass and she heard it was because of Resident #4. Staff F stated as far as she knew Resident #4 was stable but actively dying. Staff F stated the aide told her he would do an occasional moan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 14 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE] at 2:42 p.m. the Medical Director and /or Primary Provider MD stated the staff told her about the morphine missing. She stated that days later the DON stated she had spoken with the nurse that had worked with on the weekend and realized he (Resident #4) was given the wrong dosage. Medical Director stated Resident #4 was her resident. She stated he was elderly and on hospice. Medical Director stated, It was hard to say if the med (morphine) affected him or not. He was really declining. The Medical Director stated she spoke with Staff H, NP that Friday ([DATE]) and they said he was declining. The Medical Director stated she was informed he passed away. The Medical Director / Primary Provider MD stated, I am not able to say if the morphine error contributed to his death or not, hard to say. She stated, It was a high dose. She stated he was declining before the med error, difficult to contribute. Review of the facility's policy titled, Physician Orders, revised [DATE] showed The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure: admission orders: information received from the referring facility for agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. Routine orders: A nurse may accept a telephone order from the physician, physician assistant or nurse practitioner. The order will be repeated back to the physician, PA or ARNP for his / her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR / eTAR). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date to order as soon as practicable after it is provided to maintain an accurate medical record. 2. On [DATE] at 1:00 p.m , Resident #5 was observed lying down in bed with her call light within reach. She was observed with no signs of distress. She said approximately 2 weeks ago the nurse assigned to their room gave her, her roommate's medication and gave her roommate her medication. She said she did not have any negative effects, but she thought it was strange it happened. Resident #5 said she received 3 Tylenol tablets and 1 Gabapentin tablet. Review of an admission Record dated [DATE] revealed Resident #5 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent encounter, pressure ulcer of other site stage 3, nonrheumatic tricuspid (valve) insufficiency, nonrheumatic mitral (valve) insufficiency, cardiomyopathy, unspecified Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) summary score of 15, which indicated Intact cognitive abilities. Review of physician order showed: Acetaminophen tablet 325 milligram (MG), give 2 tablets by mouth every 6 hours as needed for pain, fever, order date [DATE] Coreg Oral Tablet 3.125 MG (Carvedilol), give 1 tablet by mouth two times a day for hypertension, order date [DATE] Gabapentin Oral capsule 30 milligram (MG) (Gabapentin) give 1 capsule by mouth three times a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 15 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 for Nerve pain, order date [DATE] Level of Harm - Minimal harm or potential for actual harm Midodrine hydrochloride (HCI) oral tablet 10 milligram (MG) (Midodrine HCI) give 1 tablet by mouth three times a day for hypotension hold for systolic blood pressure 120, order date [DATE] Residents Affected - Some 3. On [DATE] at 1:00 p.m., Resident # 6 was observed sitting up in her wheelchair watching television and talking to her roommate. She was observed well-groomed with no signs of distress. Resident # 6 said their nurse came in the room and gave her roommate's medication to her. She said when the nurse gave her the medication, she took all the pills, but when she got to the last pill, she noticed it was not familiar. She said when she asked the nurse about the medication, the nurse realized she made a mistake and gave her and her roommate the wrong medication. Review of Resident # 6 admission record dated [DATE] revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy, peripheral vascular disease, unspecified polyarthritis, unspecified Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 which indicated Review of physician order showed Acetaminophen tablet 325 milligram (MG), give 3 tablets by mouth every 8 hours as needed for pain, order date [DATE] Gabapentin Oral tablet (Gabapentin) Give 3000 milligrams (MG) by Prescriber mouth every 8 hours for Nerve pain hold if sedated or confused, order date [DATE] Zofran Oral Tablet 4 milligram (MG) Ondansetron Hydrochloride (HCI), give 1 tablet by mouth every 6 hours as needed for nausea and vomiting, order date [DATE] Review of a nursing progress note dated [DATE] revealed, Nurse Practitioner was notified about medication error. Resident # 6 vital signs noted. Medical Doctor (MD) ordered to monitor blood pressure every hour notify MD regarding changes. On [DATE] at 12:45 p.m., an interview was conducted with the Director of Nurses, DON. The DON said on [DATE] she received a phone call to inform her that the nurse gave Resident #5 her roommates medication and gave her roommate her medication. She said it was not clear on the incident report what medications were given to each resident, but she was made aware that it was during the 5 p.m. med pass. The DON said as she reviewed the incident report that Resident #5 received Resident # 6 Tylenol. The DON said as she continued to review the documentation, Resident # 6 incident report does not list the medication she was given at the time of the incident. The DON said her expectations are if there is a medication error the nurse should document the medication that was given to the residents, notify the MD and the family and follow any recommendation the physician may have. On [DATE] at 1:00 p.m. an interview was conducted with Staff A, Registered Nurse, RN. Staff A said she was in the middle of med pass when someone approached her, and she got distracted. Staff A said she made a mistake and gave Resident her roommate's Tylenol, and gave Resident # 6 her roommates Midodrine, Amlodipine, and Gabapentin. Staff A said she did not notify Resident #5's provider about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 16 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some incident because the resident already has a PRN (as needed) order for Tylenol, she just received it without her request. On [DATE] at 2:30 p.m., an interview was conducted with the Medical Director. The Medical Director said her expectation were nurses need to verify who they are giving medications to before the medications are administered. Review of the facility's policy, Administering Medications, revised [DATE] showed Medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and Implementation 1. Only persons licensed or permitted by the state to prepare, administer and document the administration of medication may do so. 2. The director of nursing services supervises and directs all personnel who administer medication and / or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frames. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. 9. The individual administering medications verifies the resident's identity before giving the resident his / her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking for photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 23. As required or indicated for a medication, the individual administering the medication records is in the residence medical record: a. the date and time the medication was administered; b. The dosage; c. The route of administration; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 17 of 18 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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 0760 d. The injection site (if applicable); Level of Harm - Minimal harm or potential for actual harm e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when these results were observed; and Residents Affected - Some g. The signature and title of the person administering the drug. Review of the facility's policy, Notification of Change in Condition, revised [DATE] showed The center to promptly notify the patient / resident, the attending physician, and the resident representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and resident representative when there is a (n): Accident Significant change in the patient / resident's physical, mental, or psychosocial status Need to alter treatment significantly New treatment Discontinuation of a current treatment due to but not limited to: Adverse consequences Acute condition Exacerbation of a chronic condition The nurse to complete an evaluation of the Patient / Resident. Document evaluation in the medical record. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. Notify the Patient / Resident and the resident representative of the change in condition. Documentation notification in the medical record. Document resident / patient change and condition on a 24-hour report. Complete SBAR as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 If continuation sheet Page 18 of 18