Inspection·September 26, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Nursing Home Administrator on 09/26/2023 at 1:52 p.m., she said education regarding controlled medications started on 09/15/23. Resident #6's Controlled Drug Use Record for Morphine Solution was reviewed, she said the DON notified her on 09/25/23 of controlled substance documentation issues and she was not aware of Resident #6's, 3.25 ml Morphine Solution discrepancy. The NHA said the discrepancy should have been reported, we should have known. If I were the assigned nurse, I would not have taken the key, it is the supervisor's responsibility to notify administration. I will notify the State Agency for Adult Protective Services, the police, and our pharmacy consultants about the discrepancy. The DON should have let me know. Review of the facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure Revised on 8/2022 revealed Purpose To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. Policy It is Aventura policy to empower and enable any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others (Associates) working for the Facility to make reports to the relevant authorities pursuant to the provision of the Elder Justice Act (EJA) and CMS regulations. The Facility will not retaliate against any Associate in response to lawful acts done by the Associate pursuant to the EJA. Procedure I. Duty to Report A. All Associates have duty to report any reasonable suspicion of a crime (as defined by the law of applicable political subdivision) against any individual who is a resident of, or is receiving care from, the Facility pursuant to Section 1150B of the Social Security Act. (The Elder Justice Act). B. the (sic) Facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violations pursuant to 42 CFR 483.12(c). .III. What must be reported? Crimes must be reported. Crimes include, but are not limited to, .C. Neglect a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 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 0609 Level of Harm - Minimal harm or potential for actual harm Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to maintain the health or safety of a resident and to avoid physical harm, pain, mental anguish, or emotional distress; . .F Misappropriation of Resident Property Residents Affected - Few a. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. A. Reasonable Suspicion of a Crime a. Pursuant to the EJA, Associates must report reasonable suspicions of a crime to the State Survey Agency and at least one local law enforcement entity. B. Alleged Violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violationsa. Pursuant to 42 CFR 483.12(c), Associated must report to the Administrator or other designated Facility representatives (the Facility) and the Facility must report to alleged violations to (1) The state Survey Agency (2) The adult protective services if applicable state law provides for jurisdiction in long-term care facilities, and (3) at least one local law enforcement entity . .V. When to Report? A. Reasonable Suspicion under the EJA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 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 0609 a. Level of Harm - Minimal harm or potential for actual harm If there are events that cause suspicion that the resident may suffer, or has suffered from, a serious bodily injury, then the Associate (sic) must report the suspicion immediately, but not later than 2 hours after forming the suspicion. Residents Affected - Few b. If the events that cause the suspicion do not result in serious bodily injury, the Associate must report the suspicion no later than 24 hours after forming the suspicion. B. Alleged Violations under 42 CFR 483.12 (c) a. Immediately (for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) but not later than i. 2 hours-if the alleged violation involves abuse or results in serious bodily injury ii. 24 hours-if the alleged violation does not involve abuse and does not result in serious bodily injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of facility and resident's record, the facility did not ensure supervision was provided to prevent a fall for 1 of 3 residents reviewed, Resident #3 and the facility did not ensure documentation and follow up were completed after the fall. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses to include other intervertebral disc degeneration Lumbar, Unspecified dementia, history of falling, primary insomnia, major depressive disorder, and mood disorder. Review of an annual MDS (Minimum Data Set) for Resident #3 dated 08/05/23 showed Resident #3 had a BIMS (Brief Interview for Mental Status) score of 3, indicating severe impairment. Section G showed Resident #3 required extensive assistance with two plus person's physical assistance for transfers. The resident required extensive assistance with one-person physical assistance for locomotion on and off unit. A care plan for Resident #3 initiated on 04/13/23 showed, the staff have identified that I am at risk for falls because of these risk factors, dementia, gait/balance problems, incontinence, unaware of safety needs, use of anti-psychotic medication, use of pain medication and history of falls. Interventions included, during hurricane/disaster evacuation [Resident #3] will have special transportation versus regular bus with lifts. I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I'm out of bed. Review of a document titled, [name of facility] incident list dated June 1, 2023, to September 25, 2023, showed Resident #3 had a fall while off property on 08/28/23. Review of Resident #3's Electronic Medical Record (EMR) showed there were no progress notes, assessments or evaluations documented related to a fall on 8/28/23. The record did not show that Resident #3's physician and family were notified of the fall. On 09/26/23 at 12:57 p.m., an interview was conducted with Resident #3. The resident was observed in her room, lying in bed. She could not remember any details related to the fall. The resident's side of the bed was noted with fall mats. The resident said, these are to keep me safe in case I fall. On 09/26/23 at 1:18 p.m. an interview was conducted with Staff J, Registered Nurse (RN). She stated she worked with the resident the day she fell. She said, I was at the evacuation site when Staff S, LPN/ Unit Manager brought her inside the building. He said she slid between two seats in the bus and was wedged in between and that he had to pull her out. She stated Resident #3 was injured. She stated the Resident suffered bruising on the right side of her forehead and a skin tear on her right temporal area and skin tears to both arms. Staff J stated the resident's left arm was wrapped with a small dressing. She stated she applied steri strips, but no other treatment was given. Staff J said, I saw the resident during the 3 days. I gave her medications. It was my fault I did not document. My Unit Manager (Staff S) had stated he would submit a post fall assessment. I did not do any documentation. It was my fault I should have submitted a post fall assessment. I did not do any skin checks and I did not notify the physician. I thought my Unit Manager (Staff S) would have done it. Staff J (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 stated Resident #3 was confused and unable to verbalize the events of her fall on the bus. Level of Harm - Minimal harm or potential for actual harm On 09/26/23 at 11:53 a.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN). She stated she was at the church (evacuation site) helping to check people in as they got off the bus. She stated she observed Staff S, Unit Manager pushing Resident #3 in her wheelchair. She stated Staff S said, the resident had an accident on the bus. She stated she noticed the resident had blood on her left temple. Staff E stated if a resident had a fall with an injury to the head, they notify the doctor, they do neuro (neurological) checks, and if the resident complained of head pain, they would send them out. Staff E, LPN confirmed she saw the resident's arms and it looked like she had a skin tear. She stated she was not assigned to the resident but if she was, she would have notified the family and physician, follow fall process, assess for pain, follow treatment orders and document. Residents Affected - Few On 09/26/23 at 1:10 p.m. an interview was conducted with Staff I, Certified Nursing Assistant (CNA). She stated she was working the day the resident fell. She said the resident fell while on the bus. She stated the resident slid between two seats and she could not get up. The resident had some injury to her face and bruises on her hand. She said, She was complaining of pain when you moved her. She had a sore bump on the right side of her head. The nurse (Staff J) put something on her head. On 09/26/23 at 2:27 pm. an interview was conducted with Staff F, CNA. She said, I was at the church, and we were unloading the bus when an agency CNA who was riding in the bus came to me and said the resident was pinned in the seat. I was outside of the bus. I got on the bus and saw [Resident #3] between the seats, her face was down, and her knees were touching the floor. She was squeezed into the seats. I was unable to move her. I ran to get Staff S, Unit Manager. Staff S was able to pull the resident out after several attempts. Staff F stated at the time she did not notice any bruising. Staff F stated the incident was chaotic. She stated she noticed Resident #3's bruising when they returned to the facility three days later. On 09/26/23 at 12 p.m. an interview was conducted with the Director of Nursing (DON) and Staff E, LPN Weekend Supervisor. Staff E stated after they returned to the facility, they received notification that there was a note regarding some type of injury that occurred on the bus. She said, We talked about it on 09/12/23 at the morning meeting. The administration reviewed the incident. At this point, nothing was documented. I went back and saw the resident; she had a yellow bruise and scab on the left side of her face. The DON said, I notified the doctor that during the transfer, there had been some type of incident and the resident had suffered bruising to her temple area. I did not document but, I started the incident report. The doctor had no new orders because it had been two weeks so there was not much we could do. The DON stated the issue was there was no documentation at the time, and they could not say exactly what happened. The DON stated the expectation would be to notify the supervisor of any injuries that occur to a resident. On 09/26/23 at 9:45 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She confirmed Resident #3 suffered a fall with injuries on the bus and there was no documentation. She stated she became aware the resident had fallen while getting off the bus or while on the bus during the evacuation transport. She stated The Unit Manager (Staff S) was with the resident. The NHA said, I would have expected him to document what happened per facility protocol. The resident suffered some scabbing and bruising. The nurse should have assessed, notified the physician and family. Review of an undated facility document titled, Fall Event Protocol, showed an expectation to notify supervisor of all falls immediately. Notify DON/administrator of all falls with injury immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Complete (SNF) skilled nursing facility metrics enter as much detail as possible. In point click care, complete change in condition form, fall risk assessment, pain assessment, skin assessment and the progress note showing what happened and what the immediate intervention was. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure Narcotic Cards/ Bottles Reconciliation logs were completed on 4 out 4 resident wings (A, B, C, D) and failed to document controlled narcotics in sufficient detail to enable an accurate reconciliation for 3 residents (Resident #5, Resident #6, and Resident# 11) of 3 residents reviewed on Wing B, for 2 of 2 medication carts located on Wing B. Findings included: 1. Review of the facility's Wing D Narcotic Cards\ Bottles Reconciliation log revealed between 09/07/23 and 09/25/23, there were eight shifts missing oncoming and off going nurse signatures. Review the facility's Wing B Narcotic Cards\ Bottles Reconciliation log revealed between 09/02/23 and 09/25/23, there were 29 shifts missing oncoming and off going nurse signatures. Review the facility's Wing C Narcotic Cards\ Bottles Reconciliation log revealed between 09/01/23 and 09/25/23, there were 21 shifts missing oncoming and off going nurse signatures. Review the facility's Wing A Narcotic Cards\ Bottles Reconciliation log revealed between 09/05/23 and 09/25/23, 41 shifts were missing oncoming and off going nurse signatures. On 09/25/23 at 3:22 p.m., the DON said she was not aware of any missing controlled medications and the facility has planned to start Narcotic Controls education with the nursing staff. The DON said the expectation was for staff to sign the Narcotic Cards/ Bottles Reconciliation log immediately after narcotics are counted at the beginning and end of shift. The Narcotic Cards/ bottles Reconciliation log columns should not be blank. The DON said the Control Drug Use Record should be signed at the time the medication is removed. Review of a document provided by the facility titled Narcotic Controls, undated, revealed the following directions: At the change of shift, the off-going and on-coming nurse must count all narcotics and sheets and record both on the controlled medication shift change log. Any time a new nurse takes the keys to a medication cart, the off-going and on-coming nurses must count all narcotics and sheets. The controlled medication shift change log should be completed in its entirety to include the data and time of the narcotic count. Review of the facility policy titled Medication, Administration of Medication, effective date, 04/01/22 revealed, Medications shall be administered in a safe and timely manner, and as prescribed. The scope applies to all staff authorized to administer medications to residents instructs staff to administer medications in accordance with orders, including any required time frame. Review of the facility's Drug Diversion: Prevention, Identification, Reporting and Response policy, revised 09/2022 revealed: Purpose: the drug diversion prevention, detection and response program provides A systematic coordinated and continuous approach to the prevention, recognition, and reporting of drug diversion to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 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 0755 ensure safe medication practices, safe employee behavior and to prevent patient harm Level of Harm - Minimal harm or potential for actual harm Definitions: drug diversion-intentionally and without proper authorization, using or taking possession of a prescription medication or inhalation anesthetic agent from [insert health facility name] through the through use of prescription, ordering or dispensing system examples of drug diversion include but not limited to medication theft, using, or taking possession of a medication without valid order. Residents Affected - Some Policy statement: 4) suspicion of drug diversion may arise from a variety of circumstances including but not limited to the following . discrepancies with controlled substance count . Procedures: 1) suspicion of diversion warrants an immediate thorough investigation an audit that reveals A statistical outlier in a dispensing or wasting of controlled substances require further investigation immediately to determine the error by the staff persons associated with the medication delivery system. 2) Narcotic and controlled drug security, accurate inventory counts, and the timely and accurate completion of narcotic registers shall be maintained at all time period any unresolved inventory or record variances will be reported to the supervisor/Don or designated leader immediately, who will undertake the appropriate reporting and investigations in a timely manner. A) if account discrepancy occurs in the change of shift verification and investigation is made: 1. Immediately notified the supervisor /DON/designee to assist in count reconciliation. 2. If the count cannot be reconciled anyone associated with the administration or assistance of medication may not leave the facility. Only the administrator or the administrator designee in charge may dismiss the staff persons involved in the control medication count if a discrepancy occurs. An interview with Staff B, Licensed Practical Nurse (LPN) and review of the current Controlled Substance Record was conducted on 09/25/23 at 09:45 a.m. The Controlled Substance Record is used to document controlled substances available on the wing for residents. Staff B LPN said narcotic counts are completed and documented at the beginning and end of each shift and the supervisor notified of narcotic count discrepancies. Staff B LPN reviewed the current Narcotic Cards/ Bottles Reconciliation log and verified several dates without the oncoming and off going nurses' signatures. An interview and review of the current Controlled Substance Record was conducted on 09/25/23 at 10:00 a.m. with Staff A LPN, Unit Manager (UM) who said at end of each shift the oncoming and off going nurses count the number of narcotics in the medication carts and are expected to sign the Narcotic Cards/ Bottles Reconciliation log immediately. Staff A, LPN UM, said unit managers audit the Narcotic Cards/ Bottles Reconciliation logs to ensure compliance with the policy. She said no education regarding Controlled Substance Record is provided during orientation, nurses know what to do. Staff A, LPN UM validated missing signatures on the oncoming and off going Narcotic Cards/ Bottles Reconciliation log. An interview and review of the current Controlled Substance Record was conducted on 09/25/23 at 10:30 a.m. with Staff D, LPN; she said narcotic counts are completed at the end of each shift, and count discrepancies are reported to the supervisor immediately. When narcotic medications are wasted (removed and not administered) two nurses witness, indicate the reason, and document on the Controlled Substance Record. Staff D, LPN said no education about narcotic counts has been provided. Staff D, LPN confirmed missing nurse signatures on the Narcotic Cards/ Bottles Reconciliation log. An interview and review of the current Controlled Substance Record was conducted on 09/25/23 at 11:00 a.m. with Staff C, LPN. During a review of the Controlled Substance Record, Staff C, LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some confirmed her initials beside a medication indicated as wasted. She was unsure why the medication was wasted. During an observation of number of pills on hand for one medication, Staff C LPN verified the number of narcotic pills on the Controlled Substance Record and the number of actual pills remaining did not match. Staff C, LPN said she removed, administered, and plans to document the removal on Controlled Substance Record later. Staff C LPN confirmed there were missing nurse signatures on the Narcotic Cards/ Bottles Reconciliation log. 2. Review of Resident #5 records revealed, the resident was admitted on [DATE] with diagnoses to include metabolic encephalopathy, dementia, mood disorder, and anxiety disorder. Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, severe cognitive impairment. Section C- Signs and Symptoms of Delirium documented behavior present and fluctuates. Review of Resident #5's physician orders revealed an order for Lorazepam 0.5 mg tablet every 8 hours for anxiety. Review of Resident #5's Controlled Drug Use Record for Lorazepam 0.5mg revealed on 08/26/23 at 10:00a.m., 72 pills available, 1 pill removed, 71 remaining with the word waste handwritten in the right margin. Staff initials and the reason for the waste was not documented. Review of the admission record for Resident #11 revealed an admission date of 12/09/22, with diagnoses to include Dementia and Anxiety disorder. Review of Resident #11's quarterly MDS dated [DATE] revealed a BIMS score of two out of 15, indicating severe impairment and signs and symptoms of delirium documented the behavior was present and fluctuated. Review of Resident #11's physician orders dated 02/08/23 showed Xanax tablet 0.25 mg, give 1 tablet by mouth three times a day for anxiety, hold for sedation. Review of Resident #11's MAR for 09/01/23 to 09/25/23 showed the resident received Xanax 0.25mg tablet at 9:00 a.m., 2:00 p.m., and 9:00 p.m. daily. Review or Resident #11's MAR on 09/21/23 showed Xanax 0.25mg was signed out on the MAR at 2:00 p.m., the Controlled Substance Record did not document this removal. Resident #11's MAR dated 09/22/23 showed Xanax 0.25mg was signed out at 9:00 p.m., the Controlled Substance Record did not document this removal. An observation was conducted on 09/26/23 at 1:23 p.m. of Resident #11's Control Substance Record and the number of Xanax 0.25 mg tablets on hand, found the count on the Control Substance Record and the number of pills available matched. Review of admission records revealed Resident #6 was admitted on [DATE] with diagnoses to include dementia, sacral fracture, and osteoarthritis of the hand. Review of a physician order dated 05/15/23 revealed Morphine Sulfate 100mg/5ml give 0.25 ml by mouth every 4 hours as needed for pain/dyspnea. Review of Resident #6's Medication Administration Record (MAR) and the Controlled Substance Use log for Morphine Sulfate100 mg/5ml for August 2023 and September 2023 revealed the following two entries were medications signed out as given to the resident but not recorded on the log: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 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 0755 1. Level of Harm - Minimal harm or potential for actual harm 09/03/23 at 6:20 p.m. Morphine Sulfate 0.25 milliliters for pain level 3 of 10 was administered and was effective. Residents Affected - Some 2. 08/13/23 at 09:16 a.m. resident received Morphine Sulfate 0.25 milliliters for pain level 3. Review of resident #6 Controlled Substance Use log for Morphine Sulfate100 mg/5ml revealed entries showing doses of liquid Morphine missing with no corresponding documentation of the resident receiving the medication: 9/02/23 at 0900 revealed 14 ml available, 0.25 ml removed and 13.75 ml remaining. 09/02/23 at 1300 13.75ml available, 0.25 ml removed and 13.5 ml remaining. 09/02/23 at 1700 13.25ml available, is written, 0.25 ml removed. 09/02/23, an untimed entry, revealed Count is off liquid line is at 10 mL, 10 ml amount remaining. Observation of the Morphine Sulfate bottle for Resident #6 revealed the volume of a pink colored solution was at the 10 mL line. (Photographic evidence obtained) Review of the facility's Abuse log did not reveal an immediate report for missing Morphine Sulfate solution was filed. On 09/25/23 at 4:00 p.m. a tour was conducted with the Director of Nursing (DON), to observe discontinued controlled substance storage. An unlocked two drawer file cabinet was observed in the DON's office that was completely full, both drawers, with medication cards, medication bottles and medication patches. A number of the medications were reviewed and were narcotics dated between January and September 2023 that needed to return to the pharmacy. The DON confirmed maintenance and housekeeping staff have access to the office. She said a count of the discontinued medications is unavailable, she said the previous DON stored the medications and she plans to contact the pharmacy liaison to initiate disposal of the medications and confirmed they should not have these medications stored in this location. During an interview with the Nursing Home Administrator on 09/26/2023 at 1:52 p.m., she said education regarding controlled medications started on 09/15/23. Resident #6's Controlled Drug Use Record for Morphine Solution was reviewed, she said the DON notified her on 09/25/23 of controlled substance documentation issues and she was not aware of Resident #6's, 3.25 ml Morphine Solution discrepancy. The NHA said the discrepancy should have been reported, we should have known. If I were the assigned nurse, I would not have taken the key, it is the supervisor's responsibility to notify administration. I will notify the State Agency for Adult Protective Services, the police, and our pharmacy consultants about the discrepancy. The DON should have let me know. Review of an undated document provided by the facility titled Narcotic Controls directed two nurses, including the responsible nurse were to waste controlled substances. The responsible nurse and a witness must visualize the medication to be wasted. Both nurses are required to document on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at the Bay 10300 4th St N Saint Petersburg, FL 33716 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 0755 Controlled Drug Use Record, the medication name, dose, date/time, and reason for the waste. Level of Harm - Minimal harm or potential for actual harm Review of Inservice sign in sheet provided by the facility dated 7/31/23, revealed topics covered Narcs: Following MD orders, wasting Narcs lists nine nursing staff signatures. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105688 If continuation sheet Page 12 of 12