Health inspection·October 13, 2021

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to honor resident rights, by not ensuring 1. the facility had a system in place for residents to promptly receive mail on the day that it was delivered by the US Postal Service to include weekends, and 2. the privacy for all residents in a confidential and private manner related to having residents wear a colored wrist band to identify who had or had not been vaccinated for COVID-19. Residents Affected - Few Findings included: 1. A confidential Resident Council meeting was conducted on 10/11/21 at 10:00 a.m. with a group of five alert and oriented residents in attendance. An interview with the Resident Council Group during the meeting revealed the US Postal Service delivered mail to the facility daily from Monday to Saturday. The group reported the mail was received during the week, and delivered to the residents by the Activities Department. The Resident Council Group reported that no one delivered mail to the residents on Saturdays and Sundays. An interview on 10/12/21 at 11:10 a.m. with the Community Life Director revealed the Activities Department picked up mail from the front desk when it arrives, and then the Activities Department was responsible to distribute the mail. She reported the mail was distributed daily during the week and every other weekend when an activities person is on duty. She reported that on the alternate weekend when there was no activities person in the building, if mail comes in on a Saturday, it will be delivered to the residents on Monday. In an interview on 10/12/21 at 11:39 a.m. with the Nursing Home Administrator (NHA), she reported that she spoke to the Receptionist who reported that if the resident's name is on the mail it goes straight into the activities box for the Activities Department to deliver. She reported that on July 19th the facility implemented a Manager On Duty, who is responsible for doing rounds, delivering mail, and supervision of staff. She reported there was no job description for the Manager on Duty, and staff just do the task of delivering mail. She reported the weekend receptionist also had the responsibility for delivering mail, and if it was not done, the Activities Department will deliver the mail on Monday. In an interview on 10/12/21 at 11:57 a.m. the NHA revealed that sometimes on the weekend the nursing home mail was delivered to the ALF (Assisted Living Facility), which was located next door. She reported that if the mail was delivered to the ALF on a Saturday, the nursing home did not get the mail until Monday. Review of the facility policy titled, Mail, with an effective date of May 2003, and a revision date of 5/29/2019, revealed the following: -5. Mail will be delivered to the resident on the day it is delivered to the center. (If the resident is on a Leave of Absence (LOA), the center will hold or forward as instructed). 2. Review of the Resident Council minutes from 4/7/21 to 9/1/21 revealed the following: -6/3/21-New Business: Each Resident whom have been vaccinated will be issued a yellow band to wear. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 2 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0583 This will signify who has, and have not been vaccinated. Level of Harm - Minimal harm or potential for actual harm -7/7/21- Old Business: The yellow bands to know who have or have not been vaccinated. -7/14/21-Old Business: The yellow bands to know who have or have not been vaccinated. Residents Affected - Few -8/4/21-Old Business: The yellow bands to know who have or have not been vaccinated. -9/1/21-Old Business: The yellow bands to know who have or have not been vaccinated. During the confidential Resident Council meeting with the five alert and oriented residents on 10/11/21 at 10:00 a.m. it was revealed that three of five of the residents in attendance were wearing a yellow band on their wrist, which was clearly visible from 12 feet away. When asked about the meaning of the wristbands, the group reported the yellow bands are to identify if they have had their COVID-19 vaccine. They reported that if you don't have your yellow band; then that means that you are not vaccinated against COVID. Three of the five residents in attendance at the meeting reported they had yellow bands, as they rose their hands in the air to show them, and one of the five in attendance reported that her wrist was too small and her band kept falling off, and one of the five reported that she took her yellow band off for showering and forgot to put it back on. An interview on 10/11/21 at 12:25 p.m. with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) revealed the yellow band was to let everyone know if a resident was vaccinated. The NHA reported, This process has been scrapped because it wasn't going to work. She reported the Administration was aware of the yellow band process being scrapped, but did not convey this information to all staff or to any residents. She reported the process started in June (2021) and was scrapped earlier this month. The NHA reported the yellow band was just to show who was vaccinated and was supposed to be prideful. The ADON confirmed it also identified those who have not had their vaccine, if they are not wearing a wrist band. Random observations on 10/12/21 at 12:29 p.m. of a resident residing in room [ROOM NUMBER] revealed that she was wearing a yellow band on her wrist. An interview with the resident at this time revealed the yellow band meant that she was vaccinated. An observation on 10/12/21 at 12:34 p.m. of Resident #77 revealed that she was wearing a yellow ban on her wrist. An interview with the resident at this time revealed the yellow band was to let everyone know that she was vaccinated and that she was safe. Review of page 1 of 6 of the Notice Of Privacy Practices, located in the admission packet revealed the following: our nursing facility is required to: -Maintain the privacy of your health information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 3 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility did not ensure a clean and sanitary environment was provided during four of four days (10/10/21 - 10/13/21) related to the ice machine not being clean, nine resident rooms (#50, #51, #52, #53, #55, #56, #57, #59 and #61)) not swept or mopped, ceiling vents were filled with dirt, debris and bio-growth in six resident rooms (#53, #55, #56, #57, #59 and #61), and privacy curtains and linens stained and soiled in six resident rooms (#52, #53, #55, #56, #57 and #65) in one hall (Ground Floor - Hall A) out of six halls. Findings included: During a facility tour on 10/10/21 at 9:54 a.m., resident rooms were observed on Ground Floor - Hall A with dirt, debris, and stains on the floors and the walls. room [ROOM NUMBER] was observed with stains on the walls from feeding tube spills and on the floor. room [ROOM NUMBER] was noted with a dead insect on the floor in front of bed B. In addition, the ceiling vents were observed with dirt, debris, and bio growth in resident rooms #55, #56, #57, #59, and #61. The vents were noted fully clogged with visible dark ashy-looking material. On 10/11/21 at 9:32 a.m. observations were made on Ground Floor - Hall A of resident rooms #50, #51, #52, #53, #56, #57, #59 and #61 and revealed dirt and stains on the floors and walls. A privacy curtain in resident room [ROOM NUMBER] was observed with brownish stains on the bottom hem. The ceiling vents were noted with dirt, debris, and bio growth in resident room [ROOM NUMBER]. At 10:45 a.m., room [ROOM NUMBER] and #52 were observed with bed sheets stained with brown-looking substance. On 10/11/21 at 12:20 p.m., an observation was made of a blue mattress in resident room [ROOM NUMBER], noted with brown and white satins on the surface. On 10/11/21 at 12:30 p.m., an interview was conducted with Staff L, Certified Nursing Assistant (CNA). Staff L stated that they disinfect mattresses each time they change the bed. Staff L stated that if they see stains on the sheets, they replace them. On 10/11/21 at 1:08 p.m., the ice machine on the lower-level dining room was observed with bio growth on the edges. The outside of the machine was noted with drip marks on the door surface. The floors around the ice-machine were observed with dirt, stains, and debris. On 10/12/21 at 10:09 a.m., an observation was made of the privacy curtains noted with stains and brown-looking substance in resident rooms #52, #55, #56 and #57. An interview was conducted on10/12/21 at 10:04 a.m. with Staff K, Housekeeping. Staff K stated he cleans all resident rooms once daily. He cleans walls if they are dirty. Staff K said, It is a fast-paced routine. Staff K stated if he notices a dirty privacy curtain, he cleans it. Staff K said, If it is dirty, I will clean it, or let my supervisor know. I communicate with laundry to see if they have a spare one. Staff K said the vents in this hall (Hall A) were last cleaned the previous Sunday (10/3/21). On 10/12/21 at 2:44 p.m. an interview was conducted with the Housekeeping Account Managers Staff N and Staff O. Staff N stated he supervises aides but also assists with cleaning if needed. Staff O (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 4 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated he conducts walk throughs every time he is in the building, Monday through Friday. Staff O and Staff N were shown photographic evidenced of the tour conducted on Ground Floor - Hall A. Staff N said, That looks bad we will get on it right away. Staff O stated it was their expectation the rooms are cleaned daily. Staff N said they have trained the aides to report a pest siting to maintenance and add the room to the pest log. Staff O said during angel rounds in the morning, the angel team walks into each room and completes checks. Staff O said, We wash, dry, and replace with a clean one (privacy curtain). Staff O said, Yes, curtains are washed as needed. Staff N said, Curtains should not have stains. Staff O stated he was aware the ice-machine was leaking and that was why condensation build-up was on the equipment. Staff O said, It should not have bio-growth. A follow-up interview was conducted with the Nursing Home Administrator (NHA) on10/13/21 at 1:46 p.m. The NHA stated this hall [Ground Floor-Hall A] is the last of the areas that is on their working project. NHA said, We are aware of the vents situation. It's in our QA [quality assurance]. The NHA stated they had cleaned all rooms the day before and privacy curtains are being washed. She stated that she would be ordering some more. The NHA stated her expectation is that resident rooms should be cleaned at least once daily. The expectation is to maintain a clean environment for our residents. During a tour of Ground Floor - Hall A on 10/13/21 at 3:24 p.m., Rooms #56 and #57 were observed with dirt debris, and stains on the floors and walls. These rooms were observed in the same condition since 10/10/21. An immediate interview was conducted on 10/13/21 at 3:24 p.m. with Staff I, CNA. Staff I said, No, the rooms are not clean. They sure did not clean that. Staff I confirmed she had noticed the dirt and stains throughout the week. Staff I said, They [Housekeeping] should be cleaning all rooms every day. I can't say that it happens that way. On 10/13/21 at 3:28 p.m., an interview was conducted with Staff M, Housekeeping Aide. Staff M said, I try to clean all rooms when I'm here. Staff M stated she works two days a week. Staff M said, I don't know what happens the other days. It's hard to do a thorough job. On 10/13/21 3:31 p.m., a follow - up interview was conducted with the Housekeeping Managers (Staff N and Staff O). They were notified of the two rooms (#56 and #57) that had not been cleaned since Sunday [10/10/21]. Staff O and N conducted an immediate tour of rooms #56 and #57. Staff N stated that the rooms were on his list of rooms that needed attention. Staff O stated the expectation was the resident rooms will be maintained in a clean manner. Staff O said, No, that is not clean. The stains should be washed. When asked why the two rooms had not been cleaned since Sunday, Staff O said, It is not acceptable. we will clean now. Review of a document titled, [Name of Vendor] Quality Control Inspection - Housekeeping, dated 01/01/2000, revealed the facility's unsatisfactory inspection rating results conducted as follows: 09/27/21 room [ROOM NUMBER]: floors need cleaning. 09/29/21 room [ROOM NUMBER]: vent dusty. 10/01/21 room [ROOM NUMBER]: spills on wall, under bed floor debris, dusty vent. 10/04/21 room [ROOM NUMBER] floors with trash, vent need to be cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 5 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0584 10/05/21 room [ROOM NUMBER] dusty floors under bed Level of Harm - Minimal harm or potential for actual harm 10/06/21 room [ROOM NUMBER] vent dirty 10/08/21 room [ROOM NUMBER] trash by bed side table Residents Affected - Some 10/11/21 room [ROOM NUMBER] dirty vent, floors need sweeping / mopping. 10/12/21 room [ROOM NUMBER]: floors need sweeping / mopping, vent dusty. 10/13/21 room [ROOM NUMBER]: scuffs on walls, dusty floor under bed, vent need cleaning. Review of a document titled, ground floor, dated 10/13/21, showed a privacy curtains audit conducted by Staff N and Staff O on 10/13/21 and indicated stains were present in rooms: #50 bed B, #51 bed B, #52 bed A, #53 bed A and B, #54 bed A and B, #55 bed A, #57 bed A, #58 bed A, and #59 bed A and B. Review of the facility's policy titled, Daily Patient Room Cleaning, revised 09/05/17, page 16, showed the 5-step room cleaning method should be followed as: 1. Empty trash. 2. Horizontal dusting with a cloth and disinfectant spot cleans all vertical surfaces. 3. Spot clean. With a cloth and disinfectant spot clean all vertical surfaces. 4. Dust mop floor. Use dust mop to gather all trash and debris on floor. Sweep to the door, pick up with dustpan. 5. Damp mop floor with germicide solution. Damp mop floor working from back corner to door. The same policy under the section of, Cleaning Cubicle Curtains, page 25, showed an expectation stating if a curtain is stained, remove immediately, have spare curtains on hand to immediately replace dirty or torn curtains. A review of a facility policy titled, Ice Machine and Ice Storage Chests, revised January 2012, showed a policy statement of: ice machines and ice storage or distribution containers will be used and maintained to assure a safe and sanitary supply. #3. Our facility has established procedures for cleaning and disinfecting ice machines which adheres to manufacturer's instructions. The Infection Preventionist (or designee) maintains a copy. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 6 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility did not ensure the care plan was implemented for falls related to floor mats for one resident (#55) of four residents sampled for falls, and for not ensuring partial dentures were provided for one resident (#55) of thirty-six sampled residents. Findings included: Resident #55 was admitted to the facility with diagnoses of dementia with behavioral disturbance and acquired absence of right and left above knee, upon review of the admission Record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of the progress notes in the medical record revealed the following: 10/8/21 Resident was found on the floor in front of his bed by CNA (certified nursing assistant) during rounds. It appeared he fell out of his bed. No apparent no injury noted at this time. ROM (range of motion) performed. Resident denies any complaint of pain, stated I was going down but I couldn't stop it. Doctor was notified, new orders received for scoop mattress and floor mats. Resident's sister was also notified. Review of the physician's orders in the electronic medical record reflected an order dated 10/8/21 for bilateral floor mats. A review of the care plan dated 4/14/20 reveled a Focus as: [Resident #55] has had actual falls with no injury r/t (related to) poor balance, psychoactive drug use, bilateral AKA (above the knee amputation). An intervention dated 10/8/21 indicated the use of floor mats. Review of the CNA care instructions reflected the use of floor mats under Safety. On 10/10/21 at 11:43 a.m. an observation was conducted. Resident #55 was lying in his bed on a scoop mattress. There were no floor mats at the bedside or in the room. On 10/11/21 at 9:19 a.m. a telephone interview was conducted with Resident #55's family member. She said he fell a couple days ago. He falls out of the bed often. They said they are putting mats on the floor. They weren't down when he fell. He has fallen a number of times. In addition Resident #55's family member, said Resident #55's dentures went missing before the pandemic and they have not been found. The facility doesn't know where they are. Review of the 9/5/21 MDS assessment revealed no dental concerns. Review of the dental services notes in the medical record reflected the following: *4/4/19 Set of partial dentures delivered today. Dentures adjusted with acrylic until they seated properly in the mouth. Patient given instructions on new dentures and new denture cup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 7 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm *7/18/19 Lower partial and upper partial were adjusted today. Patient given denture adhesive to help with discomfort. Follow up appointment for possible adjustment needed. *3/6/20 Patient has upper and lower partials with moderate soft deposits on the lower and no deposits on the upper. Residents Affected - Few There were no further dental notes in the record. Review of the 4/4/19 dental services receipt revealed an upper partial and lower partial denture were delivered. A social services assistant acknowledged receipt of the dentures as well as a CNA who signed the receipt. Review of the CNA care instructions in the medical record reflected under care: The resident has upper and lower natural teeth with some missing. Upper and lower partials. Report changes to the nurse. The instructions also indicated for personal hygiene/oral care the resident is totally dependent on one staff for personal hygiene and oral care. On 10/12/21 at 9:31 a.m. an observation was conducted. Resident #55 was in his bed with his eyes closed. The bed was in the low position. There were no floor mats at the bedside or anywhere in the room. On 10/12/21 at 9:40 a.m. an interview was conducted with the resident's CNA, Staff C. Staff C said she has worked at the facility before and has been at the facility for the last three to four weeks. She has cared for Resident #55 before. Resident #55 does not have dentures. He said he doesn't like them. He has a regular diet and doesn't have any chewing problems. He is a fall risk. She was not aware that he had fallen recently. Staff C said Resident #55 gets frequent checks, every half to one hour. He used to live upstairs and he had the dentures then. He doesn't like them. He won't wear them. Staff C, CNA said she looks at the [NAME] in the computer to find out what the resident's care plan is. She said she was not aware of any falls mats on his care plan. On 10/12/21 at 9:48 a.m. an observation was conducted with Staff C, CNA who confirmed there weren't any floor mats in Resident #55's room. Upon review of the care [NAME] in the electronic medical record, Staff C confirmed there were floor mats on it. On 10/12/21 at 9:04 a.m. an interview was conducted with the Social Services Director (SSD). She stated dental comes out once a month and some residents have withdrawn from the program. We made a referral for him (Resident #55) in June. He withdrew from the program. Dental reached out to the POA (power of attorney) to see if he wanted to reinstate the service. They sent the authorization to start the program. They usually will call the family and follow up with the authorization. On 10/12/21 at 10:21 a.m. a follow up interview was conducted with the SSD. She said she put in the referral on July 5th and called the dental provider. They will see him October twenty-seventh. The dentures are new information to us. We didn't know they were missing. There are no grievances about them. On 10/12/21 at 10:46 a.m. an interview was conducted with Staff D, Registered Nurse (RN)/Unit Manager. Staff D said after a fall they do the assessment and notify the doctor and family. They look at the number of falls and look at what interventions are needed. They interview the patient and try to figure out why he fell. We talk to the nurse and the CNA and try to come up with an appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 8 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intervention. Once the intervention is in place, we let MDS know and we also talk about it in morning meeting or stand down meeting. He fell from his bed. She (Staff D) was here when it happened. The fall mats are being put in place right now. Our policy states the intervention is immediate. She said she would have to ask the nurse why the floor mats weren't placed. The intervention has to be placed immediately. We check to make sure we have the intervention. Then we put the orders in. If it was later on in the evening, then we would do it in the morning meeting. On 10/12/21 at 11:07 a.m. an interview was conducted with Staff B, RN Supervisor. She said the fall intervention was a scoop mattress. He doesn't have any floor mats. He doesn't have any dentures that she knows of. On 10/12/21 at 12:46 p.m. an interview was conducted with the ADON. She said the facility has a fall protocol. They have interventions they can put in before the IDT (interdisciplinary team) gets it. It depends on why he fell. Those are things the nurse would do first before the IDT looks at it. This fall was over the weekend. We come in Monday and review it. He fell before. They put him in a bigger bed, that was the IDT intervention. He is known to flip across the bed. They are supposed to get the mats the same night as he had the fall. There was an issue with the number of mats at the time. She doesn't think he wears dentures. On 10/13/21 at 9:05 a.m. an interview was conducted with the SSD. She said the note from March 2020 said he had partials. On 10/13/21 at 10:17 a.m. a follow up interview was conducted with the ADON. She said they meet as an IDT and talk about the falls after. It is something they do right away. We have a fall package with suggestions so you can do something right away. The nurse looks at it and puts an intervention from there in right away. Maybe the mats were picked up and they forgot to put them back. He had a fall a while ago and might have had them then. He was on hourly checks to see if he is wiggling around out of the bed. On 10/13/21 at 11:31 a.m. another interview was conducted with the ADON. She said he has his own teeth. She has never seen him with partials. He has been to the hospital several times back and forth. He might have come back without them. If the CNA has to sign off something on a daily basis, then they should look, and if they didn't see it then they should go to the nurse and then to social services. We have dental services here so she would get them out to look. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 9 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to provide appropriate treatment and services for enternal feeding by not ensuring the physician's order for the tube feeding rate was followed for one resident (#195) of six residents with tube feedings. Findings included: Review of the admission record revealed Resident #195 was admitted to the facility on [DATE] with diagnoses of moderate protein calorie malnutrition and gastrostomy. Review of the 10/4/21 Initial Nutritional Evaluation revealed the following: III. Tube Feeding/Oral Nutrition A. Tube feeding orders: yes B. Tube feeding orders: Jevity 1.5 at 65 ml (milliliters) per hour Z5. Plan/Recommendations: Jevity 1.5 to run at 55 ml per hour times 20 hours/day. Review of the physician's orders in the electronic medical record dated 10/8/21 reflected Enteral feed order every shift 55 ml/ hr (hour) for 20 hours. Further review of the physician's orders dated 10/10/21 showed Jevity 1.5 at 55 ml/hr fro 20 hours. Review of the care plan dated 10/4/21 showed the following information: [Resident #195] is at risk for malnutrition r/t (related to) current diagnoses of moderate PCM (protein calorie malnutrition), dementia, COPD (chronic obstructive pulmonary disease), NPO (nothing by mouth) diet r/t esophageal stricture, failed swallow study 10/1/21. Enteral feeding provides 100% of estimated needs. Interventions included Enteral feeding as ordered. On 10/10/21 at 12:23 p.m. an observation was conducted. Staff A, Licensed Practical Nurse (LPN) came into Resident #195's room and restarted the tube feeding that was beeping. The setting on the tube feeding pump was Jevity 1.5 set at 65 ml per hour. On 10/12/21 at 9:25 a.m. an observation was conducted. The tube feed pump was running at 65 ml an hour. On 10/12/21 at 10:57 a.m. an interview was conducted with Staff B, Registered Nurse (RN) Supervisor. Staff B, RN reviewed the tube feeding order and confirmed it was 55 ml an hour. An observation at 11:01 a.m. was conducted with Staff B, RN in Resident #195's room. Staff B confirmed the setting on the pump was 65 ml an hour and wasn't correct. On 10/12/21 at 12:39 p.m. an interview was conducted with the Assistant Director of Nursing (ADON). She said when you get the note from the RD (registered dietician) the order is supposed to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 10 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete changed right away. Change it on the patient and the orders. The ADON said she got the paper from the CDM (certified dietary manager) on Thursday, That's the day I put in the orders. I called the CDM and she got the RD eval (evaluation) for me. That was on Sunday. I put the orders in. Normally the nurses would do it. I don't know if she gave it to anyone or not. On 10/13/21 at 10:12 a.m. a follow up interview was conducted with the ADON. She said usually the order for the tube feed comes from the hospital. She said, The next morning the RD will check it and then make her recommendations. The doctor would put preliminary orders in if we didn't have one from the hospital. From looking at the paperwork that I got from the CDM on Sunday, the nurse had the information, but I don't know if they tell it in report. I would have to ask. Event ID: Facility ID: 105718 If continuation sheet Page 11 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility did not ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and three errors were identified for two (Resident #41 and #48) of four residents observed. These errors constituted a medication error rate of 12 percent. Residents Affected - Few Findings included: An observation of First Level medication administration on 10/12/21 at 9:09 a.m., resulted in Staff E, Licensed Practical Nurse-Agency (LPN), not giving Resident #48 one capsule of Creon Delayed Release Particles 12000 Unit (Pancrelipase (Lip-Prot-Amyl)) on time and with meals as a digestive aid. During the observation Staff E, LPN confirmed the medication was late, and it was supposed to be administered at 7:30 (a.m.). Staff E, LPN stated, I came in and could not get access to the computer, it's always like this every time I work here. Staff E, LPN, further revealed he did not tell anyone in the facility that medications were late and did not call the physician. Staff E, LPN crushed a medication identified as Potassium Chloride CL ER Tablet Extended Release 10 milliequivalents (MEQ). On the pharmacy label, it read, Do not Chew or Crush take medication with water. Staff E, LPN indicated Resident #48 had a nectar thick diet, and all her medications needed to be crushed. He stated, I didn't realize I crushed it. According to the pharmaceutical manufacturer of CREON, their medication guide accessed at https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020725s007MedGuide.pdf Page 03 of Page 05 reads Take CREON exactly as prescribed, Page 04 of Page 05 reveals Always take CREON and with a meal or snack and enough liquid to swallow CREON completely. Record review of active physician orders for October 2021 for Resident #48 read, Creon Capsule Delayed Release Particles 12000 Unit (Pancrelipase (Lip-Prot-Amyl), Give 1 Capsule by mouth with meals for pancreatic enzyme replacement and give with meals. Review of the electronic medication administration record (EMAR) revealed the medication scheduled administration times are at 07:30, 1200 (noon) and 1700 (5:00 p.m.). The active physician order, dated 11/20/2020, read, Potassium Chloride CL ER Tablet Extended Release 10 MEQ Give 3 Tablet by mouth one time a day for Hypokalemia. A second observation of medication administration was conducted on the First Level with Staff E, LPN on 10/12/2021 at 11:36 a.m. During the observation Staff E, LPN was observed administering insulin Aspart Solution 100 Unit/milliliter (ML) and Injected 6 units subcutaneously in Resident #41's right upper arm. Staff E, LPN stated, I'm priming one unit and then the order is to give 5 units. Staff E was asked if it was the facility's policy to prime insulin flex-pens with one unit and he stated, A manufacturer pharmacist told me to do that. I was taught that way to do it. Review of the NovoLog FlexPen manufacturer's instructions for the of usage and safety guidelines: Page 02 of 14 read, Prime your pen: Turn the dose selector to 2 units. Press and hold the dose button. Make sure a drop appears. Select your dose: Turn the dose selector to select the number of units you need to inject. Record review of active physician orders for October 2021 for the Resident #41 read, Room Insulin Aspart Solution 100 Unit/ML Inject 5 unit subcutaneously three times a day related to Type 2 Diabetes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 12 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Mellitus without Complications dated 08/26/2021. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Director of Nursing (DON) on 10/12/2021 at 2:26 p.m. The DON was notified of the medication administration observations made of Staff E, LPN. The DON stated, I hear two units, but other people say 1 or 2 units when priming the flex pens. She indicated that Staff E, LPN told her what happened, and she revealed she told him it was a medication error. The DON further indicated extended-release medications should not be crushed. Residents Affected - Few On 10/13/2021 at 9:22 a.m., a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant was informed of observations made of Staff E LPN during medication administration. The Pharmacist stated, As far as crushing Extended-Release Medications, it should never be crushed, it is not acceptable to crush and administer. She further revealed that if Creon was given out of the meal-time window, it is an error. The Pharmacy Consultant then stated, As far as the insulin priming goes, that is an odd situation, but yes it's the policy to do two units when priming flex-pens, and staff must follow manufacturer's guidelines. A facility provided policy titled, Insulin Administration-Injection Pens, revision date of 10/10/2017, Page 01 of 01 read under Procedure, .Prime per manufacturer's instructions. Facility policy titled, Administering Medications, revision date of April 2019, Page 01 of 03 read under Policy Statement, Medications are administered in a safe and timely manner. The Policy Interpretation and Implementation section included: 4. Medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 13 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the facility failed to ensure one medication was stored and locked up for one day (10/12/2021) of four days of the survey and failed to follow their policy to secure medications appropriately in three (First Floor-B Hall, First Floor - A Hall, Ground Floor - A Hall) of five medication carts. Findings included: On 10/11/2021 at 3:45 p.m., an observation of the medication cart on first floor B Hall medication cart included loose tablets as follows: two round white, one white oval, one round yellow, 1/2 yellow, and four white half pieces with a white ¼ piece. Staff F, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured tablets. (Photographic Evidence Obtained.) On 10/11/2021 at 4:00 p.m., an observation was made of the First Floor medication cart located on the A Hall, and revealed one loose white tablet. Staff G, Registered Nurse (RN) confirmed the presence of the unsecured tablet. On 10/11/2021 at 4:15 p.m., an observation of the Ground Floor Medication Cart on the A Hall Ground Floor included a ½ white loose tablet. Staff H, LPN confirmed the presence of the unsecured ½ tablet. On 10/12/2021 at 9:09 a.m., an observation was made of the medication administration in resident room [ROOM NUMBER]-A. During the observation Staff E, LPN walked out of the resident's room and left medication of Artificial Tears Solution 1.4 Polyvinyl Alcohol in a clear medication cup on the resident's bedside table. When he came back into the room Staff E was immediately interviewed. Staff E, LPN did not say why, when he was asked about the unattended medication. On 10/13/2021 at 9:07 a.m., an interview with the Director of Nursing (DON) was conducted. During the interview she stated, My expectation is that there are no loose pills in the medication carts and no medications left at bedside. On 10/13/2021 at 9:22 a.m., a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant was informed of observations made of the unattended medication during medication administration and the loose medications. The Pharmacist stated, As far as loose medications in the medication cart, they should not have any; and of course the staff should not leave medications unattended at bedside. A review of the facility's policy and procedure titled, [Name of Vendor] Drug Storage Guide, effective 2019 Page 01 of 02, read, Medication Cart Check: No loose pills in drawers or sticky drawers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 14 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and policy review the facility did not ensure that foods were served from clean and sanitary dishware during two of two lunch meal service observations, in two (lower-level dining and main level dining) of two dining rooms. Findings included: On 10/11/21 at 12:31 p.m., a dining service observation was made in the lower-level dining room during the lunch meal. A group of residents were observed in the dining area being assisted by Staff I, Certified Nursing Assistant (CNA). An observation was made of the round plate covers noted with stainless steel tops and bottom inserts. The top covers were in direct contact with the resident's food during transport and service. The stainless-steel parts of the bottom and top covers were noted with brown, greasy, burnt, and built-up oily residue. (Photographic Evidence was Obtained) On 10/11/21 at 12:32 p.m., an interview was conducted with Staff I, CNA. Staff I was observed uncovering residents' trays and distributing lunch. Staff I was asked if the food covers were clean. Staff I said, Does not look clean to me. They should just scrub them. An interview was conducted on 10/11/21 at 12:46 p.m. with Staff J, CNA. Staff J was sitting at the table with lunch trays piled on one end of the table. Staff J was asked what the expectation was related to cleanliness of food covers. Staff J said, They look dirty to me. They have always been like that. I think they should clean them. Staff J confirmed that she has observed the food covers with the stained brown looking matter, but had not said anything to anyone. On 10/12/21 at 12:15 p.m., a second observation was made of serving tray covers in the main level dining room. The stainless-steel parts of the bottom and top covers were noted with brown, greasy, burnt, and built-up oily residue. Photographic Evidence was Obtained) An interview was conducted on 10/12/21 at 12:17 p.m. with the Kitchen Manager (KM). The KM observed the covers and said, Oh no, that's not good. The KM rubbed her fingers on the surface of the stainless-steel surface. Grease was noted on her fingers and the KM stated, we just need a scouring pad. The KM said, It should come off. Problem is that we run them through the machine. I don't think they are getting cleaned up. The KM stated that she would try and clean them. The KM said, If they don't clean -up, I will let the Nursing Home Administrator (NHA) know so they can purchase new ones. On 10/12/21 at 2:02 p.m., the Registered Dietician (RD) brought a cleaned plate cover and said, Look, they are cleanable. The RD stated that the KM was scrubbing all of them. The RD stated that residents should be served with clean dishware. The RD stated that she would communicate the expectation to the KM. On 10/13/21 at 10:38 a.m., when the RD was asked if she had noticed them before, the RD said, I have not paid attention to that. I prefer to leave them inserted in the cover. I do not look inside and underneath. An interview was conducted on 10/12/21 at 2:09 p.m. the NHA was asked if residents' dishware should look brownish with stains and built-up oil residue. The NHA said, Absolutely not. They should not look like that I will let the KM know they should be cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 15 of 16 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm A review of an undated facility policy titled, Dish Machine Operation, showed that the facility's goal was to ensure that all china, silverware, glassware, kitchen utensils, pots and pans are all spotlessly clean and sanitized. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 16 of 16