Inspection·October 9, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Nursing Progress Note, dated 8/30/23 at 7:47 p.m., revealed Patient c/o [complaints of] of [sic]chest pain called 911 was transported to hospital. Review of progress notes, for August 2023, did not show any documentation that the family, or the provider was notified of Resident #1's change of condition or transfer to the hospital. A review of hospital records showed Resident #1 was admitted to the hospital on [DATE]. In the Emergency Department he was found to be hypotensive and nonresponsive to normal saline bolus. Testing performed showed a urinalysis was positive for a urinary tract infection with yeast, and a chest x-ray and CAT (Computed Axial Tomography) scan were positive for right lower lobe pneumonia. Resident #1 was admitted to the Intensive Care Unit for septic shock. An interview was conducted on 10/9/23 at 1:32 p.m. with the DON. The DON said they do not necessarily call family if a resident goes to the hospital via 911. She said Resident #1 is his own responsible party, so they do not have to notify the Power of Attorney/Emergency Contact. The DON said they Only have to notify the responsible party, and Resident #1 is responsible for himself. She said The power of attorney is just on stand-by until the resident is incompetent. The DON said she was on vacation at the time of this incident. She said when she returned, she was told the family had been concerned about how long it had taken for paramedics to arrive after 911 was called and staff did not know he had called 911. The DON reviewed the grievance and said the Assistant Director of Nursing (ADON) who filled out the grievance no longer worked at the facility. The DON said It is not acceptable. That's not an appropriate response. She should not have discussed refusals. That did not have anything to do with that grievance. She should have followed up with why the family was not notified. A review of a facility policy titled Complaint/Grievance, revised 10/24/22, showed the following: Policy: The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner Procedure: 8. The individual voicing the grievance will receive follow up communicating with the resolution, a copy of the grievance resolution will be provided to the resident upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 2 of 15 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 10/09/2023 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 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 observations, interviews, and record review, the facility failed to provide adequate supervision to mitigate the risk of a fall with major injury for one resident (#1) out of three residents sampled for falls. Findings included: On 10/9/23 at 1:50 p.m., Resident #1 was observed lying in bed. During an interview, Resident #1 did not remember falling out of bed and did not want to talk further. Review of a facility document titled, Incident by Incident type, dated 10/09/23, showed on 7/22/23 at 8:45 p.m. Resident #1 had a fall incident. Review of the admission Record showed Resident #1 was originally admitted on [DATE], with diagnoses including gout, difficulty walking, idiopathic peripheral neuropathy, psychotic disorder with delusions, and lack of coordination. A diagnosis of left femur shaft fracture was added on 7/31/23. Review of Resident #1's Medicare 5-day Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed his Brief Interview for Mental Status (BIMS) score was 14, indicating he was cognitively intact. Section G - Functional Status showed for transfers the resident was total dependent with two plus person physical assist. Section G also showed Resident #1 has functional limitation in ROM (Range of Motion) in lower extremity and he required a wheelchair for mobility. Review of Resident's #1 care plan showed a Focus of Risk for falls related to deconditioning, gait/ balance problems, psychoactive drug use, initiated 01/12/23. Interventions included the following: -Anticipate meeting the resident's needs. -Educated the resident/resident's representatives / caregivers about safety reminders and what to do if a fall occurs. -Ensure that the resident is wearing appropriate footwear/ non-skid socks when ambulating or mobilizing in w/c (wheelchair). -PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed). Review of Resident's #1 care plan showed a Focus on Behaviors, throws himself on the floor, initiated 01/16/23 and revised 8/22/23. Goal: cooperate with care, initiated 1/16/23 and revised 8/3/23. Interventions: praise when behavior is appropriate initiated 1/16/23. Review of Resident's #1 care plan showed a Focus on Behaviors, resident has mood swings, aggressiveness, yells and curses at staff, throws containers on the floor, initiated 1/31/23 and revised 8/17/23. Interventions included the following: -Administer medications as ordered -Anticipate and meet the resident's needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 3 of 15 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 10/09/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Educate the resident/resident's representatives / caregivers on successful coping and interaction strategies. Review of Resident's #1 Medication Administration Record (MAR) documentation of behaviors, initiated 4/23/23 and discontinued 7/17/23, showed on 7/2/23 resident resisted care, all other entries indicate no behaviors. Review of Resident's #1 Medication Administration Record (MAR) documentation of behaviors, initiated 7/22/23 at 7:00 p.m. and discontinued 7/25/23 at 11:13 a.m., showed on 7/22/23 during the 7:00 p.m. and 7:00 a.m. resident had agitation and verbally inappropriate All other entries indicate Not Applicable NA or No behaviors. Review of doctor's progress note, dated 5/6/23, revealed Resident #1 had generalized musculoskeletal weakness. Review of Resident #1's progress notes showed on 7/22/23 there was no documentation related to the fall. Review of a nursing progress note, dated 7/24/23, revealed, The resident had a fall on Saturday, (7/22/24) threw himself on the floor. Today resident states he has pain in the left hip, knee, and ankle. MD (medical doctor) notified and X-Rays ordered. Review of an Interdisciplinary Team (IDT) note, dated 7/24/23, revealed, The IDT met to review fall that occurred on 7/22, resident throws himself on the floor. Resident has behaviors. Medications are different from the last admission. MD notified. IDT recommends therapy referral and psych [psychiatry] consult with medication review. Review of the Fall Investigation Form, dated 7/22/24, timed 3:43 p.m., shift 7:00 a.m. to 3:00 p.m., revealed the facility did not complete a fall Root Cause Analysis for Resident #1. Review of physician orders, dated 7/24/23, revealed Resident #1 had an X-ray to left hip 2 views, left knee 2 views and left ankle view, portable services needed due to weakness and fall risk. Review of Radiology Result Report, dated 7/24/23, revealed recent left intertrochanteric (thigh bone) fracture of distal (away from the center of the body) femur. Review of a nursing progress note, dated 7/25/23, revealed Advanced Registered Nurse Practitioner (ARNP) called for X-ray results of recent left intertrochanteric fracture with new orders to send the resident to the hospital for evaluation/ treatment. Review of Resident #1's electronic medical record (EMR) on 07/22/23 during the 7:00 a.m. to 7:00 p.m. shift, revealed no documentation related to behaviors throughout the day. On 10/09/23 at 4:20 p.m. an interview was conducted with the Director of Nursing (DON). She stated the resident was trying to throw himself on the floor all day on 7/22/23. She said, They said he had behaviors all day. That is not documented. I know. The nurse put it on her statement. They should have notified the doctor if he was attempting to throw himself on the floor. The DON stated the resident did not complain of new pain immediately after fall. She stated the pain started to worsen, and Morphine was ordered. On Saturday 7/24/23 an X-ray was ordered. The results came in on the same day, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 4 of 15 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 10/09/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showing he had suffered a fracture and was sent out on 07/25/23 and returned 07/31/23. The DON stated she investigated the fall and had spoken to all the nurses and Certified Nursing Assistants (CNAs). The DON produced two witness statements from Staff A, LPN and Staff B, CNA. The DON read Staff A, Licensed Practical Nurses' (LPN 's) statement, dated 07/22/23, Throughout the day patient was attempting to throw himself on the floor so he can go back to the hospital and get out of here gave resident his meds he calmed down. Went to pass meds came back in shortly and resident was on the floor next to the bed. Resident reports no new pain no new skin areas. Assisted off floor with [mechanical lift] back to bed. The DON read Staff B's statement, dated 7/22/23, CNA called me into [Resident's #1 room]. Resident was on the floor. Got resident up with a two person assist with a [mechanical lift] and back into bed. The DON stated the nurse should have notified the physician of resident's attempt to throw himself on the floor. On 10/09/23 at 5:18 p.m., an interview was conducted with Staff A, LPN. She stated she worked with the resident the day he fell. She stated she did not remember the resident having unusual behaviors. She stated she did not witness the fall. Staff A, LPN stated the resident had been telling staff he would show them how he could walk. Staff A stated if a resident was threatening to throw himself on the floor, she would notify the physician. She stated she would have contacted the DON and implemented interventions to ensure the resident's safety. Staff A stated she did not recall why the on-call [physician] was not notified. On 10/9/23 at 4:20 p.m., the DON said Staff B, CNA was not available to interview. She is out. On 10/09/23 at 4:13 p.m. an interview was conducted with Resident #1's Primary Care Physician/Medical Director (PCP/MD). He stated between him and his ARNP Resident #1 was seen at least 4 times a week. He stated during their visits, they conduct an exam, monitor vitals and document any relevant observations. He stated the resident was always the same during their visits and he did not have any concerns [including behaviors]. The PCP/MD did not have any additional information related to the resident's fall. On 10/09/23 at 5:24 p.m. an interview was conducted with the DON, Nursing Home Administrator (NHA), and the Regional Nurse Consultant (RNC). The DON stated she would have expected the nurse to notify the physician if the resident was verbalizing an intent to throw himself on the floor. The DON said, They could have laid fall mats and lowered the bed. You could not have expected the staff to provide 1:1 without orders. We did not have extra staff to sit with him, especially on a weekend. This resident has behaviors. Everyone knows that. The RNC stated if the resident was verbalizing wanting to throw himself on the floor, they would have implemented their safety procedures. She stated they would have notified the physician. Review of an undated facility document titled, New Fall Event Checklist, showed after a fall the resident is assessed, provided assistance to get up if appropriate with instructions not to move resident if injury is suspected. A risk management report to include a description of the event, what the resident reported happened and the assistance staff provided. The doctor and the resident's family / Power of Attorney (POA) is notified. The resident's change of condition, level of pain and all assessments is documented in risk management event documentation. A review of current medications is completed. A Root Cause Analysis (RCA) is completed by the IDT the next day. Review of a facility policy titled, Fall Management, revised on 07/29/19. Overview: Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 5 of 15 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 10/09/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/ herself, is considered a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) minimize the potential for a resulting injury. Process: A. Fall Mitigation: 1. Resident to be evaluated for fall risk on admission / re-admission, quarterly, annually or upon identification of a significant status change. a. Fall risk is based off results of fall risk evaluation. b. Contributing factors i.e., medications, diagnosis. B. Fall Mitigation strategies: 1. Develop resident centered interventions based on resident risk factors. C. Post Fall strategies 1. Notify the Physician and resident representative. 2. IDT to review fall documentation and complete root cause analysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 6 of 15 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 10/09/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide nursing and related services to assure one resident (#1) out of three residents sampled, attained and maintained the highest practicable physical, mental, and psychosocial well-being related to 1) not identifying a change in condition in a timely manner, 2) not notifying provider and resident representative of change in condition, 3) not being prepared for wound care, and 4) not ensuring pain was managed adequately. Findings included: An interview was conducted on 10/9/23 at 2:26 p.m. with Resident #1's family members. The family said on 8/20/23 they were on the phone with Resident #1, and he was complaining of pressure and pain in his chest. They said the resident was yelling ow and nurse, but no one came. One family member said they stayed on the phone with the resident. After about 40 minutes, another family member stated they called the nurses' station and told the person that answered the phone the resident was complaining of chest pain. The person on the phone told them they would notify the nurse and get back to the family. The first family member remained on the phone, and heard no one come in the room. The second family member said after 30 minutes they called the nurses' station again and they were told someone had been in to check on the resident. The family said it had not been the case because they were on the phone the entire time. Eventually, the family heard the nurse come to the room and Resident #1 told the nurse he was having pressure/pain in his chest. The family said they heard the nurse tell the resident It was probably indigestion, then the nurse left the room. The family called the local police department and sent an ambulance to the facility to take Resident #1 to the hospital. The family said they were on the phone throughout the process with Resident #1 for approximately 2 hours. The family said they called the police department at 7:35 p.m. and they heard paramedics arrive at approximately 7:40 p.m. The family said the facility never reached out to them after they called the nurses' station or called to notify them of Resident #1's transfer to the hospital. They said at the time the facility didn't know it was them who called the ambulance. The family said they later filed a grievance with the facility. The family members also said they are concerned about the pain the resident has. They said they had told the nurse they would like to speak to the doctor, but the nurse told them the doctor doesn't speak to anyone. Review of a Nursing Progress Note, dated 8/30/23 at 7:47 p.m., showed Patient c/o [complaints of] of [sic]chest pain called 911 was transported to hospital. Review of admission records showed Resident #1 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including fracture of shaft of left femur, severe sepsis, Type 2 Diabetes Mellitus, chronic pain syndrome, hypertensive heart disease, stage IV pressure ulcer on sacrum, psychotic disorder with delusions and anxiety disorder. Review of Resident #1's Medicare 5-day Minimum Data Set (MDS,) dated 9/15/23, Section C, Cognitive Patterns, showed the resident had a Brief Interview for Mental Status score of 14, indicating he was cognitively intact. Section G, Functional Status showed the resident was totally dependent for transfers, toilet use, and locomotion on and off the unit. Review of Resident #1's care plan showed a focus area of Chronic pain related to chronic pain syndrome, gout, neuropathy, and Acute Pain related to impaired mobility, wound, and left hip fracture, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 7 of 15 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 10/09/2023 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 0726 dated 1/12/23 and revised on 7/25/23. Interventions included the following: Level of Harm - Minimal harm or potential for actual harm -Administer analgesia as per orders. -Anticipate the resident's needs for pain relief and respond immediately to any complaint of pain. Residents Affected - Few -Monitor and document for side effects of pain medication. -Monitor/record/report to nurse any signs and symptoms of non-verbal pain. There was an additional focus area of pressure injury to sacrum, initiated 1/11/23. Interventions included: -Administer treatments as ordered and monitor for effectiveness. -If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team), and resident representative to determine why and try alternative methods to gain compliance. -Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Review of active orders showed the following: -Acetaminophen tablet 325 mg. Give 2 tablets by mouth every 6 hours as needed for mild pain. Date 9/12/23. -Oxycodone HCL oral tablet 10 mg. Give 1 tablet by mouth every 6 hours as needed for moderate pain non-acute pain exception. Date 10/1/23. -Cleanse sacrum with wound cleanser, pat dry apply Dakin's 0.25% and dry dressing. Every shift. Date 10/7/23. -Assess resident for pain every shift. Non-pharmacological interventions: 1=relaxation, 2=light touch, 3=imagery, 4=exercise, 5=music, 6=N/A, 7=other see progress notes. Document corresponding code and pain level in supplemental documentation. Date 9/11/23. -Pregabalin Oral Capsule 100 mg. 1 capsule twice a day for neuropathy. Order dated 9/12/23. Several attempts were made to interview the nurse who cared for Resident #1 on 8/29/23, but the Director of Nursing (DON) informed us the nurse was in class all day and couldn't call us. Review of Resident #1's assessments showed a Change in Condition form was started on 8/30/23 at 6:54 p.m. however, the form was never completed. No other Change in Condition forms were completed on 8/29/23 or 8/20/23 for Resident #1's transfer to the hospital. Review of progress notes did not show any documentation that the family or the provider was notified of Resident #1's change of condition or transfer to the hospital. Review of provider notes showed Resident #1 was seen by the primary care provider's nurse practitioner on 8/29/23 prior to going out to the hospital. The note showed the resident was seen for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 8 of 15 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 10/09/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few follow-up appointment and he was lying in bed and was lucid, but a poor historian. The note showed the resident is slowly improving with inpatient rehabilitation and his wound is slowly improving. The physical exam showed Resident #1 was in no acute distress, had normal respiratory effort normal to auscultation, cardiovascular had regular rate and rhythm, and genitourinary was deferred. The plan showed Patient stable at the time of visit. Continue present management, wound care, diet, colostomy care, rehabilitation, tender loving care and supportive care. The nurse practitioner noted she would Continue to follow-up and monitor the patient very closely. This had been the identical note, word for word, entered by the nurse practitioner for previous visits on 8/25, 8/24, 8/18, 8/17, 8/11, 8/10, and 8/4/2023. Review of hospital records showed Resident #1 was admitted to the hospital on [DATE]. In the Emergency Department he was found to be hypotensive and nonresponsive to normal saline bolus. Lab tests showed urinalysis was positive for a urinary tract infection with yeast, and chest x-ray, and CAT scan (Computed Tomography Scan) were positive for right lower lobe pneumonia. Resident #1 was admitted to the Intensive Care Unit for septic shock. The DON provided a signed statement saying The resident went to the hospital on 8/30/23, no change in condition was done due to the nurse not being aware of the change in condition. EMS showed up to the facility and took patient. 911 not called by nurse or facility staff. An interview was conducted on 10/9/23 at 1:32 p.m. with the DON. The DON said they do not necessarily call family if a resident goes to the hospital via 911. She said Resident #1 is his own responsible party, so they do not have to notify the Power of Attorney/Emergency Contact. The DON said they only have to notify the responsible party and Resident #1 is responsible for himself. She said, The power of attorney is just on stand-by until the resident is incompetent. The DON said she was on vacation at the time of this incident. She said when she returned, she was told the family had been concerned about how long it took for paramedics to arrive after 911 was called and staff did not know he had called 911. The DON reviewed the grievance and said the Assistant Director of Nursing (ADON) who filled out the grievance no longer worked at the facility. The DON said It is not acceptable. That's not an appropriate response. She should not have discussed refusals. That did not have anything to do with that grievance. She should have followed up with why the family was not notified. Resident #1 returned to the facility from the hospital on 9/11/23. An interview was conducted on 10/09/23 at 11:55 a.m. with Staff A, Licensed Practical Nurse (LPN.) Staff A, LPN said Resident #1 stays in his bed and wants to sleep most of the day. She said she thinks the resident has given up. Staff A, LPN said she was told in morning report Resident #1 refused wound care this morning. She said she could try again and see if he would do it. When asked if he typically received pain medication prior to attempting wound care Staff A, LPN said, He is aware and can ask for it if he wants it. She added the resident hadn't asked for pain medication before wound care previously. Staff A, LPN said she would offer him pain medication and then see if he would allow wound care to be completed. Staff A, LPN said a pain management doctor does see Resident #1 for pain control. Staff A, LPN said the resident had scheduled Morphine and Oxycodone in between prior to going to the hospital. She said she doesn't know why the Morphine was stopped. Staff A, LPN said according to the resident it helped. She said Resident #1 regularly complains of pain. Review of Resident #1's September Medication Administration Record (MAR) showed pain monitoring in place beginning 9/12/23 every shift. Nurses signed off pain monitoring each shift but did not document the pain level per the order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 9 of 15 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 10/09/2023 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 0726 Review of Resident #1's August 2023 MAR showed the resident was taking the following medications for pain prior to going to the hospital: Level of Harm - Minimal harm or potential for actual harm -Pregabalin 300 mg. 1 capsule every 12 hours for neuropathy. Residents Affected - Few -Morphine Sulfate Extended Release 30 mg. 1 tablet every 12 hours for moderate pain. -Roxicodone 30 mg. 1 tablet every 4 hours as needed for breakthrough moderate pain. -Robaxin 750 mg. 1 tablet every 12 hours as needed for moderate pain. August 2023, September 2023, and October 2023 MAR showed Resident #1 was regularly rating his pain level from 5-10 out of 10. An interview was conducted on 10/9/23 at 1:48 p.m. with Resident #1. The resident was lying in bed and had a grimace on his face when he moved. The resident said he didn't really remember the last visit to the hospital and what happened. The resident did not want to answer questions and said he was in pain. An observation was conducted on 10/9/23 at 1:50 p.m. of Staff A, LPN entering Resident #1's room and asking if she could do wound care on his sacral wound; the resident agreed. Staff A, LPN asked a Certified Nursing Assistant (CNA) to help her. At 1:52 p.m. the two staff members positioned Resident #1 on his right side for wound care. Staff A, LPN was then asked where the dressing and wound care supplies were and she said, Oh no, then left to go get the supplies. At 1:59 p.m. the resident was still propped on his right side assisted by the CNA. The treatment cart was outside Resident #1's room and the nurse was observed to be at the nurses' station looking for the wound cleaning solution that had been ordered. Staff A, LPN said it was in the treatment cart three days prior, but it wasn't at that time. The nurse found the solution on the 2nd floor of the facility. At 2:03 p.m. the nurse had the wound cleaning solution and headed back to Resident #1's room. On the way to the resident's room Staff A, LPN stopped and checked on a call light in another resident room, then stopped and talked to another resident about papers he was holding. At 2:06 Staff A, LPN had the wound care supplies and entered Resident #1's room. Fourteen minutes had passed since the resident had been positioned for wound care. When the nurse was prepared to begin the resident had already returned to lying on his backside and refused to have the wound care done. Resident #1 yelled several explicative phrases and would not allow the nurse to touch him. An interview was conducted on 10/9/23 at 1:32 p.m. with the DON. The DON said the resident was agitated and aggressive when he got to the facility. She said he would let them do wound care for a while then he started refusing. The DON said Resident #1 was on a lot of pain medications such as Lyrica, Oxycodone, and Morphine, but had gotten taken off a lot and she didn't know why. She said the resident needed a wound vacuum and she told him if he would allow the wound vacuum, they would get pain management to see what other pain medications they could give him. A follow-up interview was conducted on 10/9/23 at 2:51 p.m. with the DON. She confirmed the nurse should have had the supplies ready when the resident agreed to have wound care provided. The DON also confirmed a pain management doctor had seen the resident. The DON provided a note showing the resident had been seen by Pain Management on 2/9/23. Review of Resident #1's physician notes showed he was seen by a pain management physician on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 10 of 15 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 10/09/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm 2/7/23. The note showed the resident had constant tingling in his feet and low back with a constant pain level of 7 out of 10. His pain was worsened with heavy lifting, moving in bed, but was better with rest and pain meds. The note added the provider reviewed records, counseled the patient, discussed with rehabilitation and nursing staff to coordinate care. Residents Affected - Few The note did not mention Pain Management discontinuing care for Resident #1. An interview was conducted on 10/9/23 at 4:05 p.m. with Resident #1's primary care physician. He said he had a visit with Resident #1 2-3 days ago. He said the resident was cooperative with him, but staff had told him the resident occasionally refused medication and/or treatment. The physician said Pain Management saw the resident to manage his pain. The primary care physician said he does give the facility prescriptions if Resident #1 needs refills, but the pain management doctor is the one to make changes to medications. The primary care physician said he was unaware Resident #1's pain medication had been decreased upon his return from the hospital on 9/11/23. He said he thought the resident had been okay with pain control. Review of progress notes did not reveal any documentation showing nursing staff had contacted any provider regarding Resident #1's lack of pain control or change in pain medications. At 5:15 p.m. the DON confirmed Pain Management last saw Resident #1 on 2/7/23. The DON said the pain management doctor said the resident was stable and quit seeing him. The DON said the resident's primary care provider had been taking care of Resident #1's prescriptions. The DON did not know why nurses did not document a pain level on the MAR with pain monitoring. Review of a facility policy titled Notification of Change in Condition, revised 12/16/20, showed the following: 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. Procedure: -The nurse to notify the attending physician and Resident Representative when there is a(n): -Accidents -Significant change in the patient/resident's physical, mental, or psychosocial status -Need to alter treatment significantly . -A transfer or discharge of the Patient/Resident from the Center . -In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 11 of 15 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 10/09/2023 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 0726 -The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. Level of Harm - Minimal harm or potential for actual harm -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. Residents Affected - Few -If the Medical Director does not respond, call 911 and document in the medical record. -Notify the patient/resident and the resident representative of the change in condition. -Document resident/patient change in condition on 24 hour report. -Complete SBAR as indicated. Review of a facility policy titled Family Notification, effective 11/30/14, showed the following: Policy: It is the policy of The Company to: Keep family informed Keep families involved Procedure: 1. The family will be notified of any resident changes, i.e.: a. Room changes b. Health problems c. Accomplishments . 2. Each member and/or family representative is asked to give a list of family and/or representative members, in order of preference, who can be contacted in case of emergency or urgency. Contact will begin with the first listed and end when contact is made. 5. All significant family contact will be documented. This should include discussion of transfer, discharges, problem with care or roommate, significant changes in family support systems, etc. Review of a facility policy titled Pain Management Guidelines, revised 8/28/17 showed the following: Policy: The center strives to improve patient/resident comfort and minimize pain in order to help a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 12 of 15 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 10/09/2023 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 0726 resident attain or maintain his or her highest practicable level of well-being. Level of Harm - Minimal harm or potential for actual harm Purpose: Residents Affected - Few To ensure residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Process: . Treatment -Develop patient centered interventions (pharmacologic and non-pharmacologic) to manage pain. -Document the interventions on the care plan. Monitoring -Monitor and document the patient/resident's response to the interventions. -Evaluate the effectiveness of the interventions and progress towards goals. -Discuss new interventions and goals with the resident and/or family/resident representative. Update the care plan as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 13 of 15 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 10/09/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to respond to a pharmacist recommendation in a timely manner for one resident (#1) out of three resident sampled. Findings included: Review of a Pharmacy Consultation Report, dated 9/13/23, showed the pharmacist made a recommendation for The initial attempt at a gradual dose reduction (GDR,) please reduce Venlafaxine ER [extended release] to 75 mg (milligrams) daily AND/OR Divalproex DR [delayed release] 125 mg twice daily. The provider was notified, and he told the facility to refer to the psychiatric doctor. On 10/9/23 the psychiatric doctor had still not been notified of the pharmacist recommendation. Review of admission records showed Resident #1 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including mood disorder, major depressive disorder, Type 2 Diabetes Mellitus, chronic pain syndrome, hypertensive heart disease, stage IV pressure ulcer on sacrum, psychotic disorder with delusions and anxiety disorder. Review of Resident #1's care plan showed a focus area of use of antidepressant medication related to depression, dated 1/12/23. Interventions included the following: -Administer antidepressant medication as ordered by physician. Monitor/document side effects and effectiveness every shift. -Educate the resident/resident representative about risks, benefits, and the side effects and/or toxic symptoms of antidepressant medication. Monitor/document/report PRN adverse reactions to antidepressant therapy. An additional focus area was use of psychotropic medications related to behavior management, dated 1/18/23. Interventions included the following: - Administer psychotropic medication as ordered by physician. Monitor/document side effects and effectiveness every shift. - Monitor/document/report PRN adverse reactions of psychotropic medications. An interview was conducted on 10/9/23 at 11:22 a.m. with the DON. The DON reviewed the pharmacy recommendation for Resident #1. She said the primary care doctor had been notified of the recommendation and he wanted to refer to psychiatry due to them being the provider that manages the medications mentioned. The DON said they were planning on discussing it at the psychiatric meeting on 10/10/23. The DON did not see any issues with it not being discussed until almost one month after the recommendation was made. An interview was conducted on 10/9/23 at 4:05 p.m. with Resident #1's Primary Care Provider (PCP). The PCP said he would have expected the pharmacy recommendation from 9/13/23 to have been responded to before now. He said it should not take a month to review and respond to the recommendation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 14 of 15 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 10/09/2023 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 0756 Review of a facility provided policy titled Pharmacy Consultant Services, revised 4/1/17, did not address the process for responding to consultant pharmacist recommendations. No other policy was provided. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 15 of 15