Health inspection·August 19, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interventions included: The resident has a Suprapubic Catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. On 8/18/21 at 12:01 p.m. Resident #113 was observed in his room, lying in bed. His catheter bag was observed from the hallway, attached to the bed frame approximately a third full of dark yellow colored urine, without a privacy bag. (Photographic Evidence Obtained) On 8/18/21 at 12:15 p.m. an interview was conducted with Staff D, Registered Nurse (RN). Staff D stated that the catheter bag should be kept in a privacy bag and should not be visible from the hallway. On 8/18/21 at 12:29 p.m. an interview was conducted with Staff G, Licensed Practical Nurse (LPN)/Unit Manager. Staff G stated the expectation at the facility is that no catheter bag should be seen from the resident's door. It should be in a privacy bag, on the opposite side of the bed and away from the door. It should not be seen at all. On 8/19/21 at 11:48 a.m. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the catheter should be covered with a privacy bag, and it is inappropriate to have the catheter bag on the floor. A review of the facility's policy and procedure titled, Privacy, effective 11/30/2014, showed residents' privacy will always be respected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 2 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 - Few 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 record review, the facility did not ensure one shower room (West Unit) of two shower rooms and three resident rooms (111, 306 and 316) out of 38 resident rooms were maintained in a safe and sanitary manner for 3 out of 4 days of survey (08/16/21, 08/17/21 and 08/18/21.) Findings included: An observation of resident room [ROOM NUMBER] on 08/16/21 at 10:37 a.m., revealed on the resident's floor next to the feeding tube, spots and brown dirt that looked the same color as the tube feed. The resident was asked if the tube feed spilled, and the resident stated, I do not know why they have not come to clean my room in one week. I have said something to the staff about it. On 08/18/21 at 3:12 p.m., an observation of the residents' central shower room on the [NAME] Unit revealed soiled linens on the floor, a trash can full of used briefs and biogrowth and brown stains were observed on the two shower chairs, and on the floors inside the shower stall. An immediate interview was conducted with Staff C, Licensed Practical Nurse (LPN), who was present at the time of the observation. Staff C stated that CNAs are responsible to empty trash cans, remove soiled linens and then housekeeping staff clean the bathroom. (Photographic Evidence Obtained) Review of the facility's policy titled, Daily patient room cleaning, revised 09/05/17 showed that a 5-step room cleaning method should be as follows: 1. Empty trash. 2. Horizontal dusting with a cloth and disinfectant spot clean 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. Under the section of Bathroom Cleaning the policy showed an expectation to follow 7-step method. (5) Sanitize commode, tank, bowl, and base. Use brush inside of bowl. (7) Damp mop. Start in far corner. Get behind commode, move trash can, mop out the door. Use wet floor sign when finished. A review of the facility's job description titled, Hospitality Services Technician I - Housekeeper, under; Duties and Responsibilities, #5 On a daily basis, clean all areas of the facility assigned. An interview was conducted on 8/17/21 at 8:39 a.m. with Staff J, Housekeeping. Staff J stated that he cleans resident rooms and other resident areas. Staff J stated that they are supposed to clean all resident rooms and shower rooms once a day. Staff J stated that sometimes they do not have enough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 3 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 staff. Level of Harm - Minimal harm or potential for actual harm On 08/17/21 at 11:30 a.m., an observation was made of resident room [ROOM NUMBER]. The floor was observed with brown stains on the left and right sides of the resident's head of the bed, the only bed in the room. Dirt, debris, and brown spill stains were noted on the floor near the fall mats laid by the bedside. (Photographic Evidence Obtained) Residents Affected - Few On 08/17/21 at 11:37 a.m. an observation was made of brown matter smeared on the wall by the resident's bed in room [ROOM NUMBER]. The substance was noted to be dry and caked. The resident in Bed B (bed closest to the window) stated that she had just moved in. Resident said, I'm disgusted by the lack of cleanliness. (Photographic Evidence Obtained) Immediately following the observation an interview was conducted with Staff H, Certified Nursing Assistant (CNA). Staff H stated she had noticed the stain and had notified Housekeeping. Staff H could not remember when she first saw the stained wall or how long it had been there. On 08/18/21 at 10:44 a.m. resident room [ROOM NUMBER] was observed with brown stains, dirt and papers on the floor. On 08/18/21 at 11:20 a.m. a second observation was made of brown matter smeared on the wall by the resident's bed (Bed B closest to the window) in room [ROOM NUMBER]. The substance was noted to be dry and caked. On 8/18/21 at 11:30 a.m., an interview was conducted with Staff I, Housekeeping. Staff I stated that resident rooms are cleaned two times per week. The rooms should be cleaned on the weekend too. Staff I stated that the process of cleaning a resident room is to: announce self, restock supplies, clean bathrooms, sweep and mop floors. The Housekeeping Manager (HM) who was present during the interview with Staff I stated that resident rooms are cleaned once a day. The HM said to Staff I, You are supposed to. The HM stated, Staffing is a challenge but we are managing. An additional observation of resident room [ROOM NUMBER] on 08/18/21 at 11:41 a.m., revealed on the resident's floor next to the feeding tube were spots and brown stains that looked the same color as the tube feed. A facility tour was conducted on 08/18/21 at 2:59 p.m. with the HM. The HM made the observations in resident rooms #111, #306 and #316. The rooms were observed not to be cleaned. room [ROOM NUMBER] was observed with brown stains on the floor by the feeding tube, room [ROOM NUMBER] was observed with brown matter smeared on the wall by the resident's bed (Bed B closest to the window), and room [ROOM NUMBER] was observed with dirt, debris and brown stains on the floor and wall. The HM stated that the residents' rooms should not look like that. The HM said, I expect the rooms to be cleaned at least daily. We will take care of it. I will in-service my staff. The HM said, Our policy is to make sure the facility is clean for our residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 4 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to provide treatment and care in accordance with professional standards of practice as evidenced by not ensuring a medication was reconciled and confirmed by the physician upon readmission from the hospital resulting in the medication not being administered for one resident (#29) out of five residents sampled for unnecessary medications. Residents Affected - Few Findings included: Record review of Resident #29's admission Record revealed an initial admission date of 10/20/20 and a readmission date of 07/28/21, and the most current diagnoses included: seizure disorder, disorder of brain unspecified, benign neoplasm of meninges, and unspecified dementia with behavioral disturbances. A review of the Quarterly Minimum Data Set (MDS) Assessment, dated 5/28/21, Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating Resident #29 had moderate cognitive impairment. A review of Resident #29's physician orders dated 7/01/21-07/31/21 revealed an order for Phenytoin Sodium (Dilantin) 300 mg (milligrams) by mouth at bedtime, for a diagnosis of seizure disorder, start date 7/15/21, prior to his hospitalization. A review of Resident #29's re-admission physician orders dated 7/28/21 did not reveal orders for the medication Phenytoin Sodium (Dilantin) related to seizure disorder. A review of Resident # 29's primary care physician (PCP) progress note dated 8/2/21 under the subheading: Note Text: SEEN ON FOLLOW UP. #4. read: Seizure disorder Stable. Continue Phenytoin. A review of Resident #29's July 2021 and August 2021 MAR revealed that he did not received Phenytoin upon readmission [DATE]) to the facility or as recorded in the PCP notes to continue Phenytoin, from 8/2/21 to 8/18/2021. An interview was conducted on 08/18/21 at 8:43 a.m. with Staff C, Licensed Practical Nurse (LPN). Staff C stated that Resident #29's Dilantin (Phenytoin) is administered on the evening shift. She stated that upon reconciliation of Resident #29's medications on re- admission, the nurse reviewing and verifying the medications orders with the primary care physician should have notified the physician that Dilantin (Phenytoin) was not ordered upon his readmission to the facility. On 08/18/21 at 8:45 a.m., in an interview with Staff G, Licensed Practical Nurse (LPN)/Unit Manager, Staff G stated that he would have expected someone to follow up with Resident #29's primary care physician to resume Dilantin (Phenytoin). Staff G stated that the resident has a diagnosis of seizure and was receiving the medication prior to hospitalization on 7/24/21. In an interview with the Director of Nursing (DON) on 08/18/21 at 8:55 a.m. the DON stated the facility process is to follow the hospital discharge medication list upon the resident readmission to the facility and to verify the list with the resident's physician. She stated that she would have expected nurses who are familiar with Resident #29's medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 5 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prior to his discharge to the hospital, to follow up with his primary care physician upon readmission, regarding resuming his Dilantin (Phenytoin). The DON stated that nurses are given a Nursing admission Checklist to follow upon the admission or re-admission of a resident. She stated that to ensure previously ordered pertinent medications are reviewed with a resident's PCP, she has added to the checklist (revised as of 8/19/21) under the subheading, Orders as follows: For readmission: reconcile med lists from previous med list with new discharge med list. On 08/18/21 at 9:45 a.m., in an interview with Resident's #29's PCP, the PCP stated that he is aware of Resident #29's seizure disorder. He confirmed that Resident #29 was on Dilantin (Phenytoin) prior to his discharge to the hospital. He confirmed visiting Resident #29 upon his readmission to the facility. He stated that part of the process upon his visits, is to review his residents' medications. He stated that he cannot recall if Dilantin (Phenytoin) was or was not on the medication list when he reviewed it. He stated the Dilantin (Phenytoin) should have been resumed upon Resident #29 readmission to the facility, related to his diagnosis of seizure. Review of the facility policy and procedure titled, Physician Orders with a revision date of 3/3/2021 showed the policy as, The center will ensure that Physician orders are appropriately and timely documented in the medication record. Under the subheading, Routine Orders it read: The ordering physician or physician extender will review and confirm orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 6 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and policy review, the facility failed to ensure one resident's (#29) drug regimen of five residents sampled for unnecessary medications was free of unnecessary medications related to behavioral and side effect monitoring of psychotropic medications. Residents Affected - Few Findings included: A review of the facility policy and procedure titled, Medication Management-Psychotropic Medications, revision date 3/23/2018, under the subheading 'Procedure #4. read: Monitoring behavior and side effects every shift utilizing the Behavior Monitoring Flow Record (BMFR) or electronic equivalent . #12: Monitor resident's response to medication and progress towards goal. A review of Resident #29's admission Record revealed an initial admission date of 10/20/20 and a readmission date of 7/28/21 and the diagnoses included: unspecified dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, and unspecified mood (affective) disorder. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/28/21 Section C (Cognitive Patterns) revealed a Brief Interview of Mental Status (BIMS) of 09, indicating Resident #29 had moderate cognitive impairment. A review of Resident #29's active physician orders for August 2021 revealed orders for Ziprasidone HCI capsule 40 mg (milligram) to be given two times a day for diagnosis of Bipolar, start date of 7/29/21, and Seroquel tablet 200 mg to be given at bedtime (HS) for bipolar disorder and depression, start date of 7/29/21. The active physician orders dated 8/18/21 did not reveal orders for the monitoring of Resident #29's behavior or side effects of the medications. A review of the Medication Administration Record (MAR) dated 8/1/2021 to 8/31/2021 revealed that Seroquel 200 mg, and Ziprasidone HCI capsule 40 mg were administered on 8/1/2021-8/17/2021 as ordered. Further review of Resident #29's July 2021 and August 2021 MAR did not reveal documentation of monitoring of his behaviors and side effects of the medications, Seroquel and Ziprasidone. Review of Resident #26's care plan focus area for the use of antipsychotic therapy for psychosis, initiated on 11/20/20 included an intervention of administering the medications as ordered by the physician and monitor behavioral symptoms and side effects. On 8/18/21 at 8:43 a.m., in an interview with Staff C, Licensed Practical Nurse (LPN). Staff C stated that behavior and side effect monitoring should have been documented in Resident #29's Medication Administration Record. Staff C reviewed the August 2021 Medication Administration Record and confirmed that there was no behavior or side effect monitoring for Resident #29's psychotropic medications. On 8/19/21 at 8:48 a.m., in an interview with the Director of Nursing (DON), the DON stated her expectation was that behavior and side effect monitoring for psychotropic medication should have been in place for Resident #29. She reviewed Resident #29's physician orders for August 2021 and MAR and confirmed that physician orders for behavior and side effect monitoring were not in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 7 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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. Based on observation, interview, and policy review, the facility failed to store drugs and biologicals in a secure manner by leaving one medication unattended, with no facility staff near on the 300 Hall medication cart; and failed to appropriately store medications in three (300 Hall, 300 [NAME] Hall Cart #1 and Cart #2), of a sample of five medications carts. Findings included: On 08/17/2021 at 8:04 a.m. an observation was made of one bottle of multivitamins left out and on top of the 300 Hall medication cart. Staff A, Licensed Practical Nurse (LPN), was observed to be in a room administering medications to a resident. The medication cart was in a high traffic area, with several residents observed to be self-propelling in the hall next to the medication cart, with no staff in the vicinity of the medication cart. An immediate interview was conducted with Staff A, LPN and confirmed the presence of the medication she left out. On 08/17/2021 at 1:00 p.m. an observation was made of the 300 [NAME] Hall Medication Cart #2, which included three loose tablets located behind the fourth drawer on the right side of the medication cart, when the drawer was pulled all the way out. Staff C, LPN confirmed the presence of the unsecured medications. On 08/17/2021 at 1:30 p.m., an observation of the medication cart on the 300 Hall included in the second drawer from the top of the medication cart, one loose pill. Staff A, LPN confirmed the presence of the unsecured white tablet. (Photographic Evidence Obtained.) On 08/17/2021 at 2:15 p.m. an observation was conducted of the 300 Hall [NAME] Medication Cart #1, which included one loose pill, in the fourth drawer, on the right side of the medication cart when the drawer was pulled all the way out. Staff E, Registered Nurse (RN) confirmed the presence of the unsecured white tablet. On 08/17/2021 at 3:45 p.m., an interview was conducted with the Director of Nursing, (DON) and the Regional Clinical Services Director. During the interview the DON indicated that she was made aware of the medication left out on top of the medication cart by Staff A, LPN, and that several of her staff notified her that medications were found unsecured in the medication carts. The DON stated, Staff should not have loose pills in medication carts and no medications should be left out unattended. On 08/18/2021 at 9:38 a.m., a telephone interview was conducted with the Pharmacy Consultant, and she stated, There should be no loose pills in the medication carts, and all staff should be checking periodically the drawers, including the back of the drawer and behind the drawers. Medications should not be left out on the medication's carts; they should be stored inside of them. A facility provided policy titled, Policies and Procedures: Medication and Medication Supply Storage and Disposal, dated 11/30/2014, Page 01 of 02 Page, was reviewed and revealed: Policy: Meds [medications] will be kept in a medication cart that locks and keys are only accessible to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 8 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 licensed personnel distributing medications. Level of Harm - Minimal harm or potential for actual harm Procedures: Residents Affected - Few 6. Medication will be stored in an organized manner under proper conditions and in accordance with manufacturer's instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 9 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement an infection prevention and control program to prevent possible transmission of Coronavirus Disease 2019 (COVID-19) as evidenced by 1. failed to ensure multi-resident equipment (mechanical lift) was cleaned with an approved disinfectant, 2. failed to ensure 18 out of 52 staff members were screened at the beginning of their shift on 8/16/21. Failing to implement an infection prevention and control program to prevent possible transmission of Coronavirus Disease 2019 (COVID-19) consistently had the potential to expose a total of 112 residents. Residents Affected - Some Findings included: 1. Staff D, Registered Nurse (RN) stated and confirmed, on 8/17/21 at 9:22 a.m., that the 200-hall Medication Cart 1 did not have any bleach wipes in it. She stated that she ran out of bleach wipes yesterday (8/16/21) during the 7:00 a.m. to 3:00 p.m. shift. At this time Staff V and Staff W, Certified Nursing Assistants (CNAs) were observed removing a mechanical lift from a resident room on the 200 hall. Staff V parked the lift further down the hall, outside of the Social Service office. Staff V reported that she had cleaned the lift with hand sanitizer and a paper towel after using it for the resident. Staff V said, It's all I had. On 8/17/21 at 7:40 a.m., an interview was conducted with Staff R, Central Supply. He stated that bleach wipes are ordered once a week and people use a lot of them. He reported that a case of bleach wipes was arriving today any minute. Staff R and the Staffing Coordinator reported that the Central Supply area did not have any containers of bleach wipes. An observation was conducted with the staff members of an outside storage shed which did not contain any bleach wipes. The Staffing Coordinator called the Maintenance Director and relayed that the Maintenance Department did not have any bleach wipes. Staff R reiterated that a truck would be arriving any minute with bleach wipes. An interview was conducted on 8/17/21 at 7:57 a.m., with Staff S, CNA on the 300-hall. Staff S stated that staff had sanitizer in the soiled utility room to clean the multiple-resident vital sign machine. An observation with the staff member of the 200-300 hall soiled utility room indicated there were no disinfectant wipes in the room. On 8/17/21 at 9:30 a.m., Staff A, Licensed Practical Nurse (LPN) reported that the 300-Hall Medication Cart does not have any bleach wipes on the cart. The Director of Nursing (DON) stated, at 10:56 a.m. on 8/17/21, the facility used bleach wipes, [Brand A, and Brand B] to clean the mechanical lifts and (staff) were to put a bag over it when cleaned. She stated that there were bleach wipes on each medication cart. The DON reported that bleach wipes were on backorder and that each cart should have some and that the wipes were available in Central Supply. She stated absolutely not that mechanical lifts should not be cleaned with hand sanitizer. The Cleaning and Disinfection of Resident-Care Items and Equipment Procedure/Policy, revised on October 2018, indicated that Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers of Disease Control and Prevention (CDC) recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy identified that reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 10 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Infection Prevention and Control Program policy identified that An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Policy Interpretation and Implementation indicated that the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. A review was conducted of the received screening forms, dated 8/16/21, from the front lobby, the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON), and from the back hall screening area. The back hall did not contain any screening forms dated 8/16/21. Review of the provided screening forms, which the ICP/ADON confirmed the forms were all that she had in regard to non-contracted staff, Staff N, Dietary, Therapy and Housekeeping/Laundry departments. The review showed that no screenings were completed for eighteen staff members, per the day shift schedules on 8/16/21 for: - one out of five nurses, - three out of thirteen Certified Nursing Assistants, - seven out of thirteen Administration staff, - one out of eleven therapy staff, - four out of four Housekeeping/Laundry staff and one of one District Managers, - one out of six Dietary staff. The District Manager for Healthcare Services reported, on 8/16/21 at 11:09 a.m., that all his staff were screened for COVID-19 at the front door. The conversation occurred in the back hallway, between the kitchen and the laundry room. The Manager reiterated that his staff: housekeeping and laundry, were screened in the front lobby and that he was also screened in the lobby that morning. During an interview with the ICP/ADON, at 12:28 p.m. on 8/16/21, she stated that all staff screen at the beginning of their shift. She related that the Unit Managers, Director of Nursing (DON), herself and sometimes the Nursing Home Administrator (NHA) checked the screening forms, after morning meeting, and ensures that staff are screened. The ICP/ADON stated the facility assigned either a Certified Nursing Assistant or the Staffing Coordinator to screen staff and that sometimes an off going 11 p.m. - 7 a.m. staff member would screen the oncoming staff. She stated she did not know who was responsible for screening staff on the morning of 8/16/21. The ICP/ADON reported that the Rehabilitation, Dietary, and Housekeeping/Laundry departments keep their staff screenings. Staff L, Occupational Therapy Assistant (OTA) stated, on 8/16/21 at 12:43 p.m., that therapy keeps screening forms separate from the facility's forms. She reported that she would take a screening form from the time clock area, come to the therapy gym and screen in the area that was set up for the therapists. On 8/16/21 at 12:45 p.m., Staff M, OTA, stated she keeps track of the therapy screenings. Staff M reported that the facility has not asked for the screenings but does keep them on file in case they do. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 11 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/16/21 at 12:51 p.m. the Certified Dietary Manager (CDM) stated that she kept the dietary staff screenings, she checked them as the facility trusts her to do so, and that the facility does not ask to review them. Staff O, CNA, stated, on 8/16/21 at 1:41 p.m., that she had screened herself this morning, everyone does themselves. On 8/16/21 at 6:03 a.m. Staff P, LPN stated that usually there would be a thermometer by the employee entrance and that she would screen herself. Staff P stated that she turns in her sheet to her supervisor. An interview was conducted with ICP/ADON on 8/16/21 at 10:50 a.m. She stated that she screened herself at the employee entrance. The ICP/ADON stated that they usually assign a CNA to screen the staff. The ICP/ADON stated that she did not know which CNA was assigned today. The ICP/ADON said, I just heard there was no thermometer. Staff P, LPN stated, on 8/17/21 at 6:03 a.m., that 11 p.m. - 7 a.m. shift staff do not screen 7 a.m. - 3 p.m. staff. An observation of the time clock area in the back hall between the kitchen and laundry room indicated an over-the-bed table with a non-contact thermometer and screening forms. The staff member stated normally there was a container of bleach wipes or similar to clean the thermometer in between staff. She stated that prior to shift changes there was a staff member sitting at the time clock (to screen) but due to short staff they weren't doing that anymore. 3. On 8/17/21 at 6:42 a.m., Staff Q, CNA, was observed in the back hall screening staff members arriving for the 7:00 a.m. to 3:00 p.m. shift. The ICP/ADON arrived and walked into the kitchen, then at 6:45 a.m., came out of the kitchen and had her temperature taken by Staff Q. Staff Q stated, at 6:46 a.m., that she tried to be in the back hall by the time clock to screen but has an assignment, so she isn't able to do it all of the time. The staff member stated that the ICP/ADON did not trust the thermometer because it was taking low temperatures and was going to come back. The observations made during the screening of the 7:00 a.m. to 3:00 p.m. staff on 8/17/21 revealed that multiple staff members did not complete hand hygiene before or after using one of the two supplied pens and using the touchscreen and finger biometric timeclock. The screening area did not have any disinfectant wipes available to sanitize the pens or time clock. The DON confirmed on 8/17/21 at 10:56 a.m. that she had not completed hand hygiene after using one of the two pens, used by multiple staff members, after screening. A sign was observed on 8/18/21 at 7:17 a.m., on the outside of the door leading to the back hall where staff were to be screened. The pink sign showed: Attention All Staff: Please Do Not Clock In Unless You Have Been Screened By Authorized Screener. (Photographic Evidence Obtained) On 8/19/21 at 9:59 a.m., an interview was conducted with the ICP/ADON and the DON. They stated the expectation was for staff to screen by compliance. The DON stated her expectation was for staff to screen prior to their shift and the ICP/ADON stated screening should be done prior to coming into the resident area of the building. She stated she does look at the screening forms for everyone in the building, every shift. The DON reported that the Staffing Coordinator will crack the door between her office and the back hallway to watch screenings. The DON stated that the facility has ongoing education to remind others to screen. The ICP/ADON stated that the Administration personnel are trusted to do screenings and to notify if there was an issue, then stated staff were encouraged not to screen themselves. The ICP/ADON reported that supervisors can assign anyone to do staff screenings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 12 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's COVID-19 Pandemic Plan, dated 3/2/20 and revised 8/3/21, identified that COVID-19 is a respiratory illness thought to be spread mainly from person to person, between people who come in close contact to one another (about 6 feet). Symptoms may include fever, cough, shortness of breath, sore throat, vomiting, diarrhea, muscle pain, headache, new loss of taste or smell, chills, and repeated shaking with chills. The Pandemic COVID-19 procedure indicated Employees including contract employees, should be evaluated and observed at the beginning of each shift for signs and symptoms of COVID-19 (including temperature check). Employees should be instructed to self-report symptoms and exposure. On 8/16/21 10:32 a.m., an interview was conducted with Staff U, Dietary Aide. Staff U reported that she did not get screened because there was no thermometer available. An interview was conducted on 8/16/21 at 10:35 a.m. with the Certified Dietary Manager (CDM) / Kitchen Manager. The CDM confirmed that she did not get screened because there was no thermometer. CDM stated that she was about to find one, but she got interrupted. The CDM stated that the expectation was for employees to screen themselves or come to her if she was in the building. The CDM stated she reviews the dietary staff screening forms and files them in a drawer in her office. When asked if she knew the parameters to watch for, the CDM stated that if a temperature was above 100 degrees, she would notify the nurse. The CDM stated she was not trained to screen employees. On 8/16/21 at 10:45 a.m., an interview was conducted with Staff R, Central Supply. Staff R stated that he did not get screened today because there was no thermometer. Staff R stated that the thermometers have been problematic and that he would go out and purchase a couple new ones. Staff R was asked if Administration knew there was a problem with the thermometers. Staff R said he had not discussed it with anyone. On 8/16/21 at 11:00 a.m., an interview was conducted with Staff S, CNA. Staff S stated that she did not get screened this morning because there was no thermometer. Staff S stated that she could have gone to the front. Staff S said, I got distracted with patient needs when I got here. I will get screened now. An interview with Staff G, Unit Manager was conducted on 8/16/21 at 11:15 a.m. Staff G stated that he got screened in the front because there was no thermometer at the back. Staff G said, They should be screening everybody. Staff G stated that if there was no thermometer in the back, he would expect staff to go to the front for screening. On 08/17/21 at 5:05 a.m. this surveyor entered the facility via the side entrance off Hall 100. Staff T, CNA opened the door and let the surveyor into the building. Staff T did not direct the surveyor to the back for screening. Staff P, Registered Nurse (RN) was in the nurses' area observing as surveyor walked into the building. Staff P, RN greeted surveyor but did not conduct the screening. On 08/17/21 at 5:55 a.m. this surveyor was screened by Staff S, CNA after asking what the process was for staff coming into the building after hours. Staff S reported that they should all come in through the back door. The Centers for Disease Control and Prevention guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (date) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html), updated February 23, 2021, identified: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 13 of 14 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. - Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility. - Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. - Healthcare Personal should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 14 of 14