Health inspection·June 8, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete showed Policy: the Center to promptly notify the Patient / Resident, the attending physician, and the Resident Representative when there is a change in the status of condition. Procedure: the nurse to notify the attending physician and Resident Representative when there is a(n): significant change in the patient/resident's physical, mental, or psychosocial status; need to alter treatment significantly; new treatment. Notify the patient/resident and the resident representative of the change in condition. Document notification in the medical record. Document resident patient change in condition on 24-hour report; complete SBAR as indicted. Event ID: Facility ID: 105951 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the right to be free from neglect for one (Resident #5) of nine sampled residents. Findings include: A review of Resident #5's clinical chart, documented an admission of 03/01/2023. The medical diagnoses included: Effusion, right knee; unspecified lack of coordination; difficulty in walking; type 2 diabetes mellitus with unspecified complication; .unspecified dementia. A review of Resident #5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status score of 3, which indicated she was cognitively impaired. Section G, Functional Status, documented Bed Mobility (How the resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture) as 3/3, which indicated the resident needed extensive assistance for self-performance and two + person physical assist. A review of Resident #5's Care Plan, initiated 03/31/2023, the Activities of Daily Living performance plan, documented the resident to have a deficit due to Dementia and weakness. For interventions, the resident was documented to be totally dependent on 2 staff for toilet use, initiated on 05/14/2023; Hoyer lift use for transfers with assist of two staff, initiated 03/31/2023. On 06/08/2023 at 12:48 p.m., an interview was conducted with the Social Service Director (SSD). A review of a grievance for Resident #5 was conducted with the SSD. A review of a grievance dated 06/05/2023 for Resident #5, that had been submitted by the a family member pertaining to care, showed, [Resident #5] was found at 4:30 p.m. on 06/05/2023 with soiled clothing and diaper. Her nurse assistants found her at 3:30 p.m., she has not been changed due to no clean linens. This is unacceptable. Signed by the resident's family on 06/05/2023. Further review of the grievance reflected the Director of Nursing (DON) had been assigned responsibility of the complaint. The grievance investigation documented, After checking (the electronic medical record) POC (point of care). The Certified Nursing Assistant (CNA) that documented on the resident was [Staff C, CNA]. Last documentation at 13:33 (1:33 p.m.) showed the resident had no BM (bowel movement). No linen available in house until 5:00 p.m. The plan to resolve the grievance: Education. The grievance was documented to be resolved on 06/07/2023. The education attached to the form was Rounding with on-coming shift/ turning-re-positioning, dated 06/06/2023. The summary: Please ensure that you are rounding with the on-coming shift on your residents to check for any issues/ changes/ etc. Ensure your bed-bound / residents that are non-ambulatory are turned and repositioned at least every 2 hours. The document had eight (8) CNAs signatures. An interview was conducted on 06/08/2023 at 1:34 p.m. with the DON, regarding Resident #5's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few grievance. He stated, I believe the aid, came to me that evening, about 3:30 p.m., [Staff D, CNA]. He came (sic) to me that Resident #5 was soiled, and he wanted me to see [the resident]. He was concerned because of the amount, and it could have been a little while since she had been changed. We had gone in the room to verify. I observed and from my observation, what he was saying was true. She was soiled with feces; a blow out; it was a lot; you could see it off the sides of the diaper; it was not dried. I understood [Staff D, CNA's] concern, but the main thing was that we get her cleaned up. I wanted him to clean her up; changed; and if not changed; showered. I left the room at that point. And then the family approached me at about 4:30 p.m. with the same concern. The brief was still soiled at 4:30 p.m. I went to the laundry, between 3:30 p.m. and 4:30 p.m., I had gone down to the laundry two times to check on laundry for linens, towels, washcloths. During that time, there was no clean linen available. To fully clean the resident, the staff member needed wash cloth and towels the linen did not get on the unit until 5 p.m. and that is when she was showered. The DON confirmed no staff member was suspended as a result of the event. The DON stated he did not share the event with the Nursing Home Administrator (NHA) or the Abuse Coordinator. The DON indicated he had investigated, and had provided an in-service related to rounding with the on-coming shift/ Turning & repositioning. The DON confirmed Resident #5 being left in the soiled diaper and bedding from the time of discovery by Staff D, CNA at 3:30 p.m., to the time the linens were available at 5:00 p.m., was unacceptable. On 06/08/2023 at 2:00 p.m., during an interview with the Nursing Home Administrator (NHA), she confirmed she had one abuse/ neglect allegation, that was dated 06/02/2023. No other allegations for the month of June. She stated that during the past month, she had ordered linens, and she conducted daily checks of the linen carts. On 06/08/2023 at 2:23 p.m., an attempt to call Staff D, CNA was conducted with no return phone call. On 06/08/2023 at 2:24 p.m., an interview was conducted with the NHA. She provided 3 months of linen orders (one of which was for a different nursing home). She confirmed she did not have documentation of performing checks on the linen carts to ensure the linens were available to the aids for care and services. She said the Housekeeping Supervisor may have PAR (Periodic automatic replacement) levels available. She indicated she was not aware of the grievance for Resident #5 and the grievance was not reported as an Abuse/ Neglect allegation. On 06/08/2023 at 2:33 p.m. an interview was conducted with the Housekeeping/ Linen supervisor (H/LS). He stated, as of today, we have adequate linen stock. It was a monthly order through his company. The order went to his manager and then to the company. For the month of June, he indicated he had input the order on the first of the month. His district manager would approve the order. It was fairly fast, a couple hours. He stated, I receive the linens normally 3-4 days after I place the order. When asked if there had been an issue with the availability of linens on 06/05/2023, he stated, The linens were of good supply, but what happened was the laundry room was operating on a skeleton crew. There was a lack of staffing on my end. The laundry had not been processed (laundered). I will take the blame; it was due to lack of staffing. He confirmed there had been a shortage of the availability of clean linens that day. He indicated his manager was aware and attempts at hiring were being conducted. On 06/08/2023 at 4:07 p.m., a phone interview was conducted with two family members of Resident #5. Family member #1 stated she had submitted 3 grievances on 06/05/2023. She stated she had arrived at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility at approximately 4:30 p.m. (on 06/05/2023), she had found [Resident #5] in a soiled diaper. She stated, there was the smell, [Resident #5] had a bowel movement (BM) through her dress, dried through the pad that was underneath her; all on her backside; on her sides; and the front of her private area. The seepage was on the pad underneath her and on the top and bottom sheet. Family member #1 stated, she felt like [Resident #5] had been neglected. The person (aid) who had her in the day shift did not take the time to change her. The BM was up on her stomach like dried grass. Family member #1 stated, The aid had come in and started to clean her up. I insisted they give her a shower. When they showered her, they then told me she had an open wound on her heel. We know they had been previously treating her heel, they should have noticed if they were providing the treatment. The size of the wound on her heel was the size of a nickel. They do not take her to the shower but two times a week. Family member #2 said, When we go, we notice she always has socks on, we will take the socks off and the skin is dry and flaky on her feet. An interview was conducted with the DON on 06/08/2023 at 5:27 p.m. He stated he had not had Abuse & Neglect Training. He stated he started working at the facility on 05/31/2023. The DON indicated he had not obtained a statement from Staff C, CNA, who had been assigned to Resident #5 on 06/05/2023 during the day shift, 6:45 a.m.-3:15 p.m., to identify when the last time the resident had been provided incontinence care. He stated he had asked Staff C, CNA the next day when she had changed the resident and she stated she did not recall. The DON confirmed the documented time in the electronic ADL task symptom recorded the time the entry was made and not the time the care was provided to the resident. The time the care was provided to the resident was unknown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to implement the facility's policy and procedure for Abuse, Neglect, Exploitation & Misappropriation for one (Resident #5) of nine sampled residents. Residents Affected - Few Findings include: A review of the facility's policies and procedures for Abuse, Neglect, Exploitation & Misappropriation, N-1265, effective 11/30/2014, revision 11/16/2022, documented the policy: It is inherent in the nature and dignity of each resident at the center that he/ she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and / or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/ or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Definitions included: Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include, but are not limited to: Failure to take precautionary measures to protect the health and safety of the resident. Intentional lake of attention to physical needs including, but not limited to, toileting and bathing. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed. Failure to report observed or suspected abuse, neglect, or misappropriation of resident property to the proper authorities. Procedures included: 1. Screening . 2. Training: Employees of the center will receive education and training on Resident Rights, Resident Abuse, and Abuse Reporting during orientation and annually thereafter .Employee Obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. 3. Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation. The following systems have been implemented: Resident Council Grievance/ Concern program including posted information on the grievance official. Sufficient numbers of staff to meet the needs of the residents. Department Heads and supervisors that monitor staff to identify inappropriate behavior. 4. Identification: all reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Nursing/ designee. 5. Investigation: The Abuse Coordinator or his/ her designee shall investigate all repots or allegations of abuse, neglect, misappropriation, and exploitation Investigation will be accomplished in the following manner. Preliminary Investigation: Immediately upon an allegation of abuse or neglect, the suspect (s) shall be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/ designee shall perform and document a thorough nursing evaluation and notify the attending physician. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse Investigation: The Abuse Coordinator and/ or Director of Nursing shall take statements from the victim, the suspect (s) and all possible witnesses including all other employees in the vicinity of the alleged abuse 6. Protection: Any suspects), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The resident will be evaluated for any signs of injury, including a physical exam and/or psychosocial assessment, as appropriate . 7. Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the executive Director, the Director of Nursing is the designated abuse coordinator. Review of Report: Report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. A review of Resident #5's clinical chart, documented an admission of 03/01/2023. The medical diagnoses included: Effusion, right knee; unspecified lack of coordination; difficulty in walking; type 2 diabetes mellitus with unspecified complication; .unspecified dementia. A review of Resident #5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status score of 3, which indicated she was cognitively impaired. Section G, Functional Status, documented Bed Mobility (How the resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture) as 3/3, which indicated the resident needed extensive assistance for self-performance and two + person physical assist. A review of Resident #5's Care Plan, initiated 03/31/2023, the Activities of Daily Living performance plan, documented the resident to have a deficit due to Dementia and weakness. For interventions, the resident was documented to be totally dependent on 2 staff for toilet use, initiated on 05/14/2023; Hoyer lift use for transfers with assist of two staff, initiated 03/31/2023. On 06/08/2023 at 12:48 p.m., an interview was conducted with the Social Service Director (SSD). A review of a grievance for Resident #5 was conducted with the SSD. A review of a grievance dated 06/05/2023 for Resident #5, that had been submitted by the a family member pertaining to care, showed, [Resident #5] was found at 4:30 p.m. on 06/05/2023 with soiled clothing and diaper. Her nurse assistants found her at 3:30 p.m., she has not been changed due to no clean linens. This is unacceptable. Signed by the resident's family on 06/05/2023. Further review of the grievance reflected the Director of Nursing (DON) had been assigned responsibility of the complaint. The grievance investigation documented, After checking (the electronic medical record) POC (point of care). The Certified Nursing Assistant (CNA) that documented on the resident was [Staff C, CNA]. Last documentation at 13:33 (1:33 p.m.) showed the resident had no BM (bowel movement). No linen available in house until 5:00 p.m. The plan to resolve the grievance: Education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0607 The grievance was documented to be resolved on 06/07/2023. Level of Harm - Minimal harm or potential for actual harm The education attached to the form was Rounding with on-coming shift/ turning-re-positioning, dated 06/06/2023. The summary: Please ensure that you are rounding with the on-coming shift on your residents to check for any issues/ changes/ etc. Ensure your bed-bound / residents that are non-ambulatory are turned and repositioned at least every 2 hours. Residents Affected - Few The document had eight (8) CNAs signatures. An interview was conducted on 06/08/2023 at 1:34 p.m. with the DON, regarding Resident #5's grievance. He stated, I believe the aid, came to me that evening, about 3:30 p.m., [Staff D, CNA]. He came (sic) to me that Resident #5 was soiled, and he wanted me to see [the resident]. He was concerned because of the amount, and it could have been a little while since she had been changed. We had gone in the room to verify. I observed and from my observation, what he was saying was true. She was soiled with feces; a blow out; it was a lot; you could see it off the sides of the diaper; it was not dried. I understood [Staff D, CNA's] concern, but the main thing was that we get her cleaned up. I wanted him to clean her up; changed; and if not changed; showered. I left the room at that point. And then the family approached me at about 4:30 p.m. with the same concern. The brief was still soiled at 4:30 p.m. I went to the laundry, between 3:30 p.m. and 4:30 p.m., I had gone down to the laundry two times to check on laundry for linens, towels, washcloths. During that time, there was no clean linen available. To fully clean the resident, the staff member needed wash cloth and towels the linen did not get on the unit until 5 p.m. and that is when she was showered. The DON confirmed no staff member was suspended as a result of the event. The DON stated he did not share the event with the Nursing Home Administrator (NHA) or the Abuse Coordinator. The DON indicated he had investigated, and had provided an in-service related to rounding with the on-coming shift/ Turning & repositioning. The DON confirmed Resident #5 being left in the soiled diaper and bedding from the time of discovery by Staff D, CNA at 3:30 p.m., to the time the linens were available at 5:00 p.m., was unacceptable. On 06/08/2023 at 2:00 p.m., during an interview with the Nursing Home Administrator (NHA), she confirmed she had one abuse/ neglect allegation, that was dated 06/02/2023. No other allegations for the month of June. She stated that during the past month, she had ordered linens, and she conducted daily checks of the linen carts. On 06/08/2023 at 2:23 p.m., an attempt to call Staff D, CNA was conducted with no return phone call. On 06/08/2023 at 2:24 p.m., an interview was conducted with the NHA. She provided 3 months of linen orders (one of which was for a different nursing home). She confirmed she did not have documentation of performing checks on the linen carts to ensure the linens were available to the aids for care and services. She said the Housekeeping Supervisor may have PAR (Periodic automatic replacement) levels available. She indicated she was not aware of the grievance for Resident #5 and the grievance was not reported as an Abuse/ Neglect allegation. On 06/08/2023 at 2:33 p.m. an interview was conducted with the Housekeeping/ Linen supervisor. He stated, as of today, we have adequate linen stock. It was a monthly order through his company. The order went to his manager and then to the company. For the month of June, he indicated he had input the order on the first of the month. His district manager would approve the order. It was fairly fast, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a couple hours. He stated, I receive the linens normally 3-4 days after I place the order. When asked if there had been an issue with the availability of linens on 06/05/2023, he stated, The linens were of good supply, but what happened was the laundry room was operating on a skeleton crew. There was a lack of staffing on my end. The laundry had not been processed (laundered). I will take the blame; it was due to lack of staffing. He confirmed there had been a shortage of the availability of clean linens that day. He indicated his manager was aware and attempts at hiring were being conducted. On 06/08/2023 at 4:07 p.m., a phone interview was conducted with two family members of Resident #5. Family member #1 stated she had submitted 3 grievances on 06/05/2023. She stated she had arrived at the facility at approximately 4:30 p.m. (on 06/05/2023), she had found [Resident #5] in a soiled diaper. She stated, there was the smell, [Resident #5] had a bowel movement (BM) through her dress, dried through the pad that was underneath her; all on her backside; on her sides; and the front of her private area. The seepage was on the pad underneath her and on the top and bottom sheet. Family member #1 stated, she felt like [Resident #5] had been neglected. The person (aid) who had her in the day shift did not take the time to change her. The BM was up on her stomach like dried grass. Family member #1 stated, The aid had come in and started to clean her up. I insisted they give her a shower. When they showered her, they then told me she had an open wound on her heel. We know they had been previously treating her heel, they should have noticed if they were providing the treatment. The size of the wound on her heel was the size of a nickel. They do not take her to the shower but two times a week. Family member #2 said, When we go, we notice she always has socks on, we will take the socks off and the skin is dry and flaky on her feet. An interview was conducted with the DON on 06/08/2023 at 5:27 p.m. He stated he had not had Abuse & Neglect Training. He stated he started working at the facility on 05/31/2023. The DON indicated he had not obtained a statement from Staff C, CNA, who had been assigned to Resident #5 on 06/05/2023 during the day shift, 6:45 a.m.-3:15 p.m., to identify when the last time the resident had been provided incontinence care. He stated he had asked Staff C, CNA the next day when she had changed the resident and she stated she did not recall. The DON confirmed the documented time in the electronic ADL task symptom recorded the time the entry was made and not the time the care was provided to the resident. The time the care was provided to the resident was unknown. On 06/08/2023 at approximately 5:30 p.m., the NHA stated they would be reporting the allegation for Resident #5. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the Comprehensive Resident Centered Care Plan for three (Residents #2, #6, #7) of three sampled residents related to documenting a Daily Skilled Note. Findings included: 1. Resident #2 was admitted on [DATE] and discharged on 04/16/2023. Record review showed he had the following diagnoses but were not limited to fracture of right femur, displaced fracture of right ulna, fracture of upper end of right humerus, weakness, anemia and pressure ulcer on his coccyx. Review of the admission, Minimum Data Set (MDS) dated [DATE] showed he had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). Section G, Functional Status, showed he required extensive assistance of one for bed mobility and was totally dependent on one for transfers and toileting. Record review of physician orders showed a Daily Skilled Note was due every shift as of 03/20/23. The following care plans had interventions which included but were not limited to Monitor/document/ report PRN (as needed), pressure injury, surgical wound care, risk for alteration in psychosocial well-being, hypertension, right hip fracture, anticoagulant therapy, alteration in musculoskeletal status, and nutritional risk. Review of the March 2023 Medication Administration Record (MAR) showed documentation that the Daily Skilled Notes were performed twice a day from 03/20/23 through 03/31/23. The April MAR showed documentation the Daily Skilled Notes were performed twice a day from 04/01/23 through 04/15/23. Record review of the assessments and nursing progress notes showed no Daily Skilled Notes documented, During an interview with the Nursing Home Administrator (NHA) on 06/08/2023 at 11:57 a.m., she stated she could not find any Daily Skilled Notes. She stated the progress notes were reviewed during morning meeting. She reviewed them with the Director of Nursing (DON) and Unit Manager (UM). If they were missing something, the UM was responsible for adding a late entry or contacting the nurse to come in and add a late entry. The NHA stated she did not realize they were not performing Daily Skilled Notes and would have the DON follow-up. 2. Resident #6 was admitted on [DATE]. Review showed diagnoses included but not limited to an infection, intraspinal abscess and granuloma, pain, pleural effusion, weakness, endocarditis and heart valve disorders, and depression. Record review of the physician orders showed a Daily Skilled Note was due every shift as of 06/01/2023. The following care plans had interventions which included but were not limited to Monitor/document/ report PRN (as needed), fluid deficit, infection requiring and Intravenous antibiotic, uses antidepressant medications, nutritional risk, acute and chronic pain. Record review of the June 2023 MAR showed documentation that the Daily Skilled Notes were performed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 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 0656 twice a day from 06/01/23 to 06/07/23 and 06/08/23 on day shift. Level of Harm - Minimal harm or potential for actual harm Record review of the assessments and nursing progress notes showed the Daily Skilled Notes were only performed on 06/03/23 on day shift and 06/06/23 on day shift. Residents Affected - Some 3. Resident #7 was admitted on [DATE]. Diagnoses included but were not limited to atrial fibrillation, chest pain, chronic congestive heart failure, Chronic Obstructive Pulmonary Disease (COPD), weakness, diabetes, spinal stenosis, peripheral vascular disease, and hypertension. Record review of the admission MDS dated [DATE] showed a BIMS score of 15 or cognitively intact. Section G, functional status, showed he required extensive assistance of two for bed mobility, transfers, and one for toileting. Record review of the physician orders showed a Daily Skilled Note was due every day shift as of 05/27/2023. The following care plans had interventions which included but were not limited to Monitor/document/ report PRN (as needed), coronary artery disease (CAD), Congestive Heart Failure (CHF), altered cardiac status, fluid deficit, anticoagulant therapy, diuretic therapy, nutritional risk, pain, COPD, Record review of the May 2023 MAR showed documentation that the Daily Skilled Notes were performed daily from 05/27/23 to 05/31/23. Record review of the June 2023 MAR showed documentation that the Daily Skilled Notes were performed daily from 06/01/23 to 06/08/23. Record review of the assessments and nursing progress notes showed the Daily Skilled Notes were only performed on 05/27/23, 05/28/23, 05/29/23, 06/03/23, and 06/06/23. During an interview on 06/08/23 at 1:55 p.m. with Staff A, Licensed Practical Nurse (LPN), she stated she would check it off (documenting the Skilled Nursing Note) during medication pass on the electronic MAR. She would write the information on a piece of paper and would go back in the computer and document. She stated if she forgot, she would then go back and document. She stated, None of the Daily Skilled Notes were documented on [her] residents yesterday, [06/07/23], because it was a crazy day. I had four changes in condition and had people discharge to the hospital. She verified the Daily Skilled Notes were missing on Resident #6 and #7, including her own. During in interview on 06/08/23 at 2:05 p.m., Staff B, Registered Nurse (RN) stated when she did not have time, she would not do (Daily Skilled Note) and would do a progress note instead. She reviewed the progress notes and found none documented. She stated it was sitting in the computer to be done. She verified she had not documented the Daily Skilled Notes for Resident #2. Record review of the facility's policy, Daily Skilled Nursing Progress Note, revised 09/29/2017 showed Policy: residents receiving skilled care have progress documented daily in the medical record by the nurse. Procedure: use the Daily Skilled Nurse Note to document resident's progress daily. Document abnormal findings in a narrative note on the form. Also document in a narrative note the indications for continued skilled care using the Skilled Documentation Reference Guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 12 of 12