Health inspection·July 27, 2023

F 0585 loud. The staff member offered to fill out a grievance for the resident. Level of Harm - Minimal harm or potential for actual harm On 7/26/23 at 4:45 p.m., Staff U, CNA, was interviewed regarding Resident #33 complaining about the heat of the room. The staff member reported the resident had not complained about the heat in the room. Residents Affected - Few Staff B reported at 5:09 p.m. on 7/26/23 the roommate had agreed to keep the temperature and noise down and he would check with Resident #33 in the morning. He stated he had completed a grievance for the resident. The staff member stated the aides had come to him now and voiced the resident had complained of it being too hot in the room. A review of the facility's Monthly Grievance Logs, January - July 2023, did not indicate a grievance had been filed on behalf of Resident #33. `The admission Record for Resident #33 indicated the resident had been admitted on [DATE] and included diagnoses not limited to legal blindness as defined in USA, incomplete paraplegia, dependence on wheelchair, need for assistance with personal care, and limitation of activities due to disability. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #33 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. The MDS indicated the resident required extensive 2-person assist for bed mobility and transfers. The policy - Complaint/Grievance, effective 11/30/2014 and revised 10/24/2022, indicated the following: 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 procedure indicated that An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form and accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. The grievance procedure indicated the following: - The grievance officer/designee would act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. - The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. - The findings of the grievance shall be recorded on the Complaint/Grievance Form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 2 of 31 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 07/27/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few A review of Resident #90's admission Record identified an original admission date of 9/9/22 and an initial admission date of 11/18/22. The record included a primary diagnoses of unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The secondary diagnoses, present on admission [DATE]) included unspecified recurrent major depressive disorder, unspecified mood (affective) disorder, and unspecified anxiety disorder. The Preadmission Screening and Resident Review (PASRR) dated 11/18/22, indicated Resident #90 did not have a primary diagnosis of dementia and no mental illness (MI) or suspected mental illness (SMI). The PASRR did not indicate the resident was receiving currently or previously services for MI or Intellectual Disability (ID). A review of Resident #90's Quarterly Minimum Data Set (MDS), 5/27/23, indicated a Brief Interview of Mental Status (BIMS) of 2 out of 15, severe cognitive impairment. The comprehensive assessment of the resident included the diagnoses of anxiety disorder and depression (other than bipolar). The July Medication Administration Record (MAR) identified Resident #90 had received Trazodone 100 milligram (mg) at bedtime for depression, started on 4/26/23 and discontinued on 7/24/23. A review of physician orders, dated 7/24/23 instructed staff to administer Trazodone 50 mg (milligrams) (0.5 tablet) at bedtime for unspecified recurrent Major Depressive Disorder for 7 days as a Gradual Dose Reduction (GDR) attempt and Trazodone 50 mg tablet at bedtime for 7 days, GDR attempt with goal to discontinue (d/c). The Social Service Director reported, on 7/27/23 at 12:40 p.m., that nursing does PASRR's, and she does not have anything to do with PASRR's. The SSD stated the previous Nursing Home Administrator (NHA) wanted her to do them but the new NHA had specified nursing was to do them. On 7/27/23 at 1:06 p.m., the Interim Director of Nursing (DON) reported not having done any PASRR's since being here. The NHA stated on 7/27/23 at 1:07 p.m., when she got here no one was doing the PASRR's, and the Director of Nursing and MDS Coordinator had access in the computer to do them. The NHA reviewed Resident #90's PASRR dated 11/18/22 and stated the PASRR should have been redone, confirming the residents primary diagnosis of dementia and secondary's of Major Depressive Disorder, anxiety, and mood disorder. A review of a facility policy titled, Preadmission Screening and Resident Review (PASARR), dated 11/08/21, showed the center will assure that all Seriously Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. (1.) It is the responsibility of the center to assess and assure that the appropriate pre preadmission screenings, either level I or level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. (4.) If it is learned after admission that a PASARR level II screening is indicated, it will be the responsibility of social services to coordinate and/or inform the appropriate agency to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 3 of 31 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 07/27/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm conduct the screening and obtain the results. (5.) Results of the screening and evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. (7.) Social services will be responsible for coordinating significant change updates for these screenings, conducted by the appropriate agency. These results along with the results from the previous years will be kept in the appropriate section of the residents records. Residents Affected - Few Based on record review and interviews the facility failed to complete the Preadmission Screening and Resident Reviews (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for four residents (#17, #2, #79, and #90) of four residents sampled for PASRR. Findings included: A review of the medical record revealed Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of the admission record for the resident revealed a diagnosis of major depressive disorder on admission. The record further showed a diagnosis of unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety dated 07/13/23. A review of a Level I PASRR for Resident #17, dated 05/19/22, showed qualifying diagnoses were not checked and a Level II PASRR was not submitted for review upon newly acquired qualifying diagnoses. A review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses to include Unspecified Dementia, anxiety disorder, psychosis, major depressive disorder, history of Traumatic Brain Injury (TBI). A review of a Level I PASRR for Resident #2, dated 06/27/23, showed qualifying diagnoses were not checked and a Level II PASRR was not submitted. A review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE] with diagnoses to include Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, altered mental status. A review of a Level I PASRR for Resident #79, dated 04/26/22, showed qualifying diagnoses were not checked and a Level II PASRR was not submitted. On 07/26/23 at 12:56 p.m. an interview was conducted with Staff T, Regional Director of Clinical Services. Staff T stated PASRR's should be updated on admission to reflect the admitting diagnoses and whenever a resident receives new diagnosis. She stated the Social Services Director (SSD) should be reviewing the PASARR's and updating them accordingly. She stated if a resident had qualifying Level II indicators, a referral should be made. On 07/27/23 at 01:07 p.m., an interview was conducted with the Nursing Home Administrator (NHA.) She stated the Director of Nursing (DON) and the Minimum Data Set (MDS) nurse should be updating the PASRR's. She stated nobody had done them before and that was why they were behind. She said, Now I can do them. I'm a nurse. She stated the PASRR's should have been redone upon admission if diagnoses were not indicated. She stated they would start an audit and re-do all the PASARRs to make sure they were accurate. On 07/27/23 at 10:21 a.m., an interview was conducted with Staff S, Regional Director of Clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 4 of 31 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 07/27/2023 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 0645 Services. She stated the PASRR's should have been updated upon admission or with qualifying diagnosis changes. 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: 105951 If continuation sheet Page 5 of 31 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 07/27/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure a baseline care plan was completed for one resident (#311) of three residents reviewed for care plans. Findings included: A review of the medical record on 07/20/2023, at 10:00 a.m., revealed an incomplete base line care plan for Resident # 311 that did not reflect the resident plan of care. Photographic evidence was obtained. A review of the admission Record revealed Resident #311 was admitted on [DATE] with diagnosis to included but not limited to encounter for surgical aftercare following surgery on the skin, End Stage Renal Disease, dependence on Renal Dialysis, Acute Respiratory Failure with Hypoxia, pneumonia, unspecified organism, severe sepsis with Septic Shock, unspecified organism, Type 2 Diabetes Mellitus with unspecified Diabetic Retinopathy without macular edema. On 7/23/2023 at 10:20 a.m., an interview was conducted with the Director of Nursing (DON). The DON said Resident # 311's base line care plan was incomplete and illegible, although the facility uses those papers to carry out its resident base line care plan. She said she will work on obtaining new, more readable papers and educate her nurses on the importance of thoroughly completing baseline care plans and making sure the information is legible. A review of the facility's policy titled, Plans of Care, dated 11/30/2014, revision date 9/25/2017, indicated the following: An individualized person -centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative (s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Develop and implement an individualized Person-Centered baseline care plan of care within 48 hours of admission that includes, but not limited to, initial goals bases on the admission orders, physician orders, dietary orders, therapy services, social services, PASRR (Pre admission Screening and Resident Review) recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 6 of 31 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 07/27/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility 1) failed to hold scheduled interdisciplinary care conferences and notify resident representatives of care conferences within a time frame adopted by the facility's policy for five residents/representatives (#9, #33, #42, #51, and #62) out of 34 sampled residents, and 2) failed to revise the care plan for one resident (#33) out of 34 sampled residents related to the discontinuation of oxygen therapy. Findings included: 1) A review of Resident #9's admission Record indicated the resident was admitted on [DATE]. The admission Record for the resident included diagnoses not limited to right hand, right shoulder, and right elbow contractures, unspecified peripheral vascular disease, unspecified obesity, and Type 2 Diabetes Mellitus without complications. The record identified the resident was the responsible party with emergency contacts. The Annual Minimum Data Set (MDS) assessment, dated 6/18/23, for Resident #9 identified a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognition. On 7/24/23 at 10:35 a.m., Resident #9 reported a male staff member had asked about the care plan but, I was mad at them because they weren't doing it. The Care Conference Record for Resident #9, provided by the MDS Director, indicated the last care plan meeting was held on 6/14/22 in response to the quarterly assessment and was attended by the MDS Director, one other staff member, and not by the resident. The record did not include any comments regarding what was discussed. The Care Conference Record indicated the last note for Resident #9 was dated 12/7/21. A review of Resident 9's care plan indicated goals for the resident were revised on 3/24/23 with target dates of 10/8/23, and the last care plan review was completed on 7/10/23. The care plan did include 2 focuses, initiated on 6/26/23, that identified the resident had a mood disorder and used psychotropic medications related to (r/t) mood disorder. 2) A review of Resident #33's admission Record identified an admission date of 4/7/22 and included diagnoses not limited to hereditary spastic paraplegia and legal blindness as defined in USA. The record identified the resident was the responsible party with two family members listed as emergency contacts. The quarterly Minimum Data Set (MDS, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. On 7/24/23 at 11:55 a.m., Resident #33 reported not knowing anything about that (care plan meeting) but has family members (available). The Care Conference notes, indicated the admission conference dated 12/7/21, was In Progress. The latest Social Service Progress note, dated 1/20/23 did not identify a care plan meeting was held with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 7 of 31 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 07/27/2023 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 0657 the resident but did mention a request was made by the family for a transfer to another facility. Level of Harm - Minimal harm or potential for actual harm The care plan for Resident #33 indicated goals were revised on 1/4/23 and the latest care plan review was completed on 6/29/23. The care plan did include a focus, initiated on 5/5/23 that identified the resident had oxygen therapy related to Chronic Obstructive Pulmonary Disease (COPD) . Residents Affected - Some On 7/25/23 at 2:11 p.m., the MDS Director reviewed the findings in Resident #33's record related to the care conferences. 3) A review of the admission Record indicated Resident #42 was admitted on originally admitted on [DATE] and recently on 1/11/23. The record indicated a family member was the responsible party and health care proxy. The annual MDS assessment, dated 4/23/23, for Resident #42 identified a BIMS score of 14 out of 15 indicating an intact cognition. The care plan for Resident #42 indicated the resident did have a certificate of incapacity on file. The care plan identified the last review was completed on 5/12/23. On 7/25/23 at 2:03 p.m., the MDS Director stated the last care conference was on 7/19/22 and confirmed there was no documentation of a care plan meeting since 7/19/22. The Director reported having spoken with the resident but does not remember having a meeting in the last year. 4) A review of Resident #51's admission Record identified an admission date of 2/4/21 and a family member was the responsible party. The quarterly MDS, dated [DATE], indicated Resident #62 had an intact cognition, with a BIMS score of 15 out of 15. A review of Resident #51's Care Conference Record indicated the last care plan conference was held 2/2/22 and did not identify which items had been discussed. The care plan for Resident #51 indicated the last review was completed on 5/19/23. The MDS Director stated, on 7/25/23 at 2:20 p.m., she probably wouldn't see any quarterly note from Social Service (related to care plan meeting). The Director stated a meeting was supposed to be done quarterly in conjunction with the MDS quarterly assessment In an ideal world, and confirmed Resident #51 should have had a meeting in November and in May. 5) A review of the admission Record for Resident #62 identified an admission date of 6/11/22 and that the resident was the responsible party. The Annual MDS, was dated 6/16/23, and indicated the resident had a moderate cognition impairment as evident by a BIMS score of 9 out of 15. On 7/24/23 at 12:59 p.m., Resident #62 stated not knowing about participation in care planning. A review of the hard copy chart on 7/26/23 at 6:48 a.m., revealed it did not contain any care plan meeting information. The last Social Service note in the chart was dated 12/14/22 and indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 8 of 31 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 07/27/2023 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 0657 a missing cell phone was located in the residents bed linens. Level of Harm - Minimal harm or potential for actual harm The Social Service notes, dated 7/6/22 to 2/1/23 did not indicate that a care plan meeting had been held with the resident or representative. Residents Affected - Some A review of the assessments that were opened for Resident #62 indicated a Care Conference Record was not available. The review of Resident #62's care plan revealed the last review was on 7/10/23. On 7/25/23 at 2:29 p.m., the MDS Director reviewed the binder, which contained records of care conferences for the residents, and stated Resident #62 did not have a record. The Director stated if the Care Conference Record in the assessments was not available, one had not been opened for the resident. During an interview on 7/25/23 at 2:03 p.m., the MDS Director stated usual attendees of care plan meetings were Social Services, therapy if the resident was skilled, MDS, and the nursing manager. The Director stated he had been in the building for about year and half, and a letter announcing the care plan meeting was placed on the table in the residents' room if alert and oriented, otherwise they call the representative the day of the meeting, and he only documents when they attend. The MDS Director stated Social Services have been in and out (of the facility), 8 Social workers in the last year, Administrators in and out, and 10 Directors of Nursing in the last year. The MDS Director stated the facility does okay for the short-term residents due to discharge planning but not so good for the long-term residents. The Regional MDS Registered Nurse (RN) stated, 7/25/23 at 4:51 p.m., that care plans should be done on admission, reviewed quarterly with the MDS (assessment) and as needed. The attendees should include the resident, if resident is not alert and oriented whoever is responsible, if alert and oriented ask the resident if they would like to invite whoever, Social Services, Dietary, Therapy if receiving, Activities, and nursing - usually the Unit Manage or nurse who was responsible for the resident. The Regional MDS stated family should be notified 7-14 days prior to the meeting either by telephone and documented or by letter to the address (on record) and the notes should indicate what was discussed and who attended. A review of the letter announcing the resident's care plan meetings revealed the following: The team and (facility name) believe a meeting with the resident and/or resident representative is an important part of our planning process in order to provide the highest quality of Patient Centered Care. Your input is greatly appreciated and valued in this process. The policy - Plans of Care, effective 11/30/14 and revised 9/25/17, indicated the following procedure: - Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 9 of 31 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 07/27/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm of food and nutrition services staff, and other appropriate staff or professional in disciplines as determined by the resident's needs or as requested by the resident, and to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). Residents Affected - Some The policy - Care Plan Invitation, effective 11/30/14 and revised 9/25/17, indicated the following: The resident and/or the resident representative shall be invited to attend each of the Interdisciplinary Care Planning Conferences for the specified resident. The procedure instructed to Deliver a Care Planning Invitation to the resident 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record. If resident has capacity, ask if they wish to have the resident representative at the care conference. Per resident choice or determination of capacity, mail Care Planning Invitation to the resident representative 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record. Have all attendees to the Care Planning Conference, including resident and resident representatives sign the Care Plan Conference Record to verify their attendance. The policy - Care Conference, effective 11/30/14 and revised 10/1/19, indicated the following: The Center will hold regularly scheduled interdisciplinary care conferences for the purpose of planning and developing the resident's individualized plan of care, and providing communication between the Interdisciplinary Team (IDT), resident, and/or resident representative. The procedure indicated that The resident and/or the resident representative shall be invited to attend each of the Interdisciplinary Care Planning Conference for the specified resident. The procedure revealed that each discipline should be prepared to discuss the resident's problems, strengths and goals and identify strategies and/or interventions to address areas of opportunity. The Care Conference Record should be maintained in the medical record. 6) The review of Resident #33's admission Record identified an admission date of 4/7/22 with diagnoses that included but not limited to acute respiratory failure with hypoxia (onset date 4/7/22), unspecified chronic obstructive pulmonary disease (onset 12/4/19), and shortness of breath (onset 12/4/19). The quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #33 had shortness of breath or trouble breathing when lying flat. The quarterly assessments on 12/29/22 and 6/28/23 and the annual assessment dated [DATE] did not indicate that the resident received oxygen therapy. The Order Summary Report, active as of 7/26/23 at 5:39 p.m., did not include a physician order for Resident #33 to receive oxygen. The Weights and Vitals Summary indicated from 4/17/22 at 3:42 p.m. to 7/20/23 (the last recorded oxygen saturation) the residents oxygen saturation was valued while the resident was on room air. An observation and interview of Resident #33 at 11:51 a.m. on 7/24/23 and on 7/26/23 at 10:45 a.m. did not reveal the resident was wearing oxygen while lying mostly flat with shortness of breath. On 7/26/23 at 4:26 p.m. the resident reported not using oxygen and no oxygen equipment was observed in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 10 of 31 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 07/27/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The care plan for Resident #33 identified a focus area as: Resident has oxygen therapy related to chronic obstructive pulmonary disease (COPD), initiated and revised on 5/5/23. The interventions included Oxygen Settings: O2 per MD orders initiated and revised on 5/5/23. On 7/27/23 at 1:35 p.m., an interview was conducted with Staff P, Licensed Practical Nurse (LPN) and Staff B, Registered Nurse/Unit Manager (RN/UM). Staff P reported not thinking Resident #33 had oxygen and left the area to check. Staff B reviewed the resident's orders and stated the resident did not have an order for oxygen. Staff B reviewed the resident's care plan and stated the residents' care plan for oxygen therapy should have been resolved. Staff P returned and confirmed the resident did not have oxygen. The staff members stated Resident #33 did not utilize oxygen during their tenure (2-3 months) at the facility. The policy - Plans of Care, effective 11/30/14 and revised on 9/25/17, indicated the following: An individualized person-centered plan of care will be established by the interdisciplinary team *IDT( with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The procedure identified that the facility Review, update and/or revise the comprehensive plan of care based on changing goals, preferences, and needs or the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 11 of 31 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 07/27/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to offer and provide individualized activities and assist one resident (#83) of thirty-three sampled residents to group activities during three of four days observed, 7/24/2023, 7/25/2023, and 7/26/2023. Residents Affected - Few Findings Included: On 7/24/2023 at 8:20 a.m., the 100/300 unit station area was observed with Resident #83 reclined in a Geri chair, positioned out in the hallway between the nurse station and the 100/300 lounge room. Resident #83 was noted with his head tilted and slumped forward with a head pillow not placed correctly behind him. A white linen sheet was observed covering him from his feet to his neck. Resident #83 was observed resting with his eyes closed and not otherwise presenting with any behaviors, pain or discomfort. Resident #83 was observed in the same position in his Geri Chair from 8:20 a.m. through 12:26 p.m. During the time period from 8:20 a.m. through to 12:26 p.m., many staff members were observed to walk by Resident #83 but did not stop to interact with him, nor did staff stop to offer or bring him to any of the day's scheduled activities. When housekeeping staff were on the unit, they were observed to utilize a high speed buffing machine around him, while he was positioned in the middle of the hall area. There was no music, there was no television and there was no staff interaction with the resident during the entire observation. There were no activities staff observed during this period of time to either offer him individualized or group activities. At 12:26 p.m. a Certified Nursing Assistant (CNA) Staff M. was observed to walk by the resident and she just quickly repositioned his head to not tilt forward so much. She did not speak with him, she only lifted his head and repositioned it. She then walked away from the resident at 12:27 p.m. There was no other interaction with the resident. As soon as the CNA walked away, the resident's head tilted forward again and still with his eyes closed. At 12:36 p.m. Staff M, CNA walked by again and repositioned the residents head. She did not interact or arouse him to ask if he wanted to eat lunch. She walked away less than ten seconds after she repositioned his head. At 12:51 p.m. Staff M. walked up to Resident #83, unapplied the brakes on the Geri chair, and spoke with another staff member about his lunch meal tray. She took the tray and got an over the bed table from his room, she brought the tray it to him where he had been positioned all day. She tried to arouse him for lunch but he would not wake up. She opened the lid to the tray and tried to arouse him several times but he would not waken to eat. At 12:53 p.m. she removed the over the bed table with the meal and brought it to his room. She then transferred the resident from the unit station area, to his room. Staff M. was then able to arouse Resident #83, to be assisted with his lunch meal. He did initially accept a few bites of food. A review of the posted current month (7/2023) activities calendar, revealed the following scheduled activities for day 7/24/2023; (9:30 a.m. Coffee and Treats; 10:30 a.m. News and Trivia; 1:30 p.m. Bingo; 3:00 p.m. Resident Movie). At 1:00 p.m. an interview with CNA Staff M. revealed she has Resident #83 on her assignment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 12 of 31 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 07/27/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few routinely. She revealed she brought the resident out in the hallway this a.m. and did not ask him if he wanted to go to any activities and did not know if any activities staff offered and assisted him to any of the scheduled activities for the day. Staff M. stated she believed the activities staff were responsible for inviting and assisting with group and individual activities. Staff M. stated Resident #83 had been involved with some activities and he has recently returned to the facility. Staff M. stated the resident does like to watch television and likes music. Staff M. did not know why he was not in a position to watch television or listen to music for long periods of time today. On 7/25/2023 at 6:45 a.m., 7:20 a.m. and 8:26 a.m. the resident's room was observed and he was noted lying flat in bed and with his head on a pillow. Resident #83 was not up for the day and his eyes were observed closed. The Television was not on and there was no music playing. At 8:50 a.m. the wound care nurse and the Unit Manager were at the resident's room door and preparing treatment orders for the resident's wounds. At 9:13 a.m. Resident #83 continued to be in bed and lying flat with head on the pillow. He was observed with eyes closed and not presenting with any behaviors, pain or discomfort. The Television was not on and there was no music playing. The Geri chair was positioned at the foot of the bed area. At 10:21 a.m. Resident #83 was still noted in his room and lying flat in bed, under the covers with his head on a pillow. His eyes were closed and the call light was placed within his reach. Resident #83 was not presenting with any behaviors, pain or discomfort. The Geri chair was still positioned at foot of bed area. The Television was not on and there was no music playing. At 11:10 a.m. resident was now observed transferred out from bed to his Geri chair and staff brought him out to the nurse station area and positioned him there. Resident #83 was now observed dressed for the day wearing a gray t-shirt, tan pants, a ball cap, wearing glasses, and wearing yellow non-skid socks. At 11:13 a.m. a staff member brought a white bed linen and placed it over him, covering from his ankles up to his chest and covering his arms and hands. The staff member also brought over a pillow and placed it between the back of his neck and the back of the Geri chair. Resident now observed with his eyes open and was watching staff walking around him. He was not presenting with any behaviors, pain or discomfort. At 1:02 p.m. Resident #83's room was observed and he was noted lying flat in bed, and under the covers. His eyes were closed and the call light was placed within his reach. The Television was not on and there was no music playing. From initial observation at 7:20 a.m. through to 1:02 p.m., there were no observations of staff to include direct care staff to activities staff either offering or assisting Resident #83 to an individualized or scheduled group activity. Review of the posted current month (7/2023) activities calendar, revealed the following scheduled activities for day 7/25/2023; (9:30 a.m. Coffee and Treats; 10:00 a.m. Communion in rooms; 10:00 a.m. News and Trivia; 1:00 p.m. Bingo; 3:00 p.m. Mani's for Grannies and Pa-Pops). On 7/26/2023 at 6:40 a.m., 7:15 a.m. and 8:02 a.m. Resident #83's room was approached and each visit he was observed in his bed, lying flat with his head on a pillow. The call light was placed within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 13 of 31 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 07/27/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his reach and he was noted with his eyes closed. He was not dressed for the day. Staff had not visited him yet to get him up, dressed, etc. for the day. The television was not observed on and there was no music playing. At 9:13 a.m. Resident #83 was still noted in his room and lying in bed flat, under the covers and with his head on a pillow. The call light placed within his reach and he was also noted with his eyes closed. The television was not on and there was no music playing. At 11:00 a.m. Resident #83 was still noted in his room and lying in bed flat, under the covers and with his head on a pillow. The call light placed within his reach and he was also noted with his eyes closed. The television was not on and there was no music playing. At 12:15 p.m. a CNA Staff N. was observed to walk over to the resident's room. Prior to her going in the room she was interviewed. She revealed she knows the resident but does not have him on her assignment all the time. Staff N. did confirm he was up and out from bed yesterday on 7/25/2023 and that they do try to get hi out from bed daily. She revealed he does not participate much in activities since his readmission from the hospital and she was unaware if he likes to watch television or listen to music. Staff N. did revealed Resident #83 was taken out of bed when he makes noises and the resident cannot speak his needs with relation to care and services. Upon entering the room Resident #83 was still noted in his room and lying in bed flat, under the covers and with his head on a pillow. The call light placed within his reach and he was also noted with his eyes closed. The television was not on and there was no music playing. From initial observation at 7:15a.m. through to 12:15 p.m., there were no observations of staff to include direct care staff to activities staff either offering or assisting Resident #83 to an individualized or scheduled group activity. Review of the posted current month (7/2023) activities calendar, revealed the following scheduled activities for day 7/26/2023; (9:30 a.m. Coffee and Treats; 10:00 a.m. News and Trivia; 10:30 a.m. Bean Bag toss; 1:30 p.m. Bingo; 3:00 p.m. Dominos game; 5:00 p.m. Late Night Movie). On 7/27/2023 at 9:00 a.m. an interview with the 100/200/300 Unit Manager reveled he was not aware Resident #83 was left in the same position with no activities or staff interaction on 7/24/2023 but did see him reclined in his Geri chair out in the hall that day. He revealed Resident #83 has just been readmitted from the hospital the last couple of weeks and he remembered the resident did like to roam around the facility on his own prior to hospitalization. The Unit Manager confirmed Resident #83 does like to watch television and listen to music and has seen him in the past joining music and movie activities. The Unit Manager stated it was the responsibility of Activities staff to offer activities outside the room on a daily basis and it was the CNA's or Nurses responsibility to turn on the television for residents who cannot turn on the television themselves. A review of Resident #83's medical record revealed he was admitted to the facility on [DATE] and readmitted from the hospital on 7/11/2023. Review of the advance directives revealed the resident was not his own decision maker and had family to make his medical decisions. Review of the diagnosis sheet revealed Resident #83 had diagnoses to include but not limited to: COPD, Osteoarthritis, Cerebral infarction, Repeated falls, Dementia, Adult failure to thrive. A review of the Minimum Data Set (MDS) assessment revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 14 of 31 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 07/27/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. admission MDS dated (1/12/2023) revealed; (Cognition/Brief Interview Mental Status or BIMS score - 6 of 15, which indicated the resident was not interviewable to make his care and services decisions); (Activities of Daily Living or ADL - BED MOBILITY = Required Extensive Assistance with Two person assist, TRANSFER = Extensive Assistance with Two person assist, EATING = Supervision with One person assist, TOILETING = Extensive Assistance with One person assist, PERSONAL HYGIENE = Extensive Assistance with One person assist); (Activities - How important is it to you to have books, newspapers, and magazines to read = Somewhat important, How important is it to you to listen to music that you like = Somewhat important, How important is it to you to keep up with the news = Somewhat important, How important is it to you to do things with groups of people = Somewhat important, How important is it to do your favorite activities = Somewhat important, How important is it to you to go outside to get fresh air when the weather is good = Somewhat important, How important is it to you to participate in religious services or practices = Somewhat important. All the noted responses was documented as given by the resident himself.) 2. Quarterly MDS dated (4/14/2023) revealed; (Cognition/BIMS score - 6 of 15); (ADL - BED MOBILITY = Extensive Assistance with Two person assist, TRANSFER = Extensive Assistance with Two person assist, EATING = Limited assist with One person assist, TOILETING = Extensive Assistance with Two person assist, PERSONAL HYGIENE = Extensive Assistance with One person assist); (Activities section was not completed.) 3. Quarterly MDS dated (7/15/2023) revealed; (Cognition/BIMS score - 6 of 15); (ADL - BED MOBILITY = Extensive Assistance with One person assist, TRANSFERS = Extensive Assistance with Two person assist, EATING = Extensive Assistance with One person assist, TOILETING = Extensive Assistance with One person, PERSONAL HYGIENE = Extensive Assistance with One person assist); (Activities section was not completed.) A review of the Community Life note, dated 4/10/2023 12:44, revealed; Resident sets his own leisure time family reached out to try to encourage resident to attend group activities department offers at times he declines at times he would attend by not stay long for groups activity department will continue to encourage him. A review of the psychosocial evaluation, dated 1/24/2023, revealed; Section #15 Religious/Faith identify as Baptist; Hobbies and Interests Section #2 what time of day do you prefer your hobbies or center activities = Anytime; Section #3 Where do you prefer to do your hobbies or center activities = In my room, on the neighborhood, Section #4 what type of activities do you prefer = Independent, Television, News and current events, and likes to wander around the building while in his wheelchair. A review of the psychosocial evaluation, dated 5/17/2023, revealed unchanged activity interests as reviewed from 1/24/2023 psychosocial evaluation. The medical record revealed no other activities notes or activities assessments in the residents chart. A review of the current Care Plans with a next review date of 10/12/2023 revealed the following but not limited problem areas: a. Resident #83 has previous recreational interest/patterns. Daily contact with close friends and family with interventions in place to include: All staff converse with resident while providing care; Assist with arranging community activities; Encourage ongoing family involvement. Invite the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 15 of 31 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 07/27/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's family to attend special events, activities, meals; Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and resident's representative on admission and as necessary; Introduce the resident to residents with similar background, interests and encourage/facilitate interaction; Invite resident to scheduled activities; Provide with a community life calendar. Notify resident of any changes to the calendar of activities; Thank resident for attendance at Community Life functions. b. Has an ADL self-care performance deficit r/t weakness, dementia, COPD. At risk for further decline in ADL functioning r/t disease process with interventions in place per review. On 7/24/2023 during tour of the facility all resident rooms had posted current 7/2023 months Activities Calendar. Further, the wall directly across from the Activities Room, revealed a very large current month 7/2023 Activities Calendar for review. The following scheduled days revealed: - Monday 7/24/2023 (9:30 a.m. Coffee and Treats; 10:30 a.m. News and Trivia; 1:30 p.m. Bingo; 3:00 p.m. Resident Movie). - Tuesday 7/25/2023 (9:30 a.m. Coffee and Treats; 10:00 a.m. Communion in rooms; 10:00 a.m. News and Trivia; 1:00 p.m. Bingo; 3:00 p.m. Mani's for Grannies and Pa-Pops). - Wednesday 7/26/2023 (9:30 a.m. Coffee and Treats; 10:00 a.m. News and Trivia; 10:30 a.m. Bean Bag toss; 1:30 p.m. Bingo; 3:00 p.m. Dominos game; 5:00 p.m. Late Night Movie). - Thursday 7/27/2023 (9:30 a.m. Coffee and Treats; 10:00 a.m. Rosary; 10:30 a.m. Chair Yoga; 1:30 p.m. Bingo; 3:00 p.m. Doodle Art). Photographic evidence was taken of the month's activities calendar. On 7/27/2023 at 11:00 a.m. an interview with the Activities Director revealed she was knowledgeable of Resident #83 and knows of him and his daily routines. The Activities Director stated prior to his recent hospitalization and, during his first admission, his normal daily routine would consist of roaming around the facility while self propelling in his wheelchair. She revealed he just liked to go from hall to hall and just watch everything going on. She confirmed he did not try to leave the building and he was not an elopement risk, he just liked to move around the facility. The Activities Director stated she had not seen or done an assessment on Resident #83 since his return to the facility and she did not realize he doesn't self propel in a wheelchair anymore. She stated she did not realize he gets transferred from bed to a reclining Geri chair, and can no longer self propel. The Activities Director revealed the resident would sometimes go to group activities but would not stay long and at times he would not want to attend. She stated Resident #83 does like current events/news and music and he would attend some of those types of scheduled activities before. She said that other than that, Resident #83 would prefer to stay in his room and watch television. She further indicated that direct care staff would be the staff to get him up out of bed, turn on television during the day, and if he wished, would bring him to an activity. Further interview with the Activities Director revealed it is the direct care staff responsibility to transfer a resident who cannot do so themselves to the group activity and it is the responsibility of the Activities Department to offer in room activities on a daily basis. She stated she nor her Activities staff document daily room visits, and could not provide evidence that Resident #83 was offered or assisted with Activities since readmission. The Activities Director stated she does attend and is a part of care plans, but not for every resident, as she has other types of jobs like taking residents to appointments and assisting with transportation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 16 of 31 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 07/27/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/27/2023 the Nursing Home Administrator provided the Individual Activities policy and procedure with an original date of 11/1/2021, for review. The policy revealed the following: Residents who are unwilling and/or unable to attend scheduled group activities are provided with one-to-one individualized recreation and Community Life based on their needs, interests, and functional ability. The procedure section of the policy revealed: 1. Review the preferred activities and activity times of the resident found on the following forms: (Psychosocial Evaluation, Activity Plan of Care, MDS). 2. Identify Residents unable or unwilling to participate in group activities. 3. Include resident and family in development of recreational and Community Life interventions that meet their needs, interests, and function ability. 4. Determine and schedule activities and times that support the preferences. Take into consideration the amount and type of independent leisure activities in which the resident is involved (e.g. TV, sports, soap operas, game shows, reading, independent bible study, etc.) 5. Determine the duration of visits according to needs/tolerance, with minimum of three times per week for fifteen minute periods. 6. Obtain the appropriate supplies for the 1:1 visits, including, but not limited to, the following: (Ball, Book, Braiding or sewing cards, Clocks, Color games, Comb/Brush/Hair ribbons, Craft material, Crossword puzzles, Dressing aides, Flash Cards, Large mirrors, Large print books, Lotion, Mending kits, Musical instruments, Nail polish/files, Newspapers, paper/pencil/markers, [NAME] shakers, Scrapbook with pictures, Shape sorting, Aromatherapy, Music player/Music media, Tool kit.) On 7/27/2023 the Nursing Home Administrator provided the Group Activities policy and procedure, with 11/1/2021 original date, for review. The policy revealed the following: Group activities are scheduled to enhance the resident' well being and self esteem. The activities are planned and organized to meet a specific purpose. The procedure section of the policy revealed the following but not limited to; (#1.) Determine the need and purpose for the group activity. (#8.) Give the name and purpose of group. (#9.) Explain what will be occurring. (#12.) Instruct staff to work directly with the Residents. (#15.) Monitor for resident decline in interest or change in behavior. (#15.2.) Conclude before interest wanes and residents wander off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 17 of 31 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 07/27/2023 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 0679 (#20.) Document participation in the point of care in the Electronic Health Record (EHR). Level of Harm - Minimal harm or potential for actual harm (#21.) Document a summary of the resident's interest, motivation, and progress at least quarterly. (#22.) Review and revise as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 18 of 31 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 07/27/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility did not ensure a bedfast resident with limited mobility received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to ensure restorative services were provided for one resident (#89) of three residents sampled. Findings included: On 07/24/23 at 08:50 a.m. Resident #89 was observed in her room lying in bed. The resident stated she was not receiving any therapy and was in bed all the time. She stated she could not move her lower extremities and had limitations to her arms. She stated she did not have a wheelchair and required staff assistance to get out of bed. A review of an admission record for Resident #89 showed she was admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of Hemiplegia and Hemiparesis following Cerebrovascular disease affecting left non-dominant side. The care plan for Resident #89 showed an ADL (Activities of Daily Living) goal indicating Resident #89 has a self-care performance deficit related to CVA (Cerebral Vascular Accident), hemiplegia, weakness and at risk for further decline in ADL functioning related disease process. Interventions included among others to elevate LUE (Left Upper Extremities) per MD (Medical Doctor) orders. The resident requires extensive assistance 1-2 staff to turn and reposition. A review of a document titled PT [Physical Therapy] discharge summary dated 04/20/23 showed Resident #89 was discharged from therapy having met all goals with a plan to remain in the facility. The discharge plan showed the resident was transferred with need for support from others. The summary showed, Maximal assistance necessary for performing rolling toward right side, moderate/maximal assistance necessary for rolling to left with tactile cueing necessary to place RUE (Right Upper Extremities) on arm rail for assistance. On 07/26/23 at 09:32 a.m., an interview was conducted with Staff F, Occupational Therapist (OT) and Staff G, Physical Therapist (PT). Staff F stated she had worked with Resident #89, but it had been a while. Staff F stated Resident #89 does not walk and was dependent on staff for transfers and mobility and required maximum assistance. She stated she had worked with the resident on transfers. Staff F said, That resident was very cooperative willing to work, just very many limitations and was therefore referred to the facility's restorative program because she was not making gains. Staff G stated Resident #89 was discharged from therapy on 04/21/23. He said, She was transferred to Long Term Care and was assigned restorative. She remained dependent on staff for all ADLs. A review of a document titled, Therapy Communication to Restorative Nursing Program dated 04/20/23 showed, Resident #89 functional status was ADL dependent. Under recommendations/approaches the plan showed; (1.) PROM (Passive Range of Motion) to Left UE (Upper Extremities) in all planes. (2.) 2 lb. hand weight with Right UE in all planes x20 repetitions. On 07/26/23 at 10:05 a.m., an interview was conducted with Staff I, CNA (Certified Nurse Assistant)/ Restorative Aide. Staff I stated she had not been performing restorative aide duties because she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 19 of 31 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 07/27/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm was only focused on getting resident's weights. She stated another person who worked as a restorative aide was out and that was why she could not perform her duties. Staff I provided a plan of care for the resident effective April 2023. She stated she did not have documentation to show she had seen the resident and provided the treatment plan. Staff I confirmed she had not worked with the resident on her ROM (Range of Motion) goals. Residents Affected - Few On 07/26/23 at 10:12 a.m., an interview was conducted with Staff B, LPN (Licensed Practical Nurse)/ Unit Manager (UM). Staff B stated he did not know the resident was not receiving restorative therapy as ordered. He stated he had just spoken with Rehabilitation Therapists and learned the resident should be reassessed. He stated if a resident was refusing care, they would involve the IDT (Interdisciplinary Team) and review the resident's care plan. He stated he would expect the Restorative Aide to document each time they see a resident and let him know if they were refusing to participate in Restorative therapy. He stated if a resident was continuing to decline, he would notify therapy for further assessment. On 07/27/23 at 10:32 AM an interview was conducted with Staff S, Regional Director of Clinical Services. She stated she did not know why restorative did not follow through. She said, The order was initiated but was not pushed through for assignment. She stated she would follow -up. A review of a facility policy titled, Restorative Nursing Services, dated 04/15/22, revealed the following: The center provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition and goals. Restorative nursing programs are considered for residents who are not a candidate for rehab services and those who could benefit from restorative along with rehabilitation services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 20 of 31 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 07/27/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure a catheter was anchored to prevent excessive tension, secured to facilitate flow of urine, and ensure it was positioned below the level of the bladder for one resident (#17) out of 13 residents sampled during 3 of 4 days of survey. Findings included: On 07/24/23 at 11:43 a.m., Resident #17's catheter was observed tucked between the resident's mattress and the foot of the bed. The tubing was noted kinked on the side of the bed. The catheter was not below the resident's bladder level. The catheter did not have a privacy cover. The urine inside was noted a red color. Resident #17 did not respond to the interview. On 07/25/23 at 11:30 a.m. Resident #17's catheter was observed in the same position by the foot of the bed. A review of an admission record for Resident #17 showed he was re-admitted to the facility on [DATE] with diagnoses to include Myasthenia Gravis without acute exacerbation, unspecified dementia, Chronic Kidney Disease and Benign Prostatic Hyperplasia with lower urinary tract systems. A review of Active physician orders for Resident #17 dated 07/26/23 revealed the following: A renal ultrasound was ordered for hematuria on 07/24/23. Catheter care every shift as needed 07/11/23. Catheter bag change as needed 07/11/23. Change catheter as needed 07/11/23. Foley catheter (specify catheter 16fr and balloon size 10ml 07/11/23. On 07/26/23 at 08:50 a.m. Resident #17's catheter was observed on the floor by the foot of the bed. On 07/26/23 at 08:57 a.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA) as she walked into Resident #17's room. She made the observation of the catheter on the floor and stated she would pick it up right away. Staff A looked at the bag and said, The Unit Manager (UM) had said he would change the bag on Monday. This is not the kind of bag he should have. He should have one that has a privacy cover and a hook that allows for us to hang it. Staff A stated the bag should have been changed when the resident returned from the hospital. She stated the nurse was aware of the urine color. On 07/26/23 at 09:20 a.m. an observation was made of Resident #17's catheter tucked at the foot of bed. An interview was conducted with Staff B, Licensed Practical Nurse (LPN)/UM. He stated he was about to change the bag. He said, The one he has, has a chamber from the hospital. The facility prefers them to use one that has a privacy flap. Staff B confirmed the catheter should be hung below the resident's bladder to allow urine to flow. He stated the doctor was aware of the concerns with blood in the urine. He stated he would follow up on the results of the UA [Urinalysis]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 21 of 31 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 07/27/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/26/23 at 10:51 a.m., an interview was conducted with the Director of Nursing (DON) and Staff T, Regional Director of Clinical Services. The DON stated the bag should have been changed on re-admission. Staff T stated they use the ones with a privacy flap. The DON stated Resident #17 was readmitted on [DATE], approximately two weeks before. The DON stated the bag should not be stored at the foot of bed, it should be below bladder to ease flow. The DON stated the UM had just changed the catheter and would follow-up with the physician on the UA results. On 07/27/23 at 1:30 p.m. an interview was conducted with the Nursing Home Administrator. She stated they did not have a specific policy on catheters. She stated they follow physician's orders. A review of a facility policy titled, Physician Orders, dated 03/03/21 indicated the facility will ensure that physician orders are appropriately and timely documented FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 22 of 31 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 07/27/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and two errors were identified for two residents (#30 and #4 ) of five residents observed. These errors constituted a 6.67% medication error rate. Residents Affected - Few Findings included: 1) On 7/26/23 at 7:53 a.m., an observation of medication administration with Staff P, Licensed Practical Nurse (LPN), was conducted with Resident #30. The staff member dispensed the following medications: - Clopidogrel 75 milligram (mg) tablet - Docusate sodium 100 mg gel cap - Escitalopram 10 mg tablet - Metoprolol Succinate Extended Release (ER) 25 mg - 1/2 tablet - Vitamin B12 1000 microgram (mcg) tablet A review of the July Medication Administration Record (MAR) indicated the following physician order: - Vitamin B12 - Give 1000 mg by mouth one time a day for supplement, started on 3/20/22. On 7/26/23 at 1:32 p.m., Staff P reviewed the available Vitamin B12 tablets in the medication cart. The cart contained one bottle of Vitamin B12 1000 mcg tablets and one bottle of 500 mcg tablets of Vitamin B12. The staff member reviewed the order for Resident #30's Vitamin B12 and confirmed that it read 1000 milligrams. During the interview with Staff P, Staff B, Registered Nurse/Unit Manager (RN/UM) was consulted and stated, That's a lot of Vitamin B12. Resident #30's July MAR indicated that the order for 1000 mg of Vitamin B12 was discontinued at 1:36 p.m. on 7/26 and a new order for 1000 mcg of Vitamin B12 was to start on 7/27/23. 2) On 7/26/23 at 8:01 a.m., an observation of medication administration with Staff P, Licensed Practical Nurse (LPN), was conducted with Resident #4. The staff member dispensed the following medications: - Amiodarone 200 mg tablet - Aspirin 81 mg Enteric Coated (EC) tablet - Eliquis 2.5 mg tablet - Gabapentin 600 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 23 of 31 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 07/27/2023 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 0759 - Jardiance 10 mg tablet Level of Harm - Minimal harm or potential for actual harm - Lactobacilli Acidophilus 5 million capsule - Multi Vitamin with mineral tablet Residents Affected - Few - Potassium Chloride Extended Release 10 milliequivalent's (meq) tablet - ClearLax 3350 - capful - Trelegy 100 mcg/62.5/25 mcg inhaler Staff P confirmed dispensing 8 tablets, an inhaler, and ClearLax liquid. The staff member administered the medications, returned to the cart, and identified forgetting the residents Lasix. The staff member documented the above medications and Cholecalciferol (Vitamin D3) had been administered. The staff member dispensed and administered one tablet of 40 mg Furosemide to Resident #4. On 7/26/23 at 8:16 a.m., Staff P stated that Vitamin D3 was house stock and didn't have it in the cart, the staff member confirmed documenting the medication had been administered and would have to strike it out. On 7/27/23 at 10:30 a.m., the observations of medication errors were discussed with Staff S, Regional Director of Clinical Services. The policy - General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10, 1/1/13, and 1/1/22, indicated the following: Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. The policy instructed that Facility staff should: - Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident as set forth in facility's medication administration schedule. - Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given, injection site of a medication, if medications are refused, as needed (prn) medications, application sight) on appropriate forms. The policy - Physician Orders, effective 11/30/2014 and revised 3/3/2021, indicated the following: The center will ensure that Physician orders are appropriately and timely documented in the medical record. The section, Routine Orders, indicated that The order will be repeated back to the physician, Physician Assistant (PA), or Advanced Registered Nurse Practitioner (ARNP) for his/her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMar/eTAR). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 24 of 31 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 07/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure 1) One of one Dish Washing machines were operating per final rinse requirements during two of four days observed, on 7/24/2023 and 7/25/2023; and 2) One of one rental walk in freezer unit observed with heavy ice build up inside the unit during two of four days observed, on 7/24/2023 and 7/25/2023. Findings included: 1) On 7/24/2023 at 7:24 a.m. the facility's kitchen was approached and met with the Kitchen Manager Staff A. She indicated she has not been employed at the facility long but long enough to know her kitchen, her staff, and how to operate the kitchen. Staff J. revealed they have a Registered Dietician who routinely comes to the facility on Monday's and is usually available for contact during other days of the week. Since it was still early and the kitchen staff were just starting with plating meal trays for breakfast, it was determined that the dish washing machine had not been operating as of yet. Staff A. revealed they would be operating the dish washing machine at around 8:30 a.m.--9:00 a.m. Staff J. stated the dish washing machine was operating effectively and has not had any recent repairs, and stated the machine was a High Temperature machine. At 9:00 a.m. the Kitchen was toured with Staff J. She pointed out the dish washing machine was not being used and it could be observed for operation. She said they had some temperature issues about one month ago (6/2023), and that temperatures were not reaching appropriate temps for wash and rinse. She revealed the dish machine maintenance company had come in to look at the machine and he fixed it but at the same time he installed a sanitizing option to work in conjunction with the high temperatures. Staff J. was not sure why the service person did that, as they operate with a High Temperature machine only. She was asked if she and her staff then take sanitizer reading for each meal service to see if the sanitizer is pumped out and through the machine appropriately. She revealed she was not sure. The Staff member who was operating the machine during this observation, Staff K. confirmed the dish machine was a High Temperature machine and was not sure why there was sanitizer being pumped into the machine. Staff J. and K. were asked if they document dish machine temperatures for both the Wash and Rinse cycle and if they document the Parts Per Million (PPM) levels as well. Staff J. revealed they do have a daily log sheet and log those things every meal service, every day. Staff J. pointed out the dish machine log, which was posted on the wall around the corner of the dish machine. The current 7/2023 month log revealed Breakfast service wash temperatures ranging from 170 degrees F. to 189 degrees F. dating 7/1/2023 - 7/24/2023. The final rinse for Breakfast service ranged from 177 degrees F. to 185 degrees F. during the same date time frame. Further review of the log revealed staff documented sanitizer PPM range at 200 PPM each day from 7/1/2023 - 7/24/2023. A review of the Lunch meal service wash temperatures ranged from 170 degrees F. to 185 degrees F. and rinse ranging 175 degrees F. to 190 degrees F. during the same date time frame, and also with documented PPM at 200. The Dinner meal service wash temperatures ranged from 170 degrees F. to 185 degrees F. and with the rinse temperatures ranging from 180 degrees F. to 190 degrees F., also during the same date time frame. Further, staff documented the PPM each day at 200. Staff J. was asked why staff documented the sanitizer Parts Per Million (PPM) at 200 each day, when the dish machine was noted as a High Temperature machine. She did not know exactly other than that was why the dish machine service man installed a few weeks ago. Staff J. and Staff B. could not answer as to how they determined 200 ppm on a daily basis. Further, Staff J. and K. were asked if they had any sanitizer litmus paper test strips to take sanitizer readings and they both indicated that they did not have test strips available and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 25 of 31 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 07/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have not been using them to take sanitizer PPM readings. Staff J. and Staff K. were again asked how they came to the conclusion of documenting 200 PPM each day and each meal service, with relation to the sanitizer. Neither Staff J. or Staff K. had an answer as to why they documented 200 PPM each day. At this time Staff J. was asked if they could run a temperature demonstration for both the wash and rinse cycle. At 9:38 a.m. Staff K. was observed to run a plastic crate of dishes through the machine. Staff J. was present during the demonstration and it was observed: The wash cycle gauge reached around 168 - 169 degrees F., and the final rinse gauge when the rinse cycle started, only reached 145 - 146 degrees F. Staff J. and K. both indicated the machine was running fine just moments before this observation and the temperature for rinse was in the 170's. Staff J. confirmed the final rinse cycle temperature did not reach the required temperature. At 9:40 a.m. a second crate of dishes was run through and again the wash temperature reached 168 - 169 degrees F., and the rinse temperatures only reached around 145 degrees F. Both wash and rinse cycle was confirmed by Staff J., Kitchen Manager. Staff J. again indicated the final rinse was not reaching the required temperature. She stated she would immediately call the dish machine maintenance service person and get him/her out to the facility to look at the machine to see what was wrong. She also indicated until he/she comes and fixes the machine, they would now provide residents with paper and plastic eating ware only. She was then asked how the sanitizer is actually measured and she again confirmed that there is no way and that they had just thought when the dish machine maintenance company installed the sanitizer option, that it reached 200 ppm. There was no actual testing of the sanitizer during both machine cycle demonstrations. On 7/26/2023 at 9:42 a.m. the kitchen was visited to observe the dish machine operation. Once entered the dish machine area, there were two employees Staff L. and Staff K. observed operating the dish washing machine. Staff K. was observed bringing soiled dishes into the dish machine room while Staff L. was observed placing dishes into empty plastic crates and feeding the crates of dishes into the machine. An interview with Staff L. revealed she was knowledgeable of the machine's use and indicated the dish machine was a High temperature machine and wash temperatures are to reach at least 160 degrees F. and above, and rinse temperatures are to reach at least 180 degrees F. and above. Staff L. confirmed there is no need for sanitizer to run through the machine and that as of yesterday (7/25/2023), they are no longer pumping sanitizer in the machine. While interviewing Staff L., Staff J. confirmed the dish machine maintenance company came out to look at the machine yesterday 7/25/2025 and indicated there was a problem with a part that keeps the required water flow temperature through the machine. The Kitchen Manager Staff J. revealed the machine was fixed and the wash temperature now reached around 170 degrees F., and the rinse temperatures reaches around 185 - 190 degrees F. At 9:47 a.m. dietary aide Staff L. ran a plastic crate of dishes though the machine and the following was observed: The wash temperature reached 170 degrees F., and the Rinse temperature reached 190 degrees F. A second demonstration revealed a plastic crate of dishes ran through the machine at 9:48 a.m. with the wash temperature reaching 170 degrees and the rinse temperature reaching 197 degrees F. Staff J. was asked about the container of sanitizing liquid on the ground, placed under the dish machine. She revealed the dish machine maintenance company removed the tubing from the bottle and dish machine connection and indicated that sanitizer is not needed with regards to a High temperature machine. Staff J stated she inserviced her staff with regards to the proper use of the machine and they are not to document Parts Per Million (PPE) sanitizer results on the machine daily temperature log. Staff J. was still not sure why her staff were documenting 200 PPM each day and during each meal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 26 of 31 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 07/27/2023 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 0812 service, when they do not have any test strips to take a reading. Level of Harm - Minimal harm or potential for actual harm On 7/26/2023 at 11:20 a.m. the Kitchen Manager Staff J. provided the specifications for the dish washing machine which revealed the following: Residents Affected - Some (Machine is a Conveyor Drive Motor with a Wash motor and Wash heater. The specifications further revealed the machine is to be used as a Hot water Sanitizing machine to include minimum wash temperature at 160 degrees F., and minimum rinse temperature at 180 degrees F. On 7/26/2023 at 11:30 a.m., the Kitchen Manger Staff J. provided the surveyor with a dish machine maintenance service report, dated 7/25/2023. The report was dated one day after the machine had been observed with rinse temperatures not meeting requirement; which was on 7/24/2023. The report revealed; Extra Service Request, Request Description: Temperature issues. Service comments section of the report revealed; Upon arrival Machine was only reaching 140 degrees F. on the final rinse temperature gauge noticed it would only stop at 140 degrees F. and nothing higher, replaced temperature gauge on the final rinse now is reaching 180 +. Machine can be used as high temp spike with customer and told them they can remove the sanitizer off dish machine. There was no indication from the report as to why sanitizer option was utilized in the first place. The machine had not been operated as a Low Temperature dish washing machine previously, as per interview with all the kitchen staff to include the Kitchen Manager Staff J., and Kitchen aides Staff K. and L. 2) During kitchen tour on 7/24/2023 at 7:24 a.m., The Kitchen Manager Staff J. pointed out she has two reach in refrigerators and one is currently down and not working. She pointed out the see through glass door reach in and there was a note on it that indicated not working. Staff J. revealed this reach in had stopped working about three or four days ago and maintenance had been notified. She demonstrated and verbalized there was nothing stored in this reach in and there would not be any food stored in the reach in until it gets fixed and reading temps are under 40 degrees F. The tour continued to the walk in refrigerator and it appeared stocked with food items. Staff J. revealed the walk in freezer, located within the walk in refrigerator, was also out of order and that there was at this time no food stored in it. Staff J. verified there was no food stored in this unit. Staff J. revealed the walk in freezer had been out of order for about four weeks now and at this time they have a rented freezer trailer, that is located out in the back parking lot area. The outside walk in freezer (rented freezer trailer), was observed with the door completely shut. The seals to the door appeared in good working order and there were plastic flap strips used as a barrier to the elements. Upon entering the trailer freezer, there were various boxes of food items stored on shelves inside the unit. The back of the freezer was observed with an air conditioned chiller unit that was heavily caked with built up icing and ice [NAME]. There was a three shelved storage unit under the air conditioned chiller that was also heavily built up with ice. There was no food stored on any of the shelves. The floor directly to the right side of the three shelved cart was also observed with heavy ice build up with measured approximately three feet length, four feet wide, and approximately twelve inches high at the highest point of the ice build up pile. There was a bucket placed on top of the ice build up pile with a ladle inside. The bucket was heavily built up with ice. Photographic evidence was taken. An interview with the Kitchen Manger Staff J. revealed there had been leveling problems with the trailer freezer and back flow water was supposed to go through to a hose, and then outside of the unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 27 of 31 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 07/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and then to the concrete ground. She stated because of the way the trailer freezer sat, the water flowed back into the actual freezer and then the water froze, causing what was observed. She stated the freezer unit has had this problem for a week or so and have only had this unit for about four weeks. Staff J. further stated the maintenance department was aware of the situation and has made adjustments, but it seems it never got fully fixed. Staff J. stated the inside of the freezer unit should not be with ice build up. The analog temperature gauge inside the unit revealed 28 degrees F. On 7/25/2023 at 9:50 a.m. the outside walk in rental freezer was again observed. Staff J opened the door and the same heavy icing as observed. Staff J. revealed she had mentioned the problem to the Maintenance Director yesterday and she believed he, or the Administrator, had called the rental company to let them know of the heavy icing issue. She was not sure what the outcome of the communication was. The analog thermometer inside this freezer read 28 degrees F. On 7/26/2023 at 11:17 a.m. the kitchen was toured with Staff J. She stated they received another walk in freezer trailer rental during the night. The freezer was observed and the new one was stocked with food items and free from icing, free from frost build up. The inside temperature thermometer read 27 degrees F. Staff J. revealed the rental company did not have any written documentation to include instructions of use, and the company representative verbalized how to use the unit. On 7/27/2023 at 10:58 a.m. an interview with the Maintenance Director revealed the facility's main kitchen walk in freezer, which is within the walk in refrigerator has been out of commission for about three weeks and he had to await for parts to come in and then assistance with install. He confirmed the facility management had ordered a rental trailer freezer to use until the main freezer gets repaired. He revealed it was brought to his attention this past week that the rental freezer had created heavy icing, and ice frost build up and had to call the rental company to replace with another unit. The Maintenance Director revealed the rental company did not leave specific directions on its use but it was verbally gone through with him. He revealed if there are any problems, he or management will call the rental company and they will come and fix or correct the problem. The Maintenance Director did not have a policy and procedure with regards to rental freezer unit. The Maintenance Director revealed he was not made aware of the dish machine not maintaining the correct wash/rinse temperatures until 7/25/2023. He did say however, that the facility management called out the dish machine maintenance service representative and he/she came out to do the repairs and to his knowledge the machine is now working properly. On 7/27/2023 the Nursing Home Administrator (NHA) provided the following policy and procedures for review: 1. Warewashing, dated with a revision date of 9/2017, revealed; All dishware, service ware, and utensils will be cleaned and sanitized after each use. The Procedure section of the policy revealed: 1. The Dining Service staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware, 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature machines, 3. Temperature and/or sanitizer concentration logs will be completed, as appropriate, and 4. All dishware will be air dried and properly stored. The policy also indicated; Attachment 1. Dish Machine log. Review of the attached Dish Machine log revealed; template to document Wash, Rinse temperatures and sanitizer Parts Per Million (PPM), for all three meal services, and to include every day of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 28 of 31 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 07/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete month. The log had a Standards section at the bottom of the page that revealed; High Temp Machine: Wash = 150 - 160 degrees F., Rinse 180 degrees F. The sheet also revealed; Always defer to manufacture's guidelines regarding temperatures and correct chemical concentration for use. Per interview with he Nursing Home Administrator, there was no equipment to include walk in freezer policy and procedure for review. Event ID: Facility ID: 105951 If continuation sheet Page 29 of 31 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 07/27/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure appropriate coordination of Hospice services for one resident (Resident #8) of three residents sampled. Findings included: On 7/23/2022 at 10:00 a.m., Resident #8 was observed laying down in bed on an air mattress, his call light was observed within his reach. Resident was not able to express how he was feeling at the time of observation. His catheter bag was observed off the floor in a privacy bag. On 07/26/2023 at 11: 20 a.m., an review of Resident # 8's medical record revealed no evidence of a hospice plan of care documentation. A review of the admission Record revealed Resident # 8 was admitted on [DATE] with diagnosis to included but not limited to Metabolic Encephalopathy, Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified, Major Depressive Disorder recurrent, unspecified, Chronic Kidney Disease, Stage 4 (Severe) , and Benign Prostatic Hyperplasia. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 06 indicating the resident is severely impaired. Section 0: Special Treatment, Procedures, and Programs revealed the resident receives Hospice Care while in the facility. A review of the care plan, dated 7/26/2023, showed a referral for Hospice was sent on 3/30/2023 per family request. A review of the care plan intervention initiated on 3/31/2023 revealed a Hospice consult per family request. On 07/26/20 23 at 11:27 a.m., an interview with Staff R, RN, Minimum Data Set (MDS) Director was conducted. He stated the facility procedure when a person is admitted to hospice is to first submit a referral for hospice services. He stated, hospice services and the facility coordinate the resident care, by ensuring that hospice care plans, and their documentation is obtained and reviewed by the designated staff. He said hospice should also get invited to care plan meetings for residents who are on hospice to ensure coordination of care. He confirmed Resident #8's assessments, care plans and progress notes were not obtained for hospice services, and he has not invited hospice to any of the Residents #8's care plan meetings to review hospice services. On 07/26/2023 at 11:45 a.m., an interview was conducted with the Interim Director of Nursing (DON). She confirmed she has been working in the building since July 5, 2023, as the Interim DON. She said the facility did not have any documentation for Resident #8's hospice care, but she plans to get in contact with hospice to get all of his record. She stated her expectations for the coordination of care for hospice residents are that the facility should have documentation in the resident medical record each time they are provided hospice services, and hospice should communicate with the nursing before they leave from visiting any resident to provide the facility with an update regarding the resident hospice care. She stated hospice should be a part of the residents care plan meetings when necessary. A review of the Hospice Service Agreement, effective date October 1, 2018, indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 30 of 31 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 07/27/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few This Agreement is made between and entered into this 1st day of October 2018 by and between [Hospice Facility], doing business as [Nursing Home Facility] for and on behalf of the nursing home facilities listed in Appendix B attached hereto and [Hospice Facility] for provision of Hospice Services for residents of facility requiring such hospice services. [Nursing Facility], Hospice, and facilities agrees that this Agreement, when fully executed, shall supersede any hospice agreement currently in effective between Hospice and any individual Facility. 2. Services to Be Furnished by Hospice, 2.1. Hospice Plan of Care. Hospice will develop a Hospice Plan of Care for Residents in accordance with applicable provisions of the Conditions of Participation for hospice care and other applicable provisions of this Agreement. Hospice will update the Hospice Plan of Care for Resident in accordance with applicable provisions of the Conditions of Participation and other applicable provisions of this Agreement. Any such updates to the Hospice Plan of Care by Hospice must be reviewed with the Facility's minimum date set ( MDS) department and maintained in the facility's care plan binder 3. Services to be furnished by facility 3.6 Facility Liaison. Facility Liaison shall be responsible for collaborating with Hospice and Hospice Liaison and coordinating Facility personnel participation in the hospice care planning process, as well as communicating with Hospice Liaison and other condition of Hospice Patient. The Facility Liaison is also responsible for ensuring that Facility communicates with the Hospice Medical Director, Attending Physician, and other practitioners participating in care as needed to coordinate Hospice Services with that provided by others. Facility Liaison shall obtain the following information from the Hospice, (a) the most resent Hospice Plan of Care specific to the Hospice Patient, 4. Coordination of Services 4.2. Communication Concerning Residents. The Hospice Liaison shall communicate with Facility Liaison to coordinate the Hospice Services with the medical care being provided by other physician, in addition, each party shall communicate with the other party on an ongoing basis to ensure that the provision of this Agreement are implemented, that quality of care is provided, and that the needs if Resident and his/ her family are addressed and met on a twenty - four ( 24) hours basis. Documentation of such communications shall be maintained by each party in their respective clinical records concerning each. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 31 of 31