Health inspection·January 19, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Residents Affected - Few Definitions: .Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to; .Failure to adequately supervise a resident known to wander from the facility without the staff knowledge . An interview was conducted on 1/16/24 at 10:08 a.m. with Staff B, Activities Director (AD) she said on 12/20/23 around 12:00p.m. she relieved the receptionist. Around 12:20 p.m. to 12:30p.m. the Kitchen Manager entered the lobby from the resident hallways and Resident #1 followed behind her into the lobby. I saw him, and I thought he was a family member because he looked so much better than he did when he first came to us. His hair was combed, he was shaved, he was walking very well and confidently. I thought he was a family member, so I asked him to sign out and he wrote his name down on a blank line, he looked at the clock and signed out. It was about 5 minutes later, and his [Family Member] called me and said my husband is calling me asking me to pick him up on [Street Name] and she wanted me to make sure he was in his room. I called down to the nurse's station and the ADON answered the phone, and I asked her to look to see if he was in his room and he wasn't, so they immediately started searching for him inside and outside of the building. The [Family Member] was on hold at this time, so I told her he was not in his room, and we were looking for him. I gave her my personnel number and told her to call me on that so I could go and look for him. While I was on the phone with her [Resident #1] kept calling her and she said he was on [Street Name]. I think it was Human Resources and a nurse who found him, I'm not sure exactly where they found him, but they put him in their car and brought him back around 12:45p.m. When I got back to the facility, I saw [Resident #1] and it was at that point that I realized oh man I was the one who let him out. I couldn't believe I did that. I told the [Family Member] that we found him, and he was back, and she was a little upset and said if she didn't call me would the staff have known he was even gone? And I told her I would have the DON [Director of Nursing] call her. [Resident #1] was not injured but he did not have his [Wander Monitoring Device] on, so they put one back on him. When he walked through both doors neither alarm went off to let me know that he had an [Wander Monitoring Device] on. That's why I just thought he was a family member. When he first got here, he was door seeking and he had an [Wander Monitoring Device] on but after that I had not seen him in the hallways as often. The day he eloped it was sunny and breezy out; it was a nice day. He was wearing long sleeves, pants, loafer slippers with a rubber soul. He did not have any assistive devices when he left, and he was walking very well and confidently. He was not injured. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 1/16/24 at 10:50 a.m. she said she was Resident #1's CNA on 12/20/23, the day he eloped. She said around 11:30 a.m. she was working with his roommate getting him ready and at the time Resident #1 was sitting on his bed. When I left the room . [Resident #1] was still sitting on his bed around 11:45 a.m. I went to help another resident and while I was doing that the therapist came in and said that someone else needed to use the bathroom. I told her to tell the resident's family that I will be there in a minute I just need to finish up with this resident. When I came out of the room the family was in the hallway (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 2 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few screaming and yelling that his dad needed to use the bathroom right now. I told him I would go put my dirty linens away and be right there and he would not accept that. The ADON came over to diffuse the family member and she had asked me to step off the unit, so I went outside for about 15 minutes and the other CNA assisted the resident to the bathroom. I'm not sure where the nurse was at that time but I'm sure she was busy with a resident because this unit is the rehab [rehabilitation] unit, and it is always very busy. When I came back about 15 minutes later, I started to pass meal trays but before I could even pass one tray the ADON said [Resident #1] was missing and immediately everyone in the building started searching for him inside, outside, everywhere .When he came back, he did not have on his [Wander Monitoring Device] and he did not have any injuries thank god because that could have been really bad and he could've gotten really hurt. He walked well without any assistive devices, but he would get tired and would rest against the wall or sit down . Before he eloped, we would have to redirect him at least six or seven times a shift. When his [family] would visit and leave he would get more anxious and want to go home. He was definitely exit seeking and he did have a [Wander Monitoring Device] on his leg at one point because I would see it when he sat down and crossed his legs. He was alert but he was confused and easily redirected. The day he eloped I did not see a [Wander Monitoring Device] on him, but I also did not look. His [family] gave him a bath, shaved him, and got him dressed the night before so I did not have to do any of that in the morning and I usually check the [Wander Monitoring Device] when I do my baths . An interview was conducted with Staff C, CNA on 1/16/24 at 11:12 a.m. she said she was working the day Resident #1 eloped and she was not his CNA, but she was the other CNA on the hall. She confirmed Resident #1 was exit seeking and would need a lot of redirecting back to his room. He always wanted to go home. She said he walked well without any assistive devices he would just need to take breaks because he would get tired, and he would rest against the wall and just keep an eye on everything. An interview was conducted on 1/16/24 at 3:46 p.m. with Staff D, Human Resource (HR) she said on the day Resident #1 eloped there was an overhead page about a missing resident. She reported to the lobby and received a face sheet of the resident. As she was getting her search location Staff E, RN asked if he could drive with her. Staff D, HR said she drove out of the facility, went left, and after approximately 30 seconds she turned into a beauty salon. She said the beauty salon was located across the street from the facility. She said the resident was found sitting on a bench in front of the beauty salon and Staff E, RN got out of the car, talked to the resident for a minute, the resident walked independently with a steady gait back to the car. She said the resident got into the back seat and said I'm fine. and You're going to take me back. She drove Resident #1 and Staff E, RN back to the facility and dropped them off at the front door and went to park her car. She said she did not notice [Wander Monitoring Device], but she did not look for one. She said he did not have any injuries that she noticed. An interview was conducted on 1/16/24 at 4:00 p.m. with Staff F, Receptionist. She said on the day Resident #1 eloped she went on lunch break at 12:00 p.m. and Staff B, AD covered the receptionist desk. Staff F, Receptionist returned at 12:30 p.m. and she said when she came back everyone was a mess looking around for Resident #1 because the family member had called and said he was on the street waiting for her to pick him up. She said she asked if anyone had done an overhead page and they said they didn't, so she overhead paged for the resident to return to his room and when he didn't, she called a code silver. She said everyone continued to search for him. She was not sure where he was found. She said early the same morning between 9:00 a.m. and 10:00 a.m. the family member called her to have the nurse check on him because Resident #1 had called her and said he was leaving today and needed to be picked up. She paged the nurse and the nurse said he was in his room, and he was alright just (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 3 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 confused because he was supposed to leave the next day. Level of Harm - Immediate jeopardy to resident health or safety A phone interview was conducted on 1/17/24 at 8:44 a.m. with Staff E, RN. He said he heard the overhead page Resident #1 was missing. He said he had worked with him when he was first admitted and he was unable to walk but he knew the resident went to the hospital, came back, received rehabilitation, and saw him walking the halls without assistive devices and walked well. He said Resident #1 was confused. He said since he knew what the resident looked like, and he knew he could walk he went to check outside. When he went outside, he saw people were starting to get in their car and look, so he asked Staff D, HR if he could ride with her and she said yes, and they got into her car and went left out of the building, and he was looking for Resident #1. At the beauty salon he saw the resident sitting on the bench in front of their door. He [Resident #1] was confused, so I introduced myself to him, he did not recognize me, but he came right with me and got into the car. Staff E, RN said he brought the resident back inside the building and he heard the resident cut his wander monitoring device off. He said he spoke with the family, and they were not happy to the point they took him out of the facility right after that. Residents Affected - Few A phone interview was conducted on 1/17/24 at 10:28 a.m. with Resident #1's family member she said I was at my work, in my office it was close to noon time, 11:00-11:30 a.m., and he [Resident #1] called me and told me to go and pick him up. I thought he was just calling me from the facility but then he told me that he was on the street, and he told me [Street Name]. I was shocked because that was the name of the street the facility was on, and I thought how would he know that? I told him to wait right there. I called the facility to see if [Resident #1] was there in his room. So, everyone ran to his room, and he wasn't there, and they looked all around the facility and people were starting to drive around. I called my husband back and I said what is the name of the business you are in front of. I googled that business and I saw that it was all the way on the corner of the street .he said there are stairs and I told him to sit on the stairs I'm going to have someone pick you up. One person at the facility gave me their number so I called her, and she said she was driving in the opposite direction of where he said he was but someone else was going in that direction and the male nurse found him and brought him back to the facility and he was okay. Fortunately, [Resident #1] had his phone and he decided to call me, and I don't know what would have happened to [Resident #1] if he did not call me. I asked him how he got out, but he has memory problems and he said he hopped a fence, but the facility has security footage and he walked out of the front door, and he even signed himself out like he was a visitor. [Resident #1] is [AGE] years old, and he doesn't use a wheelchair or a walker. He did not need anything to walk at that point, so he looks like a visitor, but his mind is not right he has hallucinations and makes up stories. When he first got to the facility, he could not walk so he had a wheelchair, then he was able to use a walker, then he was able to walk on his own but still a little off balance. I was panicking because he has no memory and no sense of direction of where he was going to go .He probably just walked straight, then he got to the intersection and saw the street sign and probably did not know if he should go right or left so that is why he called me. Even if he had turned around, the road curves and you're not able to see the facility from where he was so he wouldn't know to go back there. Fortunately, I gave him his cell phone and it had enough charge on it, and he thought to call me. If those things did not happen, I don't know what would have happened to [Resident #1] if he did not think to call me. I make an effort to visit him every day, so I stay on his mind, so his mind does not forget me. He was definitely not safe to be outside by himself. When he came back to the facility for the second time after going to the hospital, they put a bracelet [Wander Monitoring Device] on him because he walked out of his room but that was probably on for only 3 or 4 days then I did not see it again. I just thought the facility took it off (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 4 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few because he wasn't walking out of his room anymore because when I would visit him, he was always in his room but when they brought him back, they told me he took off the bracelet and they put a new one on him right away. I didn't feel comfortable with him there after this happened. Resident #1's family member said she took him home the day after he eloped. A phone interview was conducted on 1/17/24 at 12:10 p.m. with Resident #1's Physician. She said she was aware Resident #1 had eloped. She said He is a patient who looks pretty good, very well dressed, talks well, but he has encephalopathy and some dementia. He was let out by activities and the staff found him a little bit after. He looks like a visitor but if you didn't know him and you didn't talk with him for a while you would think he was a visitor. It was critical for him when he got out but when he was in the building, he was fine, he was always in his room sitting next to his bed . An interview was conducted on 1/18/24 at 11:29 a.m. with Staff G, RN. She said, she was the nurse for Resident #1 on the day he eloped. She said she did not get anything in report about Residents #1's wander monitoring device and she did not check to see if his wander monitoring device was in place before he eloped. She said she gave Resident #1 his morning medications around 10:30 a.m. and 11:00 a.m. and he was sitting next to his bed. She said she had no concerns. She said Resident #1 would walk around the hallways and was an elopement risk. She said when Resident #1 returned from the elopement he did not have any injuries and he did not have a wander monitoring device on. She said he had a wander monitoring device put on when he returned. An interview was conducted with Staff I, Kitchen Manager, on 1/17/24 at 2:41 p.m. She said, it was around lunch time. I don't know what I was doing up here [the lobby]. I was going into the facility from the lobby. I was speaking to [Staff B, AD] at the desk and the gentleman [Resident #1] was coming out and I held the door for him to enter the lobby, he said hello, I said hello. He was moving slowly but steady and he had a brown bag in his hand so that is why I held the door for him. His pajama pants caught my eye to the point where I turned and watched him enter the lobby and I heard [Staff B, AD] say to him can you sign out, so I just thought he was a visitor, and she knew that. When he came back, I asked was he wearing pajama pants and they said yes, and I said oh no why didn't the alarm go off and that's when they realized he didn't have a [Wander Monitoring Device] on. In the kitchen not all the overhead pages could be heard during service. That has since been adjusted. The day of the elopement I just heard all the commotion, so I asked what is going on and that's how I found out he was missing. A phone interview was conducted with Staff H, RN on 1/17/24 at 3:08 p.m. She said she works the 7:00 p.m. to 7:00 a.m. shift. She said at the beginning of her shift, the night before Resident #1 eloped, she checked to see if he had his wander monitoring device on and it wasn't. She looked for another wander monitoring device but could not find one, so she did not put one on him. She said she did not increase supervision for the resident, and she only told the day shift nurse that he did not have his wander monitoring device on, and she could not find another one. She said the nurse charted on 12/20/23 the wander monitoring device was on the resident and when I came back after he eloped and found out about it, I asked her why she didn't put a [Wander Monitoring Device] on him, and she told me she was not really paying attention to what I was saying. Staff H, RN said 12/19/23 was the third time the resident did not have on his wander monitoring device and the second time she could not find a wander monitoring device to put back on him. The first time she realized he did not have on a wander monitoring device she told the Unit Manager and the Unit Manager said she needed one for another resident who was worse than him. So, I told the ADON I needed one and she told me she couldn't find one either. I told the day shift nurse, and she must have found one and put it on him because people were charting one was on him. After he eloped the Nursing Home Administrator told me I needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 5 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to call her and put the resident on 1 to 1 [supervision] if I can't find a [Wander Monitoring Device] but I did not know that. When I told my ADON and the Unit Manager they did not tell me I needed to do that. I asked around to other staff and some of them didn't know we had to put residents on 1 to 1 if there isn't a [Wander Monitoring Device] on the resident. I'm not sure if that education was just to me or to everyone but everyone should have gotten that education because not everyone knows about that. Review of Resident #1's admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on [DATE]. His medical diagnoses included metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #1's Admission/readmission Data Collection dated 11/28/23 revealed he was alert, oriented to person only, and his memory was OK. He was assessed to be pleasant with no obvious behavior problems and uses a walker for an assistive device. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes 3. Does the resident have poor-decision-making skills? Yes 4. Has the resident demonstrated exit seeking behavior? No 5. Does the resident wander oblivious to safety needs? Yes 6. Does the resident have a history of elopement? No 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes Review of Resident #1's Functional Abilities and Goals-Admission, dated 12/1/23, revealed he was independent with chair/bed to chair transfers, walked 150 feet, walked 10 feet on uneven surfaces, and independent with 12 steps: The ability to go up and down 12 steps with or without a rail. The resident does not use a wheelchair and/or scooter. Review of Resident #1's December Treatment Administration Record (TAR) revealed the following physician orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 6 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [Wander Monitoring Device]- to left ankle check for function each day every night shift for monitoring. start date of 11/30/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q[every] Shift for Placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q shift for placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 For the three above physician orders there was no documentation on 12/1/23 through 12/4/23. On 12/19/23 and 12/16/23 the orders were signed off as 9. Review of Chart Codes/ Follow Up Codes revealed 9=Other/ See Nurses Note. Review of Resident #1's eMAR [electronic Medication Administration Record]-Medication Administration Note dated 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. On 12/20/23 at 2:59 a.m. revealed not present. Review of Resident #1's Nursing Progress Note dated 12/12/23 at 7:40 p.m. written by Staff A, Registered Nurse (RN) revealed resident dont [sic] have the [Wander Monitoring Device] on his both ankles, informed this to adon [Assistant Director of Nursing], but she couldnt [sic] new [Wander Monitoring Device] now. Review of Resident #1's Nursing Progress Note, dated 12/13/23 at 7:00a.m., written by Staff A, RN revealed informed the morning nurse resident need the [Wander Monitoring Device], dont[sic] have one now. Review of Resident #1's medical record revealed no evidence Resident #1 had an increase in supervision when he did not have his wander monitoring device in place. Review of Resident #1's care plans revealed no elopement risk care plan and no interventions related to the monitoring or supervision of Resident #1. There was a care plan with a revision date of 10/20/23 and revealed At risk for leaving the center against medical advice R/T [related to] alcohol use due to substance disorder. The goal included Resident will understand the risk of leaving the center against medical advice. Interventions included the following. Discuss concerns and attempt to resolve issues. Educate residents of risk of leaving against medical advice. Review of the visitor log for December 20, 2023, titled Welcome To Our Center revealed the following. Name: a signature which was not legible. Person/Room Visiting: [Resident #1] Relationship: not legible writing Time In: 12/ the rest of the writing was not legible. Time Out was blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 7 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 12/20/23 it was partly cloudy with a temperature high of 67 degrees Fahrenheit and a temperature low of 47 degrees Fahrenheit. https://www.wunderground.com/calendar/us/fl/[NAME]/KTPA/date/2023-12 According to Maps, from the facility to the Beauty Salon it is approximately a 0.2-mile walk. An observation was made on 1/16/23 at 5:03 p.m. of Resident #1's walking route. It was a heavily trafficked 4-lane road with a posted speed limit sign of 40 miles per hour (MPH). Sections of the sidewalk were blocked off by construction cones with uneven ground and missing concrete. (Photographic evidence obtained) Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. Review of Resident #1's Physician Progress Note dated 12/21/23 at 12:44 p.m. revealed Note Text: Progress Note . [Resident #1] is a pt [patient] with chronic ETOH [alcohol] use, dementia, hallucinations, his [Family Member] wants to take him to the [Hospital] for more assistance, psychologist evaluation, pt was found wandering in the street yesterday. He called his [Family Member] to give his location, and staff from the facility found him. Today I examined him, he is alert still confused. [Resident #1] was ready for discharge, physical therapy evaluated him. He was walking more than 300 feet, but his [family member] says she works, and the pt will be alone the all day [sic], she wants to transfer to the [Hospital] for more resource.Recommendations/Plan: .will transfer the pt to the [Hospital], following family wishes . An interview was conducted on 1/17/24 at 1:32 p.m. with the [NAME] Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20p.m. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. The [Family Member] called at 12:30p.m. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 8 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47p.m. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done . The NHA said It was the fault of the Activities Director letting him out of the doors and the resident not having his [Wander Monitoring Device] on . Event ID: Facility ID: 105951 If continuation sheet Page 9 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to implement and develop a comprehensive care plan for one resident (#1) out of 4 residents reviewed who were at high risk for elopement. Findings included: Review of Resident #1's admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on [DATE]. His medical diagnoses included metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes 3. Does the resident have poor-decision-making skills? Yes 4. Has the resident demonstrated exit seeking behavior? No 5. Does the resident wander oblivious to safety needs? Yes 6. Does the resident have a history of elopement? No 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes B. Elopement Risk Evaluation If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-hour report. Review of Resident #1's comprehensive care plan, as of 1/2024, revealed an elopement risk care plan was not developed with individualized interventions prior to his elopement on 12/20/2023. Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 10 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. Residents Affected - Few IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. An interview was conducted on 1/17/24 at 1:32 p.m. with the Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20p.m. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. The [Family Member] called at 12:30pm. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47pm. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done . The NHA said It was the fault of the Activities Director letting him out of the doors and the resident not having his [Wander Monitoring Device] on . An interview was conducted on 1/19/24 at 2:30 p.m. with Staff J, LPN, MDS Coordinator. She said, I float between two buildings. I started on 12/25/23. I work at this building about 20 hours a week. They also have contracted traveling MDS coordinators . Upon admission all the residents need to be assessed for elopement risk and if they are an elopement risk a care plan with appropriate interventions needs to be put in place immediately. Review of the facility's Plans of Care policy and procedures with an effective date of 11/30/2014, revealed the following: Policy: 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 11 of 30 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 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr Brandon, FL 33511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Plan of care is to be maintained as part of the final medical record. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Few Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment, Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASRR 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. 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 of the resident .the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS) . Review of the facility's Elopement/Wandering Risk Guideline policy with an effective date of 9/21/2016 revealed the following. Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, readmission, 7 days post admission, quarterly, with significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain photograph. Initiate individualized interventions based on Patient/Resident's risk. Document individualized interventions in the patient/resident Care Plan and [NAME] . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 12 of 30 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 01/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide supervision to prevent an unwitnessed exit from the facility for one resident (#1) out of four residents sampled for elopement. Residents Affected - Few Resident #1 had diagnoses to include metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, and a history of falling. Resident #1 was assessed to be at high risk for elopement with a physician's order to have a wander monitoring device in place. Review of Resident #1's medical record revealed Resident #1 did not have a wander monitoring device in place on 12/12/23, 12/13/23, 12/16/23, and 12/19/23. A wander monitoring device could not be located by nursing staff to place on Resident #1 and there was no evidence of an increase in supervision for Resident #1. At approximately 12:15 p.m. on 12/20/23, Resident #1 was able to exit the facility through a door with a wander monitoring device alarm, walk into the facility lobby area, and speak with two facility staff members. One staff member held the door open for Resident #1 to enter the lobby, and the other staff member asked Resident #1 to sign out on the visitor log. Resident #1 signed the visitor log and exited out another door with a wander monitoring device alarm on it. Resident #1 walked approximately 0.2 miles down a heavily trafficked road, he crossed four lanes of traffic, and called his family member to pick him up. The facility staff were not aware Resident #1 was missing until Resident #1's family member called the facility inquiring if he was there. Resident #1 was absent for approximately 32 minutes before facility staff located him and brought him back to the facility where he was identified to not have a wander monitoring device in place. The likelihood of serious physical harm or death to Resident #1 as a result of the facility's failure to provide adequate supervision to prevent the elopement resulted in findings of Ongoing Immediate Jeopardy starting 12/12/23. Findings included: Review of Resident #1's admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on [DATE]. His medical diagnoses included metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #1's Admission/readmission Data Collection dated 11/28/23 revealed he was alert, oriented to person only, and his memory was OK. He was assessed to be pleasant with no obvious behavior problems and uses a walker for an assistive device. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 13 of 30 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 01/19/2024 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 0689 3. Does the resident have poor decision-making skills? Yes Level of Harm - Immediate jeopardy to resident health or safety 4. Has the resident demonstrated exit seeking behavior? No Residents Affected - Few 6. Does the resident have a history of elopement? No 5. Does the resident wander oblivious to safety needs? Yes 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes Review of Resident #1's Functional Abilities and Goals-Admission, dated 12/1/23, revealed he was independent with chair/bed to chair transfers, walked 150 feet, walked 10 feet on uneven surfaces, and independent with 12 steps: The ability to go up and down 12 steps with or without a rail. The resident does not use a wheelchair and/or scooter. Review of Resident #1's December Treatment Administration Record (TAR) revealed the following physician orders: [Wander Monitoring Device]- to left ankle check for function each day every night shift for monitoring. start date of 11/30/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q[every] Shift for Placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q shift for placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 For the three above physician orders there was no documentation on 12/1/23 through 12/4/23. On 12/19/23 and 12/16/23 the orders were signed off as 9. Review of Chart Codes/ Follow Up Codes revealed 9=Other/ See Nurses Note. Review of Resident #1's eMAR [electronic Medication Administration Record]-Medication Administration Note dated 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. On 12/20/23 at 2:59 a.m. revealed not present. Review of Resident #1's Nursing Progress Note dated 12/12/23 at 7:40 p.m. written by Staff A, Registered Nurse (RN) revealed resident dont [sic] have the [Wander Monitoring Device] on his both ankles, informed this to ADON [Assistant Director of Nursing], but she couldn't [sic] new [Wander Monitoring Device] now. Review of Resident #1's Nursing Progress Note, dated 12/13/23 at 7:00a.m., written by Staff A, RN revealed informed the morning nurse resident need the [Wander Monitoring Device], dont[sic] have one now. Review of Resident #1's medical record revealed no evidence Resident #1 had an increase in supervision when he did not have his wander monitoring device in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 14 of 30 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 01/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An interview was conducted on 1/16/24 at 10:08 a.m. with Staff B, Activities Director (AD) she said on 12/20/23 around 12:00p.m. she relieved the receptionist. Around 12:20 p.m. to 12:30pm. the Kitchen Manager entered the lobby from the resident hallways and Resident #1 followed behind her into the lobby. I saw him, and I thought he was a family member because he looked so much better than he did when he first came to us. His hair was combed, he was shaved, he was walking very well and confidently. I thought he was a family member, so I asked him to sign out and he wrote his name down on a blank line, he looked at the clock and signed out. It was about 5 minutes later, and his [Family Member] called me and said my husband is calling me asking me to pick him up on [Street Name] and she wanted me to make sure he was in his room. I called down to the nurse's station and the ADON answered the phone, and I asked her to look to see if he was in his room and he wasn't, so they immediately started searching for him inside and outside of the building. The [Family Member] was on hold at this time, so I told her he was not in his room, and we were looking for him. I gave her my personnel number and told her to call me on that so I could go and look for him. While I was on the phone with her [Resident #1] kept calling her and she said he was on [Street Name]. I think it was Human Resources and a nurse who found him, I'm not sure exactly where they found him, but they put him in their car and brought him back around 12:45p.m. When I got back to the facility, I saw [Resident #1] and it was at that point that I realized oh man I was the one who let him out. I couldn't believe I did that. I told the [Family Member] that we found him, and he was back, and she was a little upset and said if she didn't call me would the staff have known he was even gone? And I told her I would have the DON [Director of Nursing] call her. [Resident #1] was not injured but he did not have his [Wander Monitoring Device] on, so they put one back on him. When he walked through both doors neither alarm went off to let me know that he had a [Wander Monitoring Device] on. That's why I just thought he was a family member. When he first got here, he was door seeking and he had a [Wander Monitoring Device] on but after that I had not seen him in the hallways as often. The day he eloped it was sunny and breezy out; it was a nice day. He was wearing long sleeves, pants, loafer slippers with a rubber soul. He did not have any assistive devices when he left, and he was walking very well and confidently. He was not injured. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 1/16/24 at 10:50 a.m. she said she was Resident #1's CNA on 12/20/23, the day he eloped. She said around 11:30 a.m. she was working with his roommate getting him ready and at the time Resident #1 was sitting on his bed. When I left the room . [Resident #1] was still sitting on his bed around 11:45 a.m. I went to help another resident and while I was doing that the therapist came in and said that someone else needed to use the bathroom. I told her to tell the resident's family that I will be there in a minute I just need to finish up with this resident. When I came out of the room the family was in the hallway screaming and yelling that his dad needed to use the bathroom right now. I told him I would go put my dirty linens away and be right there and he would not accept that. The ADON came over to diffuse the family member and she had asked me to step off the unit, so I went outside for about 15 minutes and the other CNA assisted the resident to the bathroom. I'm not sure where the nurse was at that time but I'm sure she was busy with a resident because this unit is the rehab [rehabilitation] unit, and it is always very busy. When I came back about 15 minutes later, I started to pass meal trays but before I could even pass one tray the ADON said [Resident #1] was missing and immediately everyone in the building started searching for him inside, outside, everywhere .When he came back, he did not have on his [Wander Monitoring Device] and he did not have any injuries thank god because that could have been really bad and he could've gotten really hurt. He walked well without any assistive devices, but he would get tired and would rest against the wall or sit down . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 15 of 30 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 01/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Before he eloped, we would have to redirect him at least six or seven times a shift. When his [family] would visit and leave he would get more anxious and want to go home. He was definitely exit seeking and he did have a [Wander Monitoring Device] on his leg at one point because I would see it when he sat down and crossed his legs. He was alert but he was confused and easily redirected. The day he eloped I did not see a [Wander Monitoring Device] on him, but I also did not look. His [family] gave him a bath, shaved him, and got him dressed the night before so I did not have to do any of that in the morning and I usually check the [Wander Monitoring Device] when I do my baths . An interview was conducted with Staff C, CNA on 1/16/24 at 11:12 a.m. she said she was working the day Resident #1 eloped and she was not his CNA, but she was the other CNA on the hall. She confirmed Resident #1 was exit seeking and would need a lot of redirecting back to his room. He always wanted to go home. She said he walked well without any assistive devices he would just need to take breaks because he would get tired, and he would rest against the wall and just keep an eye on everything. An interview was conducted on 1/16/24 at 3:46 p.m. with Staff D, Human Resource (HR) she said on the day Resident #1 eloped there was an overhead page about a missing resident. She reported to the lobby and received a face sheet of the resident. As she was getting her search location Staff E, RN asked if he could drive with her. Staff D, HR said she drove out of the facility, went left, and after approximately 30 seconds she turned into a beauty salon. She said the beauty salon was located across the street from the facility. She said the resident was found sitting on a bench in front of the beauty salon and Staff E, RN got out of the car, talked to the resident for a minute, the resident walked independently with a steady gait back to the car. She said the resident got into the back seat and said I'm fine. and You're going to take me back. She drove Resident #1 and Staff E, RN back to the facility and dropped them off at the front door and went to park her car. She said she did not notice [Wander Monitoring Device], but she did not look for one. She said he did not have any injuries that she noticed. An interview was conducted on 1/16/24 at 4:00 p.m. with Staff F, Receptionist. She said on the day Resident #1 eloped she went on lunch break at 12:00 p.m. and Staff B, AD covered the receptionist desk. Staff F, Receptionist returned at 12:30 p.m. and she said when she came back everyone was a mess looking around for Resident #1 because the family member had called and said he was on the street waiting for her to pick him up. She said she asked if anyone had done an overhead page and they said they didn't, so she overhead paged for the resident to return to his room and when he didn't, she called a code silver. She said everyone continued to search for him. She was not sure where he was found. She said early the same morning between 9:00 a.m. and 10:00 a.m. the family member called her to have the nurse check on him because Resident #1 had called her and said he was leaving today and needed to be picked up. She paged the nurse and the nurse said he was in his room, and he was alright just confused because he was supposed to leave the next day. A phone interview was conducted on 1/17/24 at 8:44 a.m. with Staff E, RN. He said he heard the overhead page Resident #1 was missing. He said he had worked with him when he was first admitted and he was unable to walk but he knew the resident went to the hospital, came back, received rehabilitation, and saw him walking the halls without assistive devices and walked well. He said Resident #1 was confused. He said since he knew what the resident looked like, and he knew he could walk he went to check outside. When he went outside, he saw people were starting to get in their car and look, so he asked Staff D, HR if he could ride with her and she said yes, and they got into her car and went left out of the building, and he was looking for Resident #1. At the beauty salon he saw the resident sitting on the bench in front of their door. He [Resident #1] was confused, so I introduced myself to him, he did not recognize me, but he came right with me and got into the car. Staff E, RN said he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 16 of 30 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 01/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few brought the resident back inside the building and he heard the resident cut his wander monitoring device off. He said he spoke with the family, and they were not happy to the point they took him out of the facility right after that. A phone interview was conducted on 1/17/24 at 10:28 a.m. with Resident #1's family member she said I was at my work, in my office it was close to noon time, 11:00-11:30 a.m., and he [Resident #1] called me and told me to go and pick him up. I thought he was just calling me from the facility but then he told me that he was on the street, and he told me [Street Name]. I was shocked because that was the name of the street the facility was on, and I thought how would he know that? I told him to wait right there. I called the facility to see if [Resident #1] was there in his room. So, everyone ran to his room, and he wasn't there, and they looked all around the facility and people were starting to drive around. I called my husband back and I said what is the name of the business you are in front of. I googled that business and I saw that it was all the way on the corner of the street .he said there are stairs and I told him to sit on the stairs I'm going to have someone pick you up. One person at the facility gave me their number so I called her, and she said she was driving in the opposite direction of where he said he was but someone else was going in that direction and the male nurse found him and brought him back to the facility and he was okay. Fortunately, [Resident #1] had his phone and he decided to call me, and I don't know what would have happened to [Resident #1] if he did not call me. I asked him how he got out, but he has memory problems and he said he hopped a fence, but the facility has security footage and he walked out of the front door, and he even signed himself out like he was a visitor. [Resident #1] is [AGE] years old, and he doesn't use a wheelchair or a walker. He did not need anything to walk at that point, so he looks like a visitor, but his mind is not right he has hallucinations and makes up stories. When he first got to the facility, he could not walk so he had a wheelchair, then he was able to use a walker, then he was able to walk on his own but still a little off balance. I was panicking because he has no memory and no sense of direction of where he was going to go .He probably just walked straight, then he got to the intersection and saw the street sign and probably did not know if he should go right or left so that is why he called me. Even if he had turned around, the road curves and you're not able to see the facility from where he was so he wouldn't know to go back there. Fortunately, I gave him his cell phone and it had enough charge on it, and he thought to call me. If those things did not happen, I don't know what would have happened to [Resident #1] if he did not think to call me. I make an effort to visit him every day, so I stay on his mind, so his mind does not forget me. He was definitely not safe to be outside by himself. When he came back to the facility for the second time after going to the hospital, they put a bracelet [Wander Monitoring Device] on him because he walked out of his room but that was probably on for only 3 or 4 days then I did not see it again. I just thought the facility took it off because he wasn't walking out of his room anymore because when I would visit him, he was always in his room but when they brought him back, they told me he took off the bracelet and they put a new one on him right away. I didn't feel comfortable with him there after this happened. Resident #1's family member said she took him home the day after he eloped. A phone interview was conducted on 1/17/24 at 12:10 p.m. with Resident #1's Physician. She said she was aware Resident #1 had eloped. She said He is a patient who looks pretty good, very well dressed, talks well, but he has encephalopathy and some dementia. He was let out by activities and the staff found him a little bit after. He looks like a visitor but if you didn't know him and you didn't talk with him for a while you would think he was a visitor. It was critical for him when he got out but when he was in the building, he was fine, he was always in his room sitting next to his bed . An interview was conducted on 1/18/24 at 11:29 a.m. with Staff G, RN. She said, she was the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 17 of 30 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 01/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for Resident #1 on the day he eloped. She said she did not get anything in report about Residents #1's wander monitoring device and she did not check to see if his wander monitoring device was in place before he eloped. She said she gave Resident #1 his morning medications around 10:30 a.m. and 11:00 a.m. and he was sitting next to his bed. She said she had no concerns. She said Resident #1 would walk around the hallways and was an elopement risk. She said when Resident #1 returned from the elopement he did not have any injuries and he did not have a wander monitoring device on. She said he had a wander monitoring device put on when he returned. An interview was conducted with Staff I, Kitchen Manager, on 1/17/24 at 2:41 p.m. She said, it was around lunch time. I don't know what I was doing up here [the lobby]. I was going into the facility from the lobby. I was speaking to [Staff B, AD] at the desk and the gentleman [Resident #1] was coming out and I held the door for him to enter the lobby, he said hello, I said hello. He was moving slowly but steady and he had a brown bag in his hand so that is why I held the door for him. His pajama pants caught my eye to the point where I turned and watched him enter the lobby and I heard [Staff B, AD] say to him can you sign out, so I just thought he was a visitor, and she knew that. When he came back, I asked was he wearing pajama pants and they said yes, and I said oh no why didn't the alarm go off and that's when they realized he didn't have a [Wander Monitoring Device] on. In the kitchen not all the overhead pages could be heard during service. That has since been adjusted. The day of the elopement I just heard all the commotion, so I asked what is going on and that's how I found out he was missing. A phone interview was conducted with Staff H, RN on 1/17/24 at 3:08 p.m. She said she works the 7:00 p.m. to 7:00 a.m. shift. She said at the beginning of her shift, the night before Resident #1 eloped, she checked to see if he had his wander monitoring device on and it wasn't. She looked for another wander monitoring device but could not find one, so she did not put one on him. She said she did not increase supervision for the resident, and she only told the day shift nurse that he did not have his wander monitoring device on, and she could not find another one. She said the nurse charted on 12/20/23 the wander monitoring device was on the resident and when I came back after he eloped and found out about it, I asked her why she didn't put a [Wander Monitoring Device] on him, and she told me she was not really paying attention to what I was saying. Staff H, RN said 12/19/23 was the third time the resident did not have on his wander monitoring device and the second time she could not find a wander monitoring device to put back on him. The first time she realized he did not have on a wander monitoring device she told the Unit Manager and the Unit Manager said she needed one for another resident who was worse than him. So, I told the ADON I needed one and she told me she couldn't find one either. I told the day shift nurse, and she must have found one and put it on him because people were charting one was on him. After he eloped the Nursing Home Administrator told me I needed to call her and put the resident on 1 to 1 [supervision] if I can't find a [Wander Monitoring Device] but I did not know that. When I told my ADON and the Unit Manager they did not tell me I needed to do that. I asked around to other staff and some of them didn't know we had to put residents on 1 to 1 if there isn't a [Wander Monitoring Device] on the resident. I'm not sure if that education was just to me or to everyone but everyone should have gotten that education because not everyone knows about that. Review of Resident #1's care plans revealed no elopement risk care plan and no interventions related to the monitoring or supervision of Resident #1. There was a care plan with a revision date of 10/20/23 and revealed At risk for leaving the center against medical advice R/T [related to] alcohol use due to substance disorder. The goal included Resident will understand the risk of leaving the center against medical advice. Interventions included the following. Discuss concerns and attempt to resolve issues. Educate residents of risk of leaving against medical advice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 18 of 30 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 01/19/2024 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 0689 Review of the visitor log for December 20, 2023, titled Welcome To Our Center revealed the following. Level of Harm - Immediate jeopardy to resident health or safety Name: a signature which was not legible. Residents Affected - Few Relationship: not legible writing Person/Room Visiting: [Resident #1] Time In: 12/ the rest of the writing was not legible. Time Out was blank On 12/20/23 it was partly cloudy with a temperature high of 67 degrees Fahrenheit and a temperature low of 47 degrees Fahrenheit. https://www.wunderground.com/calendar/us/fl/[NAME]/KTPA/date/2023-12 According to Maps, from the facility to the Beauty Salon it is approximately a 0.2-mile walk. An observation was made on 1/16/23 at 5:03 p.m. of Resident #1's walking route. It was a heavily trafficked 4-lane road with a posted speed limit sign of 40 miles per hour (MPH). Sections of the sidewalk were blocked off by construction cones with uneven ground and missing concrete. (Photographic evidence obtained) Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated, I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. Review of Resident #1's Physician Progress Note dated 12/21/23 at 12:44 p.m. revealed Note Text: Progress Note . [Resident #1] is a pt [patient] with chronic ETOH [alcohol] use, dementia, hallucinations, his [Family Member] wants to take him to the [Hospital] for more assistance, psychologist evaluation, pt was found wandering in the street yesterday. He called his [Family Member] to give his location, and staff from the facility found him. Today I examined him, he is alert and still confused. [Resident #1] was ready for discharge, physical therapy evaluated him. He was walking more than 300 feet, but his [family member] says she works, and the pt will be alone the all day [sic], she wants to transfer to the [Hospital] for more resource.Recommendations/Plan: .will transfer the pt to the [Hospital], following family wishes . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 19 of 30 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 01/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An interview was conducted on 1/17/24 at 1:32 p.m. with the Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20pm. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. The [Family Member] called at 12:30pm. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47pm. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done . The NHA said It was the fault of the Activities Director letting him out of the doors and the resident not having his [Wander Monitoring Device] on . Review of the facility's Elopement/Wandering Risk Guideline policy with an effective date of 9/21/2016 revealed the following. Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, readmission, 7 days post admission, quarterly, with significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain photograph. Initiate individualized interventions based on Patient/Resident's risk. Document individualized interventions in the patient/resident Care Plan and [NAME]. If utilizing a wander monitoring system device check placement of the device every shift and functionality every day. Maintain the Elopement Risk Alerts in an easily accessible location. Complete routine elopement drills monthly and review in QAPI [quality assurance performance improvement] meeting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 20 of 30 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 01/19/2024 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 0689 Review of the facility's Missing Patient/Resident policy with an effective date of 11/30/24 revealed the following. Level of Harm - Immediate jeopardy to resident health or safety Overview: Residents Affected - Few Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. Procedure: Check Leave of Absence (LOA) book and Medical Record to ensure patient/resident is not on an authorized leave or medical appointment. Announce (resident name) please return to your room, over PA system. Repeat three times to alert staff of a missing patient/resident. Assign staff to search the Center and grounds. If the patient/resident is not located after an initial search the point person will notify the Director and/or Director of Nurses, Resident Representative, and Physician. The Executive Director and/or Director of Nursing or designee to notify Law Enforcement. Upon return to the Center a physical evaluation will be completed to determine if further treatment is needed. Document in the Medical Record. Notify Physician, Resident Representative, Executive Director, Director of Nurses, and Law enforcement (If applicable) of patient's/resident's return. Review and revise the interventions as indicated related to elopement and wandering risk and update the Care Plan and [NAME] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 21 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP), when the facility staff failed to prevent accidents and hazards related to the supervision of residents at risk for elopement for one resident (#1) out of four residents reviewed for elopement. Ongoing non-compliance was identified during the complaint survey on 1/16/24 through 1/19/24 related to the supervision of residents and a process to ensure staff have the necessary wander monitoring devices and wander monitoring device checkers accessible and available to them. Findings included: Review of the facility's Ad Hoc Quality Assurance & Performance Improvement Meeting, dated 12/20/23, revealed the reason for the Ad Hoc meeting was for the Facility Elopement on 12/20/23. The goal was To Ensure elopement risk residents are properly identified. . What did you do to ensure it would not happen again? Education provided to facility staff on the facility policy for Elopement. Education provided to the facility staff on Abuse Neglect and Misappropriation to include Supervision of facility residents. Who will check the system? Who will check the checker? Unit Managers and or designee to review facility residents who are at risk for elopement to ensure the facility is following the policy for elopement. DON [Director of Nursing] and or designee to review the facility elopement books to ensure they are updated as necessary. Maintenance Dept [department] and or designee will review facility [Wander Monitoring Device] system to ensure proper functioning. Findings will be reviewed monthly by the facility QAPI committee for recommendation, updates and until substantial compliance has been met. An interview was conducted on 1/17/24 at 1:32 p.m. with the Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20pm. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 22 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The [Family Member] called at 12:30pm. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47 p.m. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done. The NHA and the RNC said the immediate response was a new elopement risk assessment on everyone in facility completed on 12/20/23 and then new admissions were completed to make sure they had their seven-day elopement assessment. The RNC said, Once residents come in, we do an elopement assessment and then seven days later we do another elopement assessment to make sure we are capturing any changes after admission. We audited everyone who was at elopement risk and ensured the care plans were in place with appropriate interventions. We made sure they had physician's orders for expiration date, placement, function, and where it [wander monitor device] was placed. All the doors and the wander guard system in itself were inspected by the former Maintence and the Maintence Assistant. No issues were found with the doors or the wander guard system The NHA said It was the fault of the Activities Director letting him [Resident #1] out of the doors and the resident not having his [Wander Monitoring Device] on. The RNC said, The elopement books were updated to update the current residents at risk for elopement. The NHA said, We have them at the receptionist area, therapy, and all the nursing stations. In the books should be a colored copy of the patient, a description of the resident, and the Facesheet of the resident. The RNC said, There is also the process of what the staff need to do if an elopement occurs in the binder. The DON [Director of Nursing] is responsible for the books. The NHA said it's the clinical teams responsibility to ensure the elopement book are up to date. The RNC said, Every week day when they have the clinical meeting they [Interdisciplinary team] looks through each binder to remove discharges and add admitted residents who are at risk. The DON or designee will update the elopement books. The NHA said they are in the books every day. the NHA clarified they as the clinical team or designee. The NHA said we would do an overhead page and we would hide an actual resident and observe the staff response. We would also do door alarms to see how the staff are responding. After the drill, would be reminders on what to do. Another discussion would be if you cannot find the resident inside then you go outside and contact responsible parties and law enforcement. The RNC said, The drills were pretty heavy because we were doing them every shift multiple times a day and now we are doing all shifts once a week. The NHA said, The drills are going good. There seemed to be questions between one wing and the other on closing the door after it has already been searched. The NHA said, When the overhead page is called the staff are supposed to search their assigned areas. The RNC said, The staff are supposed to first respond to the area where the person is missing and receive their assignment on where they need to search. As they are walking to the area of the missing resident they can look around as they are headed to the area. The RNC said there was an ad hoc QAPI meeting held with the IDT team on 12/20/23, and she attended via phone. She also said there was a follow up QAPI meeting on 1/9/24. Review of Resident #1's admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on [DATE]. His medical diagnoses included metabolic encephalopathy, altered mental status, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 23 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #1's Admission/readmission Data Collection dated 11/28/23 revealed he was alert, oriented to person only, and his memory was OK. He was assessed to be pleasant with no obvious behavior problems and uses a walker for an assistive device. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes 3. Does the resident have poor-decision-making skills? Yes 4. Has the resident demonstrated exit seeking behavior? No 5. Does the resident wander oblivious to safety needs? Yes 6. Does the resident have a history of elopement? No 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes Review of Resident #1's Functional Abilities and Goals-Admission, dated 12/1/23, revealed he was independent with chair/bed to chair transfers, walked 150 feet, walked 10 feet on uneven surfaces, and independent with 12 steps: The ability to go up and down 12 steps with or without a rail. The resident does not use a wheelchair and/or scooter. Review of Resident #1's December Treatment Administration Record (TAR) revealed the following physician orders: [Wander Monitoring Device]- to left ankle check for function each day every night shift for monitoring. start date of 11/30/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q[every] Shift for Placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q shift for placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 For the three above physician orders there was no documentation on 12/1/23 through 12/4/23. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 24 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm 12/19/23 and 12/16/23 the orders were signed off as 9. Review of Chart Codes/ Follow Up Codes revealed 9=Other/ See Nurses Note. Review of Resident #1's eMAR [electronic Medication Administration Record]-Medication Administration Note dated 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. On 12/20/23 at 2:59 a.m. revealed not present. Residents Affected - Few Review of Resident #1's Nursing Progress Note dated 12/12/23 at 7:40 p.m. written by Staff A, Registered Nurse (RN) revealed resident dont [sic] have the [Wander Monitoring Device] on his both ankles, informed this to ADON [Assistant Director of Nursing], but she couldn't [sic] new [Wander Monitoring Device] now. Review of Resident #1's Nursing Progress Note, dated 12/13/23 at 7:00 a. m., written by Staff A, RN revealed informed the morning nurse resident need the [Wander Monitoring Device], dont[sic] have one now. Review of Resident #1's medical record revealed no evidence Resident #1 had an increase in supervision when he did not have his wander monitoring device in place. An interview was conducted on 1/16/24 at 10:08 a.m. with Staff B, Activities Director (AD) she said on 12/20/23 around 12:00pm. she relieved the receptionist. Around 12:20 p.m. to 12:30pm. the Kitchen Manager entered the lobby from the resident hallways and Resident #1 followed behind her into the lobby. I saw him, and I thought he was a family member because he looked so much better than he did when he first came to us. His hair was combed, he was shaved, he was walking very well and confidently. I thought he was a family member, so I asked him to sign out and he wrote his name down on a blank line, he looked at the clock and signed out. It was about 5 minutes later, and his [Family Member] called me and said my husband is calling me asking me to pick him up on [Street Name] and she wanted me to make sure he was in his room. I called down to the nurse's station and the ADON answered the phone, and I asked her to look to see if he was in his room and he wasn't, so they immediately started searching for him inside and outside of the building. The [Family Member] was on hold at this time, so I told her he was not in his room, and we were looking for him. I gave her my personnel number and told her to call me on that so I could go and look for him. While I was on the phone with her [Resident #1] kept calling her and she said he was on [Street Name]. I think it was Human Resources and a nurse who found him, I'm not sure exactly where they found him, but they put him in their car and brought him back around 12:45pm. When I got back to the facility, I saw [Resident #1] and it was at that point that I realized oh man I was the one who let him out. I couldn't believe I did that. I told the [Family Member] that we found him, and he was back, and she was a little upset and said if she didn't call me would the staff have known he was even gone? And I told her I would have the DON [Director of Nursing] call her. [Resident #1] was not injured but he did not have his [Wander Monitoring Device] on, so they put one back on him. When he walked through both doors neither alarm went off to let me know that he had a [Wander Monitoring Device] on. That's why I just thought he was a family member. When he first got here, he was door seeking and he had a [Wander Monitoring Device] on but after that I had not seen him in the hallways as often. The day he eloped it was sunny and breezy out; it was a nice day. He was wearing long sleeves, pants, loafer slippers with a rubber soul. He did not have any assistive devices when he left, and he was walking very well and confidently. He was not injured. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 1/16/24 at 10:50 a.m. she said she was Resident #1's CNA on 12/20/23, the day he eloped. She said around 11:30 a.m. she was working with his roommate getting him ready and at the time Resident #1 was sitting on his bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 25 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few When I left the room . [Resident #1] was still sitting on his bed around 11:45 a.m. I went to help another resident and while I was doing that the therapist came in and said that someone else needed to use the bathroom. I told her to tell the resident's family that I will be there in a minute I just need to finish up with this resident. When I came out of the room the family was in the hallway screaming and yelling that his dad needed to use the bathroom right now. I told him I would go put my dirty linens away and be right there and he would not accept that. The ADON came over to diffuse the family member and she had asked me to step off the unit, so I went outside for about 15 minutes and the other CNA assisted the resident to the bathroom. I'm not sure where the nurse was at that time but I'm sure she was busy with a resident because this unit is the rehab [rehabilitation] unit, and it is always very busy. When I came back about 15 minutes later, I started to pass meal trays but before I could even pass one tray the ADON said [Resident #1] was missing and immediately everyone in the building started searching for him inside, outside, everywhere .When he came back, he did not have on his [Wander Monitoring Device] and he did not have any injuries thank god because that could have been really bad and he could've gotten really hurt. He walked well without any assistive devices, but he would get tired and would rest against the wall or sit down . Before he eloped, we would have to redirect him at least six or seven times a shift. When his [family] would visit and leave he would get more anxious and want to go home. He was definitely exit seeking and he did have a [Wander Monitoring Device] on his leg at one point because I would see it when he sat down and crossed his legs. He was alert but he was confused and easily redirected. The day he eloped I did not see a [Wander Monitoring Device] on him, but I also did not look. His [family] gave him a bath, shaved him, and got him dressed the night before so I did not have to do any of that in the morning and I usually check the [Wander Monitoring Device] when I do my baths . An interview was conducted with Staff C, CNA on 1/16/24 at 11:12 a.m. she said she was working the day Resident #1 eloped and she was not his CNA, but she was the other CNA on the hall. She confirmed Resident #1 was exit seeking and would need a lot of redirecting back to his room. He always wanted to go home. She said he walked well without any assistive devices he would just need to take breaks because he would get tired, and he would rest against the wall and just keep an eye on everything. An interview was conducted on 1/16/24 at 3:46 p.m. with Staff D, Human Resource (HR) she said on the day Resident #1 eloped there was an overhead page about a missing resident. She reported to the lobby and received a face sheet of the resident. As she was getting her search location Staff E, RN asked if he could drive with her. Staff D, HR said she drove out of the facility, went left, and after approximately 30 seconds she turned into a beauty salon. She said the beauty salon was located across the street from the facility. She said the resident was found sitting on a bench in front of the beauty salon and Staff E, RN got out of the car, talked to the resident for a minute, the resident walked independently with a steady gait back to the car. She said the resident got into the back seat and said I'm fine. and You're going to take me back. She drove Resident #1 and Staff E, RN back to the facility and dropped them off at the front door and went to park her car. She said she did not notice [Wander Monitoring Device], but she did not look for one. She said he did not have any injuries that she noticed. An interview was conducted on 1/16/24 at 4:00 p.m. with Staff F, Receptionist. She said on the day Resident #1 eloped she went on lunch break at 12:00 p.m. and Staff B, AD covered the receptionist desk. Staff F, Receptionist returned at 12:30 p.m. and she said when she came back everyone was a mess looking around for Resident #1 because the family member had called and said he was on the street waiting for her to pick him up. She said she asked if anyone had done an overhead page and they said they didn't, so she overhead paged for the resident to return to his room and when he didn't, she called a code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 26 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm silver. She said everyone continued to search for him. She was not sure where he was found. She said early the same morning between 9:00 a.m. and 10:00 a.m. the family member called her to have the nurse check on him because Resident #1 had called her and said he was leaving today and needed to be picked up. She paged the nurse and the nurse said he was in his room, and he was alright just confused because he was supposed to leave the next day. Residents Affected - Few A phone interview was conducted on 1/17/24 at 8:44 a.m. with Staff E, RN. He said he heard the overhead page Resident #1 was missing. He said he had worked with him when he was first admitted and he was unable to walk but he knew the resident went to the hospital, came back, received rehabilitation, and saw him walking the halls without assistive devices and walked well. He said Resident #1 was confused. He said since he knew what the resident looked like, and he knew he could walk he went to check outside. When he went outside, he saw people were starting to get in their car and look, so he asked Staff D, HR if he could ride with her and she said yes, and they got into her car and went left out of the building, and he was looking for Resident #1. At the beauty salon he saw the resident sitting on the bench in front of their door. He [Resident #1] was confused, so I introduced myself to him, he did not recognize me, but he came right with me and got into the car. Staff E, RN said he brought the resident back inside the building and he heard the resident cut his wander monitoring device off. He said he spoke with the family, and they were not happy to the point they took him out of the facility right after that. He said after the elopement they did elopement education, supervision education, and did elopement drills but as of last week there is still confusion on exactly how the drills are supposed to be run. At first everyone was meeting in one area to get their assignments. Then everyone was staying in their areas to look but that did not get told to everyone so there was confusion. A phone interview was conducted on 1/17/24 at 10:28 a.m. with Resident #1's family member she said I was at my work, in my office it was close to noon time, 11:00-11:30 a.m., and he [Resident #1] called me and told me to go and pick him up. I thought he was just calling me from the facility but then he told me that he was on the street, and he told me [Street Name]. I was shocked because that was the name of the street the facility was on, and I thought how would he know that? I told him to wait right there. I called the facility to see if [Resident #1] was there in his room. So, everyone ran to his room, and he wasn't there, and they looked all around the facility and people were starting to drive around. I called my husband back and I said what is the name of the business you are in front of. I googled that business and I saw that it was all the way on the corner of the street .he said there are stairs and I told him to sit on the stairs I'm going to have someone pick you up. One person at the facility gave me their number so I called her, and she said she was driving in the opposite direction of where he said he was but someone else was going in that direction and the male nurse found him and brought him back to the facility and he was okay. Fortunately, [Resident #1] had his phone and he decided to call me, and I don't know what would have happened to [Resident #1] if he did not call me. I asked him how he got out, but he has memory problems and he said he hopped a fence, but the facility has security footage and he walked out of the front door, and he even signed himself out like he was a visitor. [Resident #1] is [AGE] years old, and he doesn't use a wheelchair or a walker. He did not need anything to walk at that point, so he looks like a visitor, but his mind is not right he has hallucinations and makes up stories. When he first got to the facility, he could not walk so he had a wheelchair, then he was able to use a walker, then he was able to walk on his own but still a little off balance. I was panicking because he has no memory and no sense of direction of where he was going to go .He probably just walked straight, then he got to the intersection and saw the street sign and probably did not know if he should go right or left so that is why he called me. Even if he had turned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 27 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few around, the road curves and you're not able to see the facility from where he was so he wouldn't know to go back there. Fortunately, I gave him his cell phone and it had enough charge on it, and he thought to call me. If those things did not happen, I don't know what would have happened to [Resident #1] if he did not think to call me. I make an effort to visit him every day, so I stay on his mind, so his mind does not forget me. He was definitely not safe to be outside by himself. When he came back to the facility for the second time after going to the hospital, they put a bracelet [Wander Monitoring Device] on him because he walked out of his room but that was probably on for only 3 or 4 days then I did not see it again. I just thought the facility took it off because he wasn't walking out of his room anymore because when I would visit him, he was always in his room but when they brought him back, they told me he took off the bracelet and they put a new one on him right away. I didn't feel comfortable with him there after this happened. Resident #1's family member said she took him home the day after he eloped. A phone interview was conducted on 1/17/24 at 12:10 p.m. with Resident #1's Physician. She said she was aware Resident #1 had eloped. She said He is a patient who looks pretty good, very well dressed, talks well, but he has encephalopathy and some dementia. He was let out by activities and the staff found him a little bit after. He looks like a visitor but if you didn't know him and you didn't talk with him for a while you would think he was a visitor. It was critical for him when he got out but when he was in the building, he was fine, he was always in his room sitting next to his bed. I was involved with their plan of correction to prevent this from happening again and I signed off on everything. An interview was conducted on 1/18/24 at 11:29 a.m. with Staff G, RN. She said, she was the nurse for Resident #1 on the day he eloped. She said she did not get anything in report about Residents #1's wander monitoring device and she did not check to see if his wander monitoring device was in place before he eloped. She said she gave Resident #1 his morning medications around 10:30 a.m. and 11:00 a.m. and he was sitting next to his bed. She said she had no concerns. She said Resident #1 would walk around the hallways and was an elopement risk. She said when Resident #1 returned from the elopement he did not have any injuries and he did not have a wander monitoring device on. She said he had a wander monitoring device put on when he returned. An interview was conducted with Staff I, Kitchen Manager, on 1/17/24 at 2:41 p.m. She said, it was around lunch time. I don't know what I was doing up here [the lobby]. I was going into the facility from the lobby. I was speaking to [Staff B, AD] at the desk and the gentleman [Resident #1] was coming out and I held the door for him to enter the lobby, he said hello, I said hello. He was moving slowly but steady and he had a brown bag in his hand so that is why I held the door for him. His pajama pants caught my eye to the point where I turned and watched him enter the lobby and I heard [Staff B, AD] say to him can you sign out, so I just thought he was a visitor, and she knew that. When he came back, I asked was he wearing pajama pants and they said yes, and I said oh no why didn't the alarm go off and that's when they realized he didn't have a [Wander Monitoring Device] on. In the kitchen not all the overhead pages could be heard during service. That has since been adjusted. The day of the elopement I just heard all the commotion, so I asked what is going on and that's how I found out he was missing. A phone interview was conducted with Staff H, RN on 1/17/24 at 3:08 p.m. She said she works the 7:00 p.m. to 7:00 a.m. shift. She said at the beginning of her shift, the night before Resident #1 eloped, she checked to see if he had his wander monitoring device on and it wasn't. She looked for another wander monitoring device but could not find one, so she did not put one on him. She said she did not increase supervision for the resident, and she only told the day shift nurse that he did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 28 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have his wander monitoring device on, and she could not find another one. She said the nurse charted on 12/20/23 the wander monitoring device was on the resident and when I came back after he eloped and found out about it, I asked her why she didn't put a [Wander Monitoring Device] on him, and she told me she was not really paying attention to what I was saying. Staff H, RN said 12/19/23 was the third time the resident did not have on his wander monitoring device and the second time she could not find a wander monitoring device to put back on him. The first time she realized he did not have on a wander monitoring device she told the Unit Manager and the Unit Manager said she needed one for another resident who was worse than him. So, I told the ADON I needed one and she told me she couldn't find one either. I told the day shift nurse, and she must have found one and put it on him because people were charting one was on him. After he eloped the Nursing Home Administrator told me I needed to call her and put the resident on 1 to 1 [supervision] if I can't find a [Wander Monitoring Device] but I did not know that. When I told my ADON and the Unit Manager they did not tell me I needed to do that. I asked around to other staff and some of them didn't know we had to put residents on 1 to 1 if there isn't a [Wander Monitoring Device] on the resident. I'm not sure if that education was just to me or to everyone but everyone should have gotten that education because not everyone knows about that. Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. Review of Resident #1's Physician Progress Note dated 12/21/23 at 12:44 p.m. revealed Note Text: Progress Note . [Resident #1] is a pt [patient] with chronic ETOH [alcohol] use, dementia, hallucinations, his [Family Member] wants to take him to the [Hospital] for more assistance, psychologist evaluation, pt was found wandering in the street yesterday. He called his [Family Member] to give his location, and staff from the facility found him. Today I examined him, he is alert still confused. [Resident #1] was ready for discharge, physical therapy evaluated him. He was walking more than 300 feet, but his [family member] says she works, and the pt will be alone the all day [sic], she wants to transfer to the [Hospital] for more resource.Recommendations/Plan: .will transfer the pt to the [Hospital], following family wishes . An interview was conducted on 1/17/24 at 4:25 p.m. with the NHA, he said when he came to the facility on [DATE] he has just been doing the elopement drills with the post drill education. The RNC said audits are completed weekly. The RNC said she participated in the investigation via phone calls. The NHA said since I have been here, we ordered [Wander Monitoring Devices]. The RNC said, The NHA approves the order, and when they arrive, they are dispersed between all of the nurse's medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 29 of 30 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 01/19/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few carts. The NHA said About two weeks ago a sister facility asked if we had an extra [Wander Monitoring Device], we gave them one and we noticed we did not have enough extra to make us feel comfortable, so we ordered more. The RNC said she told the old Assistant Director of Nursing (ADON) to distribute all the wander monitoring devices between the medication carts. An interview was conducted with the Director of Nursing (DON) on 1/17/24 at 5:00 p.m. she said we are not doing audits on the medication to ensure extra wander monitoring devices are stored in them. I have seen [Wander Monitoring Devices] laying around. I know I have seen one in my office and one in the old ADON's office. I have been doing medication cart audits for medication storage and I don't remember seeing any [Wander Monitoring Devices] but I was not looking for it. An interview was conducted on 01/17/2024 at 5:02 p.m. with the DON. She stated the facility had six medication carts, three on the west side of the building and three on the east side of the building. The six medication carts and nurse interviews were conducted in the presence of the DON. West Side: On 01/17/2024 at 5:06 p.m. an interview was conducted with Staff G, RN. She reported she had no residents on her assignment who had a wander [NAME][TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 30 of 30