Health inspection·January 15, 2021

F 0867 cleanser or normal saline. Clean wound using circular motion beginning from center toward the outside. Discard gauze and repeat as necessary. Level of Harm - Minimal harm or potential for actual harm #20 Cleanse peri-wound with separate moistened gauze and repeat as necessary. Residents Affected - Few #21 Remove gloves. Perform hand hygiene (soap and water or hand sanitizer). #22 [NAME] gloves and apply treatment as ordered. In an interview with the Nursing Home Administrator (NHA) and the Director of Nurses (DON) on 04/09/2021 beginning at 2:30 p.m., they confirmed all nurses were trained on the wound care policy and were observed for competency while performing wound care. All nurses passed the competency checks and observation continued randomly of the nurses during wound care to ensure there was compliance. The DON confirmed the observation for the competency check off and observations for the auditing for the plan of correction were conducted by the nurse Unit Managers and the Assistant Director of Nurses. The DON confirmed the Unit Manager that was present during the wound care on 04/08/2021 was the same nurse that checked the nurses' competencies and conducted the wound care audits for the plan of correction. A review of the attendance sheets for training on the wound care policy and review of the completed competencies for wound care revealed all facility nurses had been trained and completed the competency review. A review of the wound care audits revealed there was no non-compliance documented. During the survey conducted 04/07/2021 - 04/09/2021 the following concerns related to infection control and prevention during wound care were identified: Medical Record review was conducted for Resident #3 that indicated on admission Record form diagnoses which included pressure ulcer of sacral region, encounter for surgical after care following surgery on the skin and subcutaneous tissue. Review of Admission/readmission Data Collection form dated 4/2/2021 showed right buttock surgical incision proximal line 3.0 x 0.3 x 0.3, -5 staples intact then midline dehiscence open 5.0 x 2.5 x 1.5 75% red beefy granulation and 25 % slough distal incision 6.5 x 0.3 x 0.3 x - 8 staples. Review of the Pressure Ulcer Wound Rounds dated 4/2/2021 showed right gluteal fold pressure length 1.5 x width 0.9 x 0.7 depth stage 3. (inaccurate documentation, pressure ulcer is on left gluteal fold). On 4/8/2021 at 1:05 p.m. wound care observation was conducted with Staff Member E, RN and Staff Member H, Wound Care Nurse (WCN); the WCN stated that Resident #3 had a surgical cite and a pressure ulcer that were due for a dressing change. Supplies gathered included a bottle normal saline, collagen powder, small souffle cup that contained medi-honey, cotton tipped applicators, bulk gauze dressing, and 4 packages of adhesive bordered dressings. The supplies were placed on top of a barrier. Resident #3 was observed lying in bed when approached and appeared comfortable. She was receptive to the observation as she smiled when asked. The WCN went to the left side of the bed and assisted the resident to reposition. The WCN stood on the left side of the bed holding the resident in position. The bed sheet was removed and revealed five different dressings in place. The first dressing removed was the left gluteal fold/pressure area. It revealed an opening approximate size of a dime with the surrounding tissue pale white in color. The dressing to the left upper buttock was removed and revealed approximated staples in place. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 2 of 9 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 106017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Palma Sola Bay 6305 Cortez Rd W Bradenton, FL 34210 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 right buttock was observed with three separate dressings in place. The center of the right buttock revealed the surgical wound that presented a large oblong in shape and width, and the wound bed contained beefy bright red tissue with moderate amount of serosanguinous drainage. The two remaining dressings, one located above, and one located below the surgical cite were removed and presented with additional approximated staples. Residents Affected - Few The WCN directed Staff Member E to change her gloves and wash her hands. Staff Member E applied the normal saline to the surgical wound and with her left hand used a gauze dressing to wipe the wound; the gauze was dropped into the garbage can. The same process was used for the three stapled areas and the left gluteal fold. After the areas were cleaned, and without changing gloves and practicing hand hygiene, Staff Member E individually dried each wound area with a new gauze dressing. Staff E removed her gloves and used Alcohol Based Hand Sanitizer (ABHS) at the bedside and donned new gloves. The surgical wound was packed with the collagen and a secondary dressing applied. Staff Member E removed her gloves and performed hand hygiene. She donned clean gloves and prior to applying the medi-honey into the left gluteal fold the WCN stopped her and informed staff that her glove was ripped. Staff Member E removed the left glove from her hand and immediately donned a clean glove; no hand hygiene was performed. The medi-honey was applied to the pressure ulcer with her left hand, during which her bracelet that contained multiple dangling charms touched the top of the barrier. In an interview with the Director of Nursing (DON) at 1:40 p.m. on 4/8/2021, she confirmed that after cleaning a wound, gloves should be changed, and hand hygiene would be practiced. At 1:50 p.m. on 4/8/2021 an interview was conducted with Staff Member E and the WCN. They confirmed after cleaning the surgical wound, pressure ulcer and staples, Staff Member E did not remove the soiled gloves, or practice hand hygiene, prior to drying the cleaned areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 3 of 9 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 106017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Palma Sola Bay 6305 Cortez Rd W Bradenton, FL 34210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy review, and Centers for Disease Control and Prevention and Control (CDC) guidelines the facility did not ensure infection control and prevention practices were implemented to prevent the spread of COVID-19 on one nursing unit (new admission observation unit) of three nursing units as evidence by: 1. Two staff members (A, and B) failed to perform hand hygiene after removing gloves when exiting resident rooms, and failed to changed gloves and perform hand hygiene between providing care for two residents (#327 and #328) and failed to handle trash and soiled linens in a manner to prevent the spread of COVID-19, and 2. Failed to ensure two staff members (D and E) were wearing eye protection on the new admission observation unit, and 3. One staff member (E), during pressure ulcer care for one resident (#328) of two residents reviewed, failed to perform hand hygiene and removed treatment items from the room after care. Residents Affected - Few Findings included: 1. On 1/13/21 at 9:33 a.m. an observation was conducted on the new admission observation unit consisting of 10 resident rooms (room [ROOM NUMBER] - 210). There were personal protective equipment (PPE) kits throughout the hallway outside of resident room doors with gowns, gloves, bleach wipes, and surgical masks in them. There were two divided hampers marked for trash and linens in the middle of the hallway on the unit. There was sanitizer on the medication cart, on top of the food delivery cart, one on the wall near the entry to the unit, another at the nurses' station, and one in the middle of the hallway on the wall above the location of one of the divided hampers. During the observation, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON said he stays on the unit all day to assist with admissions. The ADON confirmed the staff were to wear the required PPE of gown, gloves, mask and eyewear while on the unit. On 1/13/21 at 9:40 a.m. Staff A, Certified Nursing Assistant (CNA) was observed to exit room [ROOM NUMBER] with an unbagged resident gown and took it down the hallway to the divided linen hamper in the middle of the hallway near room [ROOM NUMBER]. Staff A, CNA was wearing gloves when she exited the room. After Staff A, CNA placed the gown in the linen side of the hamper, she removed the gloves and placed them in the trash side of the hamper. Staff A, CNA went back down the hall toward room [ROOM NUMBER] where she stopped at room [ROOM NUMBER] and removed a pair of gloves from the PPE kit outside the door. Staff A, CNA put the clean gloves on without performing hand hygiene and returned and entered room [ROOM NUMBER]. On 1/13/21 at 9:44 a.m. an observation was conducted. Staff B, CNA exited room [ROOM NUMBER], removed the extra gown, which was recommended by another State Agency, and the gloves she was wearing, walked across the hallway, and placed them in the divided hamper on the side marked trash. Staff B, CNA did not perform hand hygiene. Staff B, CNA went down the hall to the therapy gym. Staff B, CNA opened one of the doors with her contaminated hand and entered the therapy gym. Staff B, CNA returned a moment later through the therapy doors. At 9:45 a.m. in an interview with Staff B, CNA she said she did hand hygiene in the back because she was going to take the trash out. On 1/13/21 at 10:00 a.m. an observation was conducted. Staff A, CNA exited room [ROOM NUMBER] and went to the PPE kit in front of room [ROOM NUMBER] to get a pair of gloves. In an interview with Staff A, CNA she said there weren't any gloves in the rooms because they could get contaminated. She returned to room [ROOM NUMBER], opened the door, and picked up a soiled brief and used gloves that were lying on the floor in the doorway. Staff A, CNA walked down the hallway to the soiled linen and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 4 of 9 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 106017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Palma Sola Bay 6305 Cortez Rd W Bradenton, FL 34210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few trash hamper with the unbagged trash and placed them in the trash side of the hamper that was located outside of room [ROOM NUMBER]. On 1/13/21 at 10:04 a.m. in an interview with the ADON, he said there are trash bags on the linen cart. He walked down the hallway to the linen cart and pointed out some large trash bags on it. He agreed staff shouldn't be walking with trash and soiled linens down the hall unbagged and should not move the hamper. On 1/13/21 at 10:09 a.m. an observation was conducted. Staff A, CNA exited room [ROOM NUMBER] again with a soiled towel and the meal box from breakfast with gloved hands. She walked down the hallway to the divided linen and trash hamper in front of room [ROOM NUMBER]. Staff A, CNA brought the hamper down the hallway and placed it outside room [ROOM NUMBER]. Staff A put trash and linen in the hamper. Staff A, CNA did not perform hand hygiene after removing the gloves. Next, Staff A, CNA removed a clean gown and gloves from the PPE kit outside of room [ROOM NUMBER] and put them on. In an interview with Staff A, CNA conducted after she put on the gown and gloves, she said she performed hand hygiene down there before she brought the hamper down the hallway. She said she used the sanitizer that was on top of the medication cart. Staff A was not observed performing hand hygiene after disposing soiled linen and trash, before donning clean PPE. On 1/13/21 at 10:40 a.m. an observation was conducted. The call light was activated by Resident #327. Staff A, CNA entered the room after putting on another gown and some gloves. She went to the side of the room where Resident #327 was residing. The surveyor was at the bedside of Resident #328 on the other side of the room behind a privacy curtain. It was unknown what type of assistance Staff A, CNA provided to Resident #327. When Staff A, CNA finished attending to the needs of Resident #327, she came over to Resident #328's side of the room wearing the same gloves and asked if she could check Resident #328's brief. Staff A, CNA proceeded to pull the covers back and remove the right-side brief tab. Then Staff A, CNA recovered Resident #328 after returning the brief tab. Staff A, CNA assisted Resident #328 with repositioning because she was complaining of discomfort. Staff A, CNA removed some pillows from the recliner at the bed side. Then Staff A, CNA removed the covers from Resident #328's legs, lifted her feet and placed them on the pillow. Then she returned the covers to her legs. Staff A, CNA returned to the recliner and picked up another pillow. She lifted the fitted sheet on the resident's left side of the bed and placed the pillow under the resident's left side. In an interview with Staff A, CNA conducted in the residents' bathroom, she said she couldn't change her gloves because there aren't any in the room. She doesn't know why they aren't keeping them in the room. In an observation in the residents' bathroom, a glove container on the wall was empty. On 1/13/21 at 11:15 a.m. an interview was conducted with the ADON. He said he doesn't know why there weren't any gloves in the resident rooms. 2. On 1/13/21 at 11:17 a.m. another observation was conducted on the new admission observation unit. Staff D, Licensed Practical Nurse (LPN) Supervisor was observed entering room [ROOM NUMBER] wearing an N95 mask with a surgical mask on top and one gown. Staff D, LPN Supervisor did not have any eye protection on, and he was not wearing any gloves. Before Staff D, LPN Supervisor exited the room he went to the bathroom and washed his hands in the sink. On 1/13/21 at 11:25 a.m. an interview was conducted with Staff D, LPN Supervisor. He said he had brought an ice tray and ice packs from the kitchen to the nurse. He said goggles or face shields, a gown and an extra gown, which is based on another State Agency's recommendations, and gloves had to be worn in the rooms. He confirmed he did not have any eye protection on and didn't put on another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 5 of 9 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 106017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Palma Sola Bay 6305 Cortez Rd W Bradenton, FL 34210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 gown or any gloves, but he said he did wash his hands in the sink. Level of Harm - Minimal harm or potential for actual harm 3. Resident # 328 was admitted to the facility with a diagnosis of left femur fracture. A review of the January 2021 physician's orders in the medical record revealed the following: Residents Affected - Few 1/9/21 L (left) heel cleanse area with NS (normal saline) pat dry apply skin prep every other day and as needed every night shift for DTI (deep tissue injury) pressure wound. R (right) heel cleanse with NS pat dry apply skin prep every other day and as needed every night shift for DTI pressure wound. On 1/14/21 at 1:55 p.m. an observation was conducted during the treatment to Resident #328's heels, with Staff E, LPN. Staff E, LPN removed a saline syringe, skin prep wipes, and gauze 2x2's form the treatment cart. Staff E, LPN entered Resident #328's room after putting on a pair of gloves and knocking on the door. Staff E, LPN placed the treatment supplies on Resident #328's bed near the resident's feet. The nurse applied the skin prep to the resident's heels and disposed of the gauze in the trash can and removed her gloves. Staff E, LPN picked up the remaining saline syringe and skin prep wipes (2) from Resident #328's bed and exited the room. Staff E, LPN did not perform hand hygiene. Staff E, LPN brought the supplies back down the hallway to the treatment cart that was sitting next to the nurses' station and placed them on top. She removed keys from her pocket and unlocked the treatment cart. The surveyor asked if the residents in that room were on any precautions. She said they were. Then Staff E, LPN threw the saline syringe and skin prep in the trash can nearby. Staff E, LPN failed to clean or disinfect the top of the care that the supplies were on and at that time performed hand hygiene. Based on facility policy and CDC guidelines the residents were on transmission based precautions for being on the new admissions unit. On 1/15/21 at 1:23 p.m. an interview was conducted with the Director of Nursing (DON). When asked what has been done to mitigate COVID-19 in the facility the DON stated lots of education, audits, observations, mask techniques, donning/doffing, what COVID is. The DON also said that gloves are expected to be in the rooms. The DON said, That's what we use to provide care. We don't wear gloves in the hallways. So, they have to be in the rooms. The DON also stated that soiled linen and trash go in a bag before they come out of the room. She said these concerns (observations) were not her expectation. The DON agreed staff need to do hand hygiene after they take their gloves off and between patients always. The DON said, Yes, they have to have eye protection . they have to have them on. The treatment supplies stay in the room or go in the trash. A review of the policy title, Safe Handling and Processing of Soiled Linen, dated 11/30/2014, revealed the following information: Policy: To enforce the practice that all soiled linen/laundry is considered contaminated. Staff will be required to use precautions listed in this procedure as well as the capital EPC Plan. For handling all linen by placing same in bags at the place of care/treatment. Staff must also ensure handled, stored, and processed, so as to control the spread of infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 6 of 9 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 106017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Palma Sola Bay 6305 Cortez Rd W Bradenton, FL 34210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Procedure Level of Harm - Minimal harm or potential for actual harm Handling: Residents Affected - Few a. Ensure appropriate clean bags/containers are available as close to the point of care/treatment as possible. 3. Place soiled linen immediately into bag at the location of care/treatment. Be careful not to touch the outside of the bag with the soiled linen. 4. Linen should not be carried/transported down the hallway without first being placed in the appropriate bag/container (labeled soiled linen). 6. Ensure bag is closed/tightly secured. 7. Place bag in designated covered container/hamper. The container must be labeled soiled linen only. 8. Never place or drop soiled linen on floor or other surfaces. 10. Remove PPE. Wash hands by following our established Hand Washing Procedure. Review of the policy title, COVID-19 Pandemic Plan, revised 1/10/20, revealed the following relevant information: Policy COVID-19 is a respiratory illness thought to be spread mainly from person to person, between people who come in close contact to one another (about 6 feet). The virus is spread through droplets produced when an infected person coughs or sneezes. Symptoms include fever, cough, shortness of breath, sore throat, vomiting, diarrhea, muscle pain, headache, new loss of taste or smell, chills, repeated shaking with chills. 1. Staff will be trained on the facility pandemic COVID-19 plan and related policies and procedures. 2. Staff will be retrained in hand hygiene and proper use of PPE including competency. 17. The center will designate an area and cohort new admissions/readmissions: Initiate transmission based precautions based on CDC guidance (standard, contact, and droplet and eye protection). Including PPE - respirator, (or facemask if respirators are not available), face shield or eye protection, gown, and gloves. The center will designate an area (PUI unit) for residents who: (bullet 4) Place resident in a private room or cohort with another resident whose status is unknown, initiate transmission based precautions (standard, contact, and droplet). Including PPE - respirator, (or facemask if respirators are not available) face shield or eye protection, gown, and gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 7 of 9 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 106017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Palma Sola Bay 6305 Cortez Rd W Bradenton, FL 34210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Infection Prevention and Control Level of Harm - Minimal harm or potential for actual harm 8. Implement universal source control for all staff per CDC guidance: Face mask Residents Affected - Few Eye protection for centers located in areas with moderate to substantial community transmission. A review of CDC recommendations on 1/18/21, updated on 11/20/20, found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, included the following information: Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices. Make necessary PPE available in areas where resident care is provided. Further review of the CDC guidance at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html reflected the following: Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Additional review of CDC guidelines, updated 11/20/20, at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html reflected the following: Evaluate and Manage Residents with Symptoms of COVID-19. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated. Additional information was found upon review at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated 12/14/20, and included the following information: Implement Universal Use of Personal Protective Equipment HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 8 of 9 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 106017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Palma Sola Bay 6305 Cortez Rd W Bradenton, FL 34210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: -Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Hand Hygiene -HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. -HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. -Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. Eye Protection -Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays. -Ensure that eye protection is compatible with the respirator so there is not interference with proper positioning of the eye protection or with the fit or seal of the respirator. -Remove eye protection after leaving the patient room or care area, unless implementing extended use. Gloves -Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. -Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Gowns -Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 9 of 9