Health inspection·July 12, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/11/24 at 1:39 p.m. an interview was conducted with Staff G, Licensed Practical Nurse (LPN) Resident #248's nurse. Staff G, LPN said the use of the geriatric chair is because Resident #248 is a fall risk and can get up from the chair when the footrest is lowered. Staff G confirmed Resident # 248 cannot independently get out the geriatric chair. On 07/11/24 at 2:40 p.m. an interview was conducted with the Director of Nursing (DON), she said resident #248 was placed in the geriatric chair for comfort. The DON said the geriatric chair's restriction on Resident #248, it did not cross my mind and is not ideal. On 07/11/24 at 8:00 p.m. Resident #248 was observed with eyes closed and laying in a geriatric chair facing the nurses' station. On 07/12/24 at 08:15 a.m. Resident #248 was observed with eyes closed and laying in a geriatric chair facing the nurses' station. Review of facility's policy titled, Resident Rights, effective on 11/30/2024, showed: Policy -1. Make residents and their legal representatives aware of residents' rights. -2. Ensure that residents' rights are known to staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 2 of 15 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 07/12/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a comprehensive care plan related to the use of a sling for one resident (#18) out of 26 residents sampled. Findings included: On 07/08/24 at 01:07 PM, Resident #18 was observed in the common area of the secured unit during dining with a sling on the left arm that was bunched up by her elbow, not supporting any of her arm . The left hand appeared swollen, and the resident was resting the left arm down on the left thigh. An attempt to interview the resident revealed the resident was not interviewable. A review of the admission Record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses to include dementia, Chronic Obstructive Pulmonary Disease (COPD), metabolic encephalopathy, and muscle weakness. A review of the care plan for Resident #18 revealed the following: Focus: The resident is at risk for changes in mood and behavior symptoms related to history of dementia and depression, history of panic attacks, aggression, exit seeking/wandering, elopement risk, removes sling. Date initiated: 05/30/2023; Revision on 05/10/2024 Goal: The resident will maintain involvement in activities of daily living (ADL's) and daily routine through next review date. Date initiated: 05/30/2023; Revision on: 05/28/2024; Target date: 08/27/2024 Interventions: Administer medications as ordered. Monitor/document for side effects an effectiveness. Date initiated: 05/30/2023 Assist the resident, resident representative to identify strengths, positive coping skills and reinforce these. Date initiated: 05/30/2023 Educate the resident/resident representative regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. Date initiated: 05/30/2023 Review of Resident #18 orders revealed; Apply sling to left arm as tolerated. Start date:02/06/2024 On 07/08/24 at 03:05 PM an interview was conducted with Staff J, Certified Nursing Assistant. Staff J stated the resident has the sling on to keep her arm from swelling up. Staff J stated she does not know why her arm is swollen. An observation on 07/09/24 at 04:34 PM revealed Resident #18 in the common area of the east wing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 3 of 15 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 07/12/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm memory unit ambulating with left arm sling bunched up around her elbow not supporting her arm. Her left arm was hanging down , near her waist. An observation on 07/10/24 at 09:30 AM revealed Resident #18 in common area of east wing memory unit, sitting with left arm sling bunched up to her elbow. Her left hand is swollen resting on her left thigh. Residents Affected - Few An observation on 07/10/24 at 01:35 PM revealed Resident #18 with the left arm sling bunched up to her elbow, her left hand is swollen and resting on her left thigh. An observation on 07/10/24 at 03:43 PM revealed Resident #18 sitting in a chair on the east wing memory unit. Her sling was bunched up to her elbow. Her left hand was swollen and resting on her left thigh. An observation on 07/11/24 at 10:19 AM revealed Resident #18 with her left arm sling bunched up to her elbow. Her left hand was swollen and resting on her left thigh. An interview was conducted on 07/11/24 at 11:35 AM with Staff M,RN. Staff M stated usually the certified nursing assistant (CNA) puts Resident #18 left arm sling on, then the nurse checks it for proper placement. Staff M stated Resident #18 will move her arm down. Staff M stated they remind Resident #18 to position it properly. Staff M went on to state they usually have a compression sleeve on. Staff M stated therapy works with her currently. Staff M stated she does not think Resident #18 has treatment from therapy for edema. Staff M stated she will do range of motion (ROM) with Resident #18 occasionally. Staff M stated she does not think there is an order for compression sleeve. Staff M stated the staff apply it every day. Staff M stated compression sleeves are house stocked in the supply room. Staff M stated therapy does the initial assessment and provided the sling. Staff M stated she usually looks at the care plans. Staff M stated she does not go to care plan meetings because of her schedule. Staff M stated she would talk Director Of Nursing (DON)/ supervisor to initiate change if what they are doing is not effective. Staff M stated Resident #18 is on a diuretic for the edema. An interview was conducted on 07/11/24 at 12:09 PM the Director of Nursing (DON) stated she was unable to say why they would continue using the sling if it was not effective. The DON stated compression sleeves are generally ordered. The DON went on to state nursing can put in orders for compression sleeves. The DON stated the facility has not referred Resident #18 to a lymph specialist as far as she is aware. The DON stated they have discussed Resident #18 compliance, but the facility has not discussed any treatment changes, An interview on 07/11/24 at 03:33 PM Staff N,MDS Coordinator is aware of Resident #18 use of sling. Staff N stated Resident #18 left arm sling is in care plan under ADL, was not aware of compression sleeve use. Staff N stated she was aware of the left arm swelling. Staff N stated the facility has not discussed Resident #18's lymph edema. Staff N stated she reviews orders for care plans to initiate interventions and new areas of concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 4 of 15 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 07/12/2024 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 Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Cross Reference F600, F684, F726, and F880 Based on observation, interview, and record review the facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 7/8/24 through 7/12/24 as evidenced by: 1) failure to protect the residents' right to be free from neglect related to not implement implementing systems for providing physician ordered medications to two newly admitted residents (#3 and #6) out of five newly admitted residents sampled (F600), 2) failure to ensure one resident (#5) out of thirteen residents with non-pressure related wounds received treatment per physician orders (F684), 3) failure to have sufficient and competent nurse staffing to complete the admission process for new residents in a timely manner and effectively complete a medication reconciliation for two newly admitted residents (#3 and #6) out of five newly admitted residents (F726), and 4) failed to implement an effective Infection Control program as evidenced by three staff members (B, C, and D), not using Personal Protective Equipment (PPE) for two residents (#3 and #6) out of three residents reviewed on contact precautions (F880). Findings included: During an interview on 08/29/2024 at 5:11 p.m. the Nursing Home Administrator (NHA) stated the Quality Assurance (QA) Committee includes herself, the Medical Director, the Director of Nursing (DON), Environmental Services, Pharmacy Regional, Dietician, Social Services Director, Activities Director, Human Resources (HR), Business Office Manager, a Certified Nursing Assistant (CNA) and a nurse. The NHA said she was the Committee Chairperson. The NHA reported the QA Committee meets on the last Thursday of every month. She stated the facility held a QAPI meeting in July and the August meeting was originally scheduled for 08/29/2024 and had been postponed for a week. During the QAPI meetings they discuss information for the prior month and find areas that need improvement and set up a plan of action. An action plan was developed based on the situation. Depending on what it was that needed to be monitored, they would start with monitoring daily and then tier it back to weekly, monthly and then quarterly. The NHA reported the only thing they were currently watching was PASARR's (Pre admission Screening and Resident Reviews). The NHA was not sure if there were any other Performance Improvement Plans (PIPs) in place and would have to get back with that information. The administrator reported that each year the annual training plan for employees was reviewed in the month of January, and the annual review of procedures was also done every January. The NHA did not return to the team to present any other QAPI information or PIPs in place prior to the survey exit on 8/29/24 beginning at approximately 6:45 p.m. Review of the facility's policy titled Quality Assurance Performance Improvement Program (QAPI) with a revision date of 10/24/22 showed the facility .has a comprehensive, data-driven QAPI Program that focuses on indicators of the outcomes of care and quality of life. The QAPI program was an on-going comprehensive review of care and services to residents to include: medical care, clinical care, pharmacy services, admissions, and medical records. Important function areas included: admission process, resident assessment, quality of care, potential adverse events, infection control, and allegations of abuse, neglect, and misappropriation of resident property. The QAPI activities included: infection control, medication use, wound care/prevention, staff orientation, in-service and competency, and medication errors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 5 of 15 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 07/12/2024 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 Residents Affected - Some The facility's Executive Director/Nursing Home Administrator (NHA) was accountable for the overall implementation and functioning of the QAPI program to include implementation which identify priorities, ensures adequate resources, ensures corrective actions are implemented to address identified problems in systems, evaluates the effectiveness of actions, establishes expectations for safety and quality. The Quality Assessment and Assurance Committee (QAA) meetings are at least quarterly, but may be held more frequently as appropriate. QAA Committee members include but are not limited to the Executive Director/(NHA), Medical Director/designee, Director of Nursing /designee, Infection Preventionist and at least three other staff members that understand the facility and the care and services delivered by each unit or department. The facility will obtain feedback to assist in identifying problems and areas of opportunity. Feedback may be obtained by direct care staff, other staff members, residents, and resident representatives. The feedback may The facility will identify data sources and timeframe for collection. Data sources may include direct observation tools, audit tools, grievance logs, incident/accident logs, The facility will ensure systems and actions are in place to improve performance by establishing and utilizing a systematic approach to identify underlying causes of problems, including root cause analysis and failure mode effect analysis. The facility will develop corrective actions based on the information gathered and review effectiveness of the actions to include medical errors and adverse events. The facility will obtain and review information on any medical error and adverse event. Information may be obtained from incident/accident logs, skin and wound logs, infection control logs, 24 hour report logs, and allegations of abuse, neglect, misappropriation of resident property. The facility will develop and monitor action plans. The facility will monitor department performance systems to identify issues or adverse events. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). The facility may choose the method of corrective action i.e. Plan, Do, Study, Act'' or Performance Improvement Project'' The facility utilizes performance improvement projects to improve a systemic problem or improve quality in absence of a problem. Performance Improvement Projects (PIPs) are based on the facility services and resources identified in the Facility Assessment. At a minimum, the facility must conduct one performance improvement project annually which focuses on high-risk or problem prone areas identified. The team will collect and analyze data, determine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 6 of 15 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 07/12/2024 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 Residents Affected - Some root cause, determine steps for resolution, implement corrective action(s), evaluate effectiveness of the action(s), and report progress to the QAPI committee Review of the facility's plan of correction for the survey ending 7/12/24 with a completion date of 8/11/24 revealed the following measures would be taken to correct the deficient practice which was identified at

F600: (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. Director of Clinical Services/Designee re-educated the licensed nurses on the components of this regulation with an emphasis on. Staff education on abuse and neglect was conducted on 7/12/24 and ongoing. License Nursing Staff educated on Change in Condition policy, documentation in change of condition, notifying the physician in a timely manner, anticoagulant therapy policy, monitor signs and symptoms of bleeding, honoring resident and family wishes if they want their family member sent to the hospital. Director of Nursing/Designee initiated competency with all licensed Nursing staff on change in condition on 7/12/24. License Nursing staff and certified nursing assistant educated by Director of Nursing/designee on use of restraints and honoring resident s preferences on 8/2/24. Director of Clinical Services/Designee re-educated the licensed nurses and certified nursing assistants on the components of this regulation with an emphasis on. Residents to be evaluated by physical therapy for the use of geri chair placement During clinical morning meeting Director of Clinical Services/Designee will review the 24 hour report, labs, weekly skin checks, order listing to ensure changes in condition were addressed and documented and physician were notified timely. Evaluations will be completed by physical therapy for the use geri chair placement Newly hired licensed nurses and certified nurse assistant will receive education in orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The facility Director of Clinical Services /designee will conduct a weekly audit of 5 residents to ensure residents with anticoagulants have orders to check for bleeding on all Treatment Administration Recordss [sic] weekly x4 weeks, and then every 2 weeks x 2 months. The facility Director of Clinical Service/designee will conduct a weekly audit of 5 resident to ensure weekly skin sweep are completed and no dressing changes with bleeding weekly x4 weeks, and then every 2 weeks x 2 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 7 of 15 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 07/12/2024 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 Residents Affected - Some The facility Director of Clinical Services /designee will conduct a weekly audit of 5 residents to ensure residents are properly evaluated for Geri chair placement weekly x 4 weeks, and then every 2 weeks x 2 months. The Executive Director/designee will conduct a weekly audit of 5 residents with a Brief Interview for Mental Status of 9 and above to ensure that they are free from abuse and neglect weekly x 4 weeks, then every 2 weeks x 2 months. The facility Director of Clinical Services/designee will perform a skin check weekly of 5 residents with a Brief Interview for Mental Status of 9 and below to ensure that they are free from abuse and neglect weekly x 4 weeks, then every 2 weeks x 2 months. Director of Clinical Services/Designee will conduct a quality review of 5 residents on each unit weekly x 4 weeks, and then every 2 weeks x 2 months to ensure residents with change in condition has been identified, documented and physician were notified timely. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Nurse Consultant when completing their systems review. On 8/26/24 through 8/29/24 a revisit survey was conducted to ensure compliance with F600. The revisit survey identified on-going concerns and noncompliance with F600. Review of the facility's plan of correction for the survey ending 7/12/24 with a completion date of 8/11/24 revealed the following measures would be taken to correct the deficient practice which was identified at

F684: (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. License Nursing Staff educated on Change in Condition policy, documentation in change of condition, notifying the physician in a timely manner, anticoagulant therapy policy, monitor signs and symptoms of bleeding, honoring resident and family wishes if they want their family member sent to the hospital. Licensed staff education was initiated on 7/12/24 the components of the regulations related to Quality of Care and Resident Rights and with an emphasis on: Identifying and reporting any change in condition. Listening to the Resident and honoring their wishes as long as it does not impact them negatively. Monitoring and documenting to ensure that the resident is stable. Non-licensed staff education was initiated on 7/12/24 by Director of Nursing/Designee ensuring they understand the purpose and importance of using the Stop and Watch tool. Director of Nursing/Designee initiated competency with all licensed Nursing staff on change in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 8 of 15 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 07/12/2024 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 condition on 7/12/24. Level of Harm - Minimal harm or potential for actual harm During clinical morning meeting Director of Clinical Services/Designee will review the 24 hour report, labs, weekly skin checks, order listing to ensure changes in condition were addressed and documented and physician were notified timely. Residents Affected - Some Newly hired licensed nurses and certified nurse assistant will receive education in orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The facility Director of Clinical Services /designee will conduct a weekly audit of 5 residents to ensure residents with changes in condition are completed with MD and family notification weekly x4 weeks, and then every 2 weeks x 2 months. The facility Director of Clinical Service/designee will conduct a weekly audit of 5 resident discharges to ensure changes in condition were captured promptly and documentation is in place weekly x4 weeks, and then every 2 weeks x 2 months. The facility Director of Clinical Service/designee will conduct a weekly audit of 5 resident to ensure physician orders pertaining to vital signs are being followed weekly x4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review. On 8/26/24 through 8/29/24 a revisit survey was conducted to ensure compliance with F684. The revisit survey identified on-going concerns and noncompliance with F684. Review of the facility's plan of correction for the survey ending 7/12/24 with a completion date of 8/11/24 revealed the following measures would be taken to correct the deficient practice which was identified at

F726: (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. Director of Clinical Services/Designee re-educated the licensed nurses on the components of this regulation with an emphasis on. Documentation on Change in Condition, ensuring anticoagulants have an order showing on the treatment sheet, honoring residents family wishes if they want their family member send out. Director of Clinical Services/Designee re-educated the licensed nurses and certified nursing assistant on the components of this regulation with an emphasis on. Identifying and documenting change in condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 9 of 15 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 07/12/2024 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 Following physician orders for vital signs. Level of Harm - Minimal harm or potential for actual harm During clinical morning meeting Director of Clinical Services/Designee will review changes in condition documentation. Identify any residents with current issues that may need a change in condition. Residents Affected - Some Orders are reviewed for vitals signs and ensuring they are accurate on Medication Administration Records. Newly hired licensed nurses and certified nursing assistant will receive education in orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The facility Director of Clinical Services /designee will conduct a weekly audit of 5 residents to ensure residents with changes in condition are completed with MD notification and family notification weekly x 4 weeks, and then every 2 weeks for 2 months. The facility Director of Clinical Services /designee will conduct a weekly audit of 5 residents discharges to hospital to ensure changes in condition were captured promptly and documentation is in place weekly x4 weeks, and then every 2 weeks x 2 months. The facility Director of Clinical Service/designee will conduct a weekly audit of 5 resident to ensure physician orders pertaining to vital signs are being followed weekly x4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review. On 8/26/24 through 8/29/24 a revisit survey was conducted to ensure compliance with F726. The revisit survey identified on-going concerns and noncompliance with F726. Review of the facility's plan of correction for the survey ending 7/12/24 with a completion date of 8/11/24 revealed the following measures would be taken to correct the deficient practice which was identified at

F880: (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. Director of Clinical Services/Designee re-educated the staff on the components of this regulation with an emphasis on. Licensed Nursing Staff educated on enhance barrier signage on admission. During clinical morning meeting Director of Clinical Services/ADON will review all enhance barrier precaution orders and review all new admissions to ensure those who need enhance barrier precautions have the proper signage and discontinue those who no longer need them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 10 of 15 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 07/12/2024 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 Newly hired licensed nurses will receive education in orientation. Level of Harm - Minimal harm or potential for actual harm (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. Residents Affected - Some The facility Director of Clinical Services /designee will conduct a weekly audit of 5 residents to ensure residents with enhance barrier precautions have proper signage weekly x4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review. On 8/26/24 through 8/29/24 a revisit survey was conducted to ensure compliance with F880. The revisit survey identified on-going concerns and noncompliance with F880. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 11 of 15 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 07/12/2024 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, record review, and interviews, the facility failed to maintain and implement an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to prevent the development and transmission of communicable diseases and infections as evidenced by a lack of enhanced barrier precaution signage on doors of two residents (#81, #297) out of 20 residents on enhanced barrier precautions. Residents Affected - Few Findings included: 1. On 07/08/24 at 1:00pm observed Resident #297 IV (intravenous) port and dressing to right upper arm. Observed no enhanced barrier precaution sign on door and no storage bin outside of Resident #297 door with personal protective equipment (PPE) supplies. On 07/11/24 at 8:52 a.m. observed Resident #297 door with no enhanced barrier precaution signage or storage bin with PPE supplies located outside of door. Photo evidence obtained. Review of electronic medical record (EMR) for Resident #297 showed an admission date of 07/05/24 with included diagnoses of encephalopathy, acute and subacute infective endocarditis, presence of artificial heart valve, arteriovenous malformation site unspecified, atherosclerosis of coronary artery bypass graft(s) without angina pectoris. Review of code status showed resident listed as a full code. Review of the Minimum Data Set (MDS) for Resident #297, dated 07/06/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. A review of the 3008 form, dated 07/05/24, revealed: - Comments section Daptomycin 300 mg IV daily. Duration 6-8 weeks. - Treatment devices, right PICC (peripherally inserted central catheter) inserted 06/21/24. Review of the physician orders revealed: - Return IV pump to pharmacy following IV therapy -Change dressing on admission or 24 hours after insertion and weekly thereafter and PRN -IVs: Type of access: midline. - IVs: Flush PICC or Midline with 10 mls of normal saline every shift and as needed. - Infectious disease appt 07/12/24 at 2:00 p.m. A review of the care plan for Resident #297, dated 07/06/24, revealed the following: -A focus of The resident requires enhanced barrier precautions related to use of indwelling medical device IV PICC and is at risk for a CDC MDRO infection. Date initiated 07/08/2024. With (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 12 of 15 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 07/12/2024 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 intervention, Signage at designated area to alert staff and visitor of enhanced barrier precautions. Date initiated: 07/08/24. - A focus of The resident is on IV Medications r/t [related to] Endocarditis. Date Initiated: 07/06/24. With a goal of The resident will have not have [will not have] any complications related to IV Therapy through the review date. Date Initiated: 07/06/2024, Target Date: 10/04/2024. A review of the medical record for Resident #297 on 07/08/24 showed no physician order for enhanced barrier precaution. Review of the facility matrix revealed 20 residents are marked for enhanced barrier precautions. Resident #297 was not listed on facility matrix for enhanced barrier precautions. 2. On 07/09/24 at 8:48 a.m., observed Resident #81's door with no enhanced barrier precaution signage on door. On 7/11/24 at 8:55 a.m. observed no enhance barrier precaution signage on Resident #81 door. Review of the medical record for Resident #81 showed an admission to facility on 03/02/24 with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal region, quadriplegia, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, malignant neoplasm of unspecified site of unspecified breast, colostomy status, presence of urogenital implants. Review of code status showed resident listed as do not resuscitate (DNR). A review of the Physician orders revealed: -03/02/24 PEG Tube, catheter and colostomy. -07/09/24 Enhance Barrier Precautions related to percutaneous endoscopic gastrostomy (PEG) Tube, Foley catheter and colostomy. A review of the care plan, dated 06/03/24, revealed: - A focus of enhanced barrier precautions related to use of indwelling medical device Foley Catheter, Peg tube, Colostomy and is at risk for a CDC MDRO infection. Date initiated 07/09/24. Interventions included Signage at designated area to alert staff and visitor of enhanced barrier precautions. Date initiated 07/09/24. - A focus of the resident requires enhanced barrier precautions related to chronic wounds requiring dressing/covering and is at risk for a CDC MDRO infection dated 07/09/24. With interventions that include education of need for enhanced barrier precaution provided to resident/family/caregivers. and signage at designated area to alert staff and visitor of enhanced barrier precautions. date initiated 07/09/24. An interview was conducted on 07/11/24 at 1:47 p.m. with Staff E, Certified Nursing Assistant (CNA). She stated for any resident on infection precautions she is made aware by the signage on the door. She follows what the sign says, If it says gown and mask, I put on gown and mask before going in the room and take off and put in wastebasket before coming out to the hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 13 of 15 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 07/12/2024 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 An interview was conducted on 07/11/24 at 1:51 p.m. with Staff D, Housekeeper. She stated, she knows when to wear PPE in a residents room by I follow signs on door and pointed to enhanced barrier precaution sign on a resident's door. An interview was conducted on 07/11/24 at 1:55 p.m. with Staff B, Physical Therapy Assistant. She stated she goes by the sign on resident's door and what is in a residents therapy evaluation to determine if a patient is on precautions before entering the room, to know what type of PPE is necessary. An interview was conducted on 07/11/24 at 2:10 p.m. with Staff A, Licensed Practical Nurse. She stated the residents should have a precaution sign on their door and plastic bin with proper PPE supplies. She stated they can look in medical record under resident medication administration record (MAR) and they should have a physician order for precautions. She stated enhanced precautions are for residents with Wound, intravenous therapy (IV), Foley etc. She stated PPE for enhanced precautions are gown, gloves and mask to be worn when entering room for staff providing direct care to resident. Hand washing for visitors or staff if no direct care is provided. She stated Staff C, Assistant Director of Nursing is the infection preventionist and is in charge of putting up and taking down all infection precaution signs. She stated if she is not available the nurse in charge of the resident would be responsible. An interview was conducted on 07/11/24 at 3:00 p.m. with Staff C, Infection Preventionist. She stated the three types of precautions followed are droplet, contact and enhanced barrier at the facility. She stated enhanced precautions require gloves, gowns and masks for staff who are providing direct patient care. Any resident with an indwelling medical device such as Foley's, IV's, PEG tubes, nephropathies, wound vac would be placed on enhanced precautions. She stated she would put signage on the door and get a bin of PPE when a confirmed resident is on any type of precaution. She stated currently they have bins ordered so they are being shared on the hallway till new ones arrive. She stated the resident would need to have an order in the EMR for a type of isolation or precaution. She stated if she is off work or resident admits over the weekend, the Director of Nursing (DON) or unit manager would be expected to hang signage and place PPE bin outside the door and ensure physician order is placed in the chart and relay information to hall nurse. She reviewed Resident #297's medical record and stated She has an order for enhanced precautions. It should have started when she was admitted on [DATE]. She stated, She has an IV so she automatically should be on enhanced precautions. She stated she would expect the DON or Unit Manager to complete PPE signage and bin for new resident as she is off when resident admitted . She stated, that's my mistake, the enhanced precautions sign should have been on the door (referring to Resident #297). She stated is should have been placed on day of admission because the resident was admitted with the IV. When questioned why Resident #81 did not have enhanced precaution signage on the door. She stated she should have been placed on enhanced precaution on 5/4/24 because of her Foley, peg tube and colostomy. She stated it was her mistake, I missed it. She stated the order in the chart for enhanced should have started on 05/04/24, the current order started on 07/09/24. She stated, We didn't catch it. Review of facility policy for enhanced barrier precautions, dated August 2022, revealed the policy interpretation and implementation included: -#5 Enhanced barrier precautions (EBP) are indicated for resident with wounds and/or indwelling medical devices regardless of multidrug resistance organism (MDRO) colonization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 14 of 15 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 07/12/2024 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 -#10 Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106017 If continuation sheet Page 15 of 15