Health inspection·January 29, 2021

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 1/27/2021 a medical record review was conducted for Resident#30. He was admitted to the facility in 2019 with multiple diagnosis to include chronic obstructive pulmonary disease, acute chronic respiratory failure, sleep apnea, and insomnia. A review of Resident #30's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 15 indicating cognition intact. A review of Resident#30 plan of care revealed the following information: The resident has altered respiratory status/difficulty breathing related to sleep apnea date initiated 11/13/2019- Interventions: CPAP (Continuous positive airway pressure) as ordered/needed, encourage sustained deep breaths, position resident with proper body alignment for optimal breathing pattern. The goal for the care plan was for the resident to maintain a normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through next review date with a target date of 2/18/21. Residents Affected - Few On 01/27/21 at 10:33 AM, Resident #30 was observed with his C-PAP device on and running. He was asked if the nurse had placed the C-PAP on him, monitored his breathing or established a respiratory rate. The resident replied, Are you kidding me. I do this all myself. A second observation was conducted on 01/28/21 at 10:23 AM. Resident#30 was observed with his C-PAP on and running. He was asked again if the nurse had applied the C-PAP. Again he stated, No they never set this machine up. I have to do it myself. An interview was held with Staff A, Unit Manager/Licensed Practical Nurse (LPN), on 1/28/2021 at 10:30 AM. She was asked to review the care plan for this resident along with the surveyor. She confirmed that he was not care planned to set-up the equipment himself and he did not have the ability to establish his own respiratory rate. The Nursing Home Administrator (NHA) walked into the conference room as the interview was in progress and was informed of the current findings. She was not aware that the resident was applying his own C-PAP machine. The NHA provided the facility policy and procedure for the general administration of a CPAP or BIPAP dated 4/1/2019. Under the heading procedure the following was revealed: Review Physicians orders. Gather equipment and proceed to the resident's room. Perform hand hygiene prior to setting up equipment. Assess the resident. Establish baseline respiratory rate, heart rate, and breath sounds. Place the mask over the residents nose and adjust size. Adjust straps until significant leaks are eliminated. Set settings according to physicians orders. Based on observation, interview, medical record review, and policy review the facility failed to provide respiratory care in accordance with standards of practice and the comprehensive plan of care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 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 0695 Level of Harm - Minimal harm or potential for actual harm for four (#30, #51, #62, #66) sampled residents out of 45 facility residents receiving respiratory treatment as evidenced by: 1) the improper storage of respiratory equipment for Resident #51, #62, and #66, and 2) Resident #30 not receiving administration and oversight of a C-PAP (Continuous positive airway pressure ) device. Residents Affected - Few Findings included: 1. On 01/26/21 at 12:19 p.m., observation of Resident #62's room revealed a nebulizer facemask was located in the nightstand's first drawer. Resident #62 was interviewed about the placement of the equipment. Resident #62 indicated she placed the facemask in the top drawer and indicated that the staff don't have time to stay while the treatment is administered. She stated, They [referring to the nursing staff] have no time to do that, they are busy. Clinical record review of the active Physician Order dated 12/04/2020 for Resident #62 revealed she received Ipratropium Albuterol Solution 0.5-2.5 (3) MG/ML 3 ml inhale orally every 4 hours as needed for (Diagnosis) Acute Respiratory Distress Syndrome (ARDS). 2. On 01/26/21 at 10:10 a.m., an observation was conducted of Resident #66's respiratory equipment. The nebulizer facemask was not stored in an appropriate plastic storage bag, and oxygen tubing was hanging over the resident's bed with the nasal cannula portion resting on the floor. A subsequent observation of Resident #66's room was conducted on 01/27/21 at 08:45 a.m. The nebulizer facemask was observed to be wedged in between the nebulizer machine and a paper bag next to a Christmas tree on top of the resident's nightstand. Resident #66 was interviewed and asked about the storage of her respiratory equipment. Resident #66 stated, I just received a respiratory treatment; they were not in the room, and I could not reach the plastic storage bag to put it away in there. Clinical record review of the active Physician Order dated 10/28/2019 for Resident #66 revealed she received Albuterol Sulfate Nebulization Solution (2.5 MG/3ML 0.083% 3ml inhale orally via nebulizer every 6 hours related to Interstitial Pulmonary Disease. 3. On 01/27/21 at 11:02 a.m., Resident #51 was observed to be lying in bed with the nebulizer machine and facemask next to her in bed resting on the bed linens. The resident was interviewed at the time of the observation. She stated that she had just received a nebulizer treatment from the nurse. A repeat observation of Resident 51's room was conducted on 01/27/21 at 12:48 p.m., the facemask and nebulizer machine were in the same spot on the resident's bed with a cover over it. An additional observation was conducted on 1/28/21 at 10:58 a.m. of Resident #51's room. Resident 51's nebulizer facemask and nebulizer machine were in the resident's bed again. Clinical record review of the active Physician Order dated 09/10/2020 for Resident #51 revealed she received Ipratropium Albuterol Solution 0.5-2.5 (3) MG/ML 3 ml inhale orally every 4 hours as needed for (Diagnosis) Shortness of Breath (SOB related to Chronic Obstructive Pulmonary Disease, every 4 hours. On 1/28/21 at 09:20 a.m., an interview was conducted with Staff I, Unit Manager (UM) related to the storage of Resident #51, #62 and #66's respiratory equipment. She was asked about the facility policy and stated, I can't recall, I would have to go find out from my DON [Director of Nursing]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/29/21 at 10:38 a.m., an interview was conducted with the DON related to the observations of Resident #51, #62, and #66's respiratory equipment. The DON confirmed that her nursing staff should be staying in resident rooms until the respiratory treatment was completed, and respiratory nebulizer facemasks and oxygen tubing should be stored in a plastic storage bag, according to their facility policy. A review of facility policy titled Nebulizer (small volume nebulizer) with a revision date of 03/20/2018 revealed: .Disassemble device and rinse the mouthpiece and nebulizer cup with water and air dry. Place entire unit in a bag to be maintained in the resident's room . Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that one (#314) of 40 sampled residents had medically necessary appointments for the Cardiologist and the Ophthalmologist scheduled in a timely manner and followed through. Residents Affected - Few Findings included: An interview with Resident #314 on 1/27/2021 at 9:30 a.m. revealed that he has been requesting the facility Social Worker to set up an appointment for him to see a Cardiologist as recommended by the dentist to have two of his teeth removed. Resident #314 stated that the facility has not made the appointment for him to see a Cardiologist. The resident stated that his eyesight has been getting progressively worse to the point where he was now legally blind, and he had been requesting a follow up appointment to see the eye doctor for quite a while, but no one was assisting him with the appointment. Medical record review for Resident #314 revealed an original admission date in 2019 and a re-admission date in November of 2020 with multiple diagnosis including chronic obstructive pulmonary disease, heart failure, unspecified protein calorie malnutrition, Type 2 diabetes, major depressive disorder, anemia, and generalized anxiety. A review of Resident's Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating he was cognitively intact. A review of the Social Worker progress note dated 1/30/2020 revealed that an appointment was scheduled for the eye doctor for 2/10/2020, nearly one year ago. A review of the nurses notes dated 10/13/2020 revealed that, a call was received from the eye doctor's office regarding resident appointment for the a.m. The scheduler stated that they attempted to get in touch with resident, but the resident did not respond. A review of nurses notes dated 11/10/2020 revealed that the eye doctor's office called to confirm the resident's appointment, but because the resident was recently hospitalized , he would need a negative COVID-19 test to enter their facility for an appointment. A new appointment was then scheduled for 12/15/2020. During an interview on 1/27/2021 at 1:16 p.m. with the Social Service Director (SSD), she revealed that a dental consult was initiated for Resident #314, but she was not aware of any appointments to see the Cardiologist. She stated that she had made an appointment for him to see the ophthalmologist, but she can't remember why it was not followed up on. An interview with the Director of Nursing (DON) on 1/27/21 at 1:19 p.m., confirmed that appointments were set up for Resident #314 to see the eye doctor and a Cardiologist, but due to COVID-19, and Resident #314's frequent hospitalizations, the appointments were not kept. The DON revealed that if a resident was alert and oriented, the resident may be called by an institution to confirm or verify scheduled appointments. The DON stated that she expected that appointments should be scheduled and set up in a timely manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of an email dated 12/22/2020 at 10:07 a.m. from the dental services company to the Social Service Assistant (SSA) revealed that Resident #314 was scheduled to see the dentist on Tuesday, December 29th, 2020 and was in need of extractions. However, for the dentist to proceed with the extraction .the following information was needed: 1. Medical clearance and 2. Information regarding number of days patient needs to be taken off medication etc . The SSA responded on 12/22/220 at 5:10 p.m. stating that the physician refused to sign medical clearance pending a cardiologist appointment. The form stated that the facility was trying to schedule a cardiologist appointment and continues to try. An interview with the DON on 1/27/2021 at 1:20 p.m. revealed that she was unable to retrieve the resident's primary care physician notes with the recommendation for Resident #314 to see a Cardiologist. She confirmed that the physician refused to sign the consent for extraction of Resident's #314 teeth unless he sees a Cardiologist. On 1/29/2021 at 11:30 a.m., a follow-up interview with the DON related to Resident #314's appointment with the eye doctor scheduled for 12/15/2020 was never kept. Review of the SSD Job description indicated under the heading Purpose of Your Job states: To ensure that the medically related emotional and social needs of the residents are met/maintained on an individual basis. Under the heading Job Functions. It reads, Responsible for providing services to responds to the emotional needs of the residents and their families. Assist with resident admissions and referral process. Further, review under the heading Duties and Responsibilities, States: #5- conduct and document a social services evaluation, including identification of resident's problems/needs. #6-Provide/arrange for social work services as indicated by resident/family needs. #10 - Maintain a current list of community resources to facilitate referrals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews, and policy review, the facility did not appropriately secure medications in six (200 Low, 200 High,100 High, Cart #1, Cart #2, 100 Low) of seven medication carts and failed to ensure controlled substances were stored in a permanently attached container in one (300 hall medication storage room) of two refrigerators sampled. Findings included: Review of facility provided policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date of 07/23/19 revealed under General Storage: 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 01/29/21 at 10:21 a.m., an observation of the 200 Low Hall medication cart included a ½ and ¼ loose pieces of a tablet in second drawer from the top, and a white ¼ piece of white tablet in the drawer. Staff B Registered Nurse (RN), confirmed the presence of the unsecured tablets and pieces in both drawers. On 01/29/21 at 10:31 a.m., an observation of the 200 Hall High medication cart included in the second drawer ¼ pink pill, and in the fourth drawer 3 white ¼ pieces of loose medications. Staff C, (RN) confirmed the presence of the unsecured tablets. On 01/29/21 at 11:04 a.m., an observation was conducted of the medication on the 100 High Hall that included in the third drawer a ¼ piece of a white tablet, and located on the side third drawer from the top of the medication cart included one (1) white oval loose tablet. Staff D Licensed Practical Nurse (LP), confirmed the presence of the unsecured medications. On 01/29/21 at 11:36 a.m., an observation of medication cart #1 on the 300 Hall included a pink ½ tablet in the second drawer from the top of the medication cart. Staff E (LP) confirmed the presence of the unsecured tablet. On 01/29/21 at 11:45 a.m., an observation of medication cart #2 located on the 300 Hall, included in the front of the second drawer from the top of the medication cart one (1) white round tablet, and in the back of the drawer four (4) white, one (1) green round, one (1) round yellow, two (2) white oval, and two (2) green ½ pieces of loose tablets. Staff HO (LP), confirmed the presence of the 9 total unsecured tablets with two ½ pieces, in the drawer. On 01/29/21 at 11:58 a.m. an observation of the medication cart on 100 Low Hall included a loose white square tablet in the second drawer from the top. Staff F (LPN) confirmed the presence of the unsecured tablet. On 01/29/21 at 11:42 a.m., an observation of the 300 hall medication storage rooms revealed the refrigerator was locked. Staff E (LPN) unlocked the refrigerator to allow for inspection and observed on the second shelf was a brown plastic bag labeled with a resident's name on it. The bag contained Lorazepam (Ativan) 2MG/ML with two (2) unopened vials in it. The scheduled IV medication was not in a separately locked contained, attached to the refrigerator. Staff E, (LPN) confirmed the presence of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 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 0761 the medication not being in a separate locked box, and stated I know other units have a separate drawer. Level of Harm - Minimal harm or potential for actual harm According to The United States Drug Enforcement Administration (DEA) drug scheduling alphabetical listing, https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf, Page 11 of 17, Lorazepam (Ativan) DEA number 2885, is a Benzodiazepine, a Schedule IV medication and a considered a controlled substance. Residents Affected - Few A review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date of 10/28/19, revealed: 3. General Storage Procedures 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. On 01/29/21 at 12:11 p.m., the Director of Nursing (DON) stated, My nurses should be checking their medication carts routinely and destroying all medications that are loose. I did not know that there was not a double lock draw in that refrigerator, that was not affixed. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and policy review the facility failed to ensure that food items were labeled and dated in three (100, 200, and 300) of three nourishment refrigerators on the units. Findings included: On 1/26/21 at 10:08 a.m., a tour of the kitchen and nourishment areas was conducted with the Certified Dietary Manager (CDM). The nourishment refrigerator on the 200 unit was observed with a brown substance in the bottom of the refrigerator. There was a jar of open cheese that was not dated. There were also containers of unknown food in bags unlabeled and undated. The nourishment refrigerator on the 300 unit was observed with unknown food in bags unlabeled and undated. The nourishment refrigerator on the 100 unit was observed with one bag of food with room [ROOM NUMBER]B written on the bag with a black marker, but the food items were undated. The Certified Dietary Manager (CDM) reported that the unlabeled/undated food in bags probably belonged to staff and confirmed that the items were not labeled and/or dated as they should be. The policy Food Storage: Cold Foods revised on 04/2018 revealed the following: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 9 of 9