Inspection·April 1, 2022

F 0550 The procedure indicated that Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations. 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: 106116 If continuation sheet Page 2 of 24 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 04/01/2022 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure two (Residents #73 and #97) of forty-three sampled residents were assessed for self-administration of medications. Residents Affected - Few Findings included: 1. During an observation and interview, on 3/29/22 at 12:33 p.m., with Resident #73, Staff A, agency Licensed Practical Nurse (LPN) sat a medication cup which contained a tablet of medication down on the over-bed table in reach of the resident then left the room. On 3/29/22 at 12:36 p.m., Resident #73 ingested the tablet identifying it as Lisinopril. On 3/29/22 at 12:46 p.m., Staff A reported that he had left Lisinopril with Resident #73. He said the resident was getting it after other hypertensive's due to the resident having low kidney function. A review was conducted on 3/29/22 at 12:55 p.m., of Resident #73's assessments. The review indicated that an assessment to evaluate the resident's ability to self administer medications was not completed. The review of Resident #73's Order Summary Report, active as of 3/30/22, revealed the resident did not have a physician order for the self-administration of medications. Resident #73's care plan did not include a focus area that identified the resident had been assessed for self-administration of medications. The resident's care plan identified, The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to (r/t) Cognitive deficits, Immobility, (and) Physical Limitations. The quarterly Minimum Data Set (MDS) dated [DATE], identified Resident #73's Brief Interview of Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. 2. An observation was made on 3/30/22 at 10:35 a.m., of a medication cup with orange liquid, one medication cup with dark green liquid, and a medication cup with at least six medication tablets/capsules sitting on the over-bed table of Resident #97. The observation also identified a medication cup containing one tan-colored capsule and a bottle of Calcium Carbonate Antacid tablets. The resident stated he was legally blind and did not know the tan-colored pill was there. The resident stated the nurse had dropped off the liquids and the cup with multiple pills, as the resident had bad reflux and wanted to eat first. During the interview, on 3/30/22 at 10:58 a.m., with Resident #97, Staff BB, agency Licensed Practical Nurse (LPN) arrived to the resident room and stated she would stay with the resident while he took the medications. She identified the tan-colored capsule as Gabapentin and she had not given it to the resident. A review of the assessments completed for Resident #97 indicated the resident had not been evaluated for the self-administration of medications and a review of the residents' Order Summary Report, active as of 3/30/22 at 3:59 p.m., did not include a physician order for the self-administration of medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 3 of 24 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 04/01/2022 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 0554 Level of Harm - Minimal harm or potential for actual harm The care plan for Resident #97 identified that the resident had behaviors such as refusing treatment of paracentesis, refusing dialysis, non-compliant with prescribed diets, and refused medications. The interventions regarding the resident's behaviors indicated the staff should Administer medications as ordered and monitor/document for side effects and effectiveness. The 5-day Minimum Data Set (MDS), dated [DATE], identified the resident was cognitively intact and vision was highly impaired. Residents Affected - Few The Regional Clinical Leader (RCL) stated, on 3/30/22 at 3:41 p.m., every resident was assessed at admission for appropriateness of self-administration of medication, a physician order would be obtained, and the resident would be asked what they wanted to do with the medications, if kept at bedside, the facility would provide a locked container. The RCL stated she did not think any resident was able to self-administer but would have to check. The RCL reviewed both Resident #73 and #97's assessments and physician orders and stated neither residents had an assessment completed or a physician order for the self-administration of medication. She reviewed the care plan for Resident #97 and stated there was no focus area related to the resident's ability to self-administer medications. The Policies and Procedures - Self-Administration of Medication at Bedside, effective 11/30/14 and revised 8/22/17, indicated The resident may request to keep medications at bedside for self-administration accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. The procedure identified that staff were to: - Verify physician's order in the resident's chart for self-administration of specific medications under consideration. - Complete Self-administration of Medications Evaluation. - The Interdisciplinary Team will review the evaluation an d will document Section III. Approval granted must be checked yes or no. Interdisciplinary team member sign the evaluation section. If approval is not granted, a statement must be written as to reason for denial. - Self-administration of meds is reviewed by the Care Plan Team with each quarterly review, and when any change in status is noted. - The MAR must identify meds that are self-administered and the medication will need to follow-up with resident as to documentation and storage of medication during each med pass. If kept at bedside, the medication must be kept in a locked drawer. - When a resident is unable to self- administer medication, they will be given by nursing staff until the resident can be reevaluated by the Interdisciplinary Team. The Facility's Pharmacy Services policy - General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10, 1/1/13, and 1/1/22, indicated in section 5, subsection 5.10 instructed staff Observe the resident's consumption of the medication(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 4 of 24 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 04/01/2022 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure physician orders were in place for one (Resident #90) of one sampled resident with an orthopedic device. Residents Affected - Few Findings included: During a facility tour on 03/29/22 at 10:00 a.m., Resident #90 was observed lying on her bed with an abductor pillow in place. Both legs were noted secured with the pillow. Resident #90 stated she wore the pillow all day. Resident #90 stated she was wearing it because she fell and broke her left hip. Resident #90 stated she would like to walk again. Resident #90 stated she did not like wearing the device but was looking forward to her ortho (orthopedic) appointment to evaluate the healing process. Review of an admission record for Resident #90 showed Resident #90 was re-admitted to the facility on [DATE] with a diagnosis of an encounter for orthopedic aftercare, displaced intertrochanteric fracture of unspecified femur and subsequent encounter for closed fracture with routine healing. Review of Resident #90's minimum data set (MDS) dated [DATE] showed a brief interview for mental status (BIMS) of 15, which indicated intact cognition. Section G, functional status showed Resident #90 required extensive assistance for transfers, bed mobility, locomotion on and off unit. Review of electronic medical record (EMR) physician orders for Resident #90 showed there were no orders for the abductor pillow. Review of a care plan for Resident #90 dated 02/14/22 showed a focus area for a pathological bone fracture right femur. The interventions to include: If orthopedic fixation device or traction is present, follow MD (medical doctor) orders for monitoring, maintaining device and providing skin care. The care plan did not show a focus or interventions related to the left hip fracture. On 04/01/22 at 9:55 a.m., an interview was conducted with Staff M, Licensed Practical Nurse (LPN). Staff M stated the therapy department put on the pillow and took it off the resident. Staff M did not know if there was an order or not. Staff M said, therapy should have it. Staff M stated the order should also be in the EMR. An interview was conducted with the Unit Manager on 04/01/22 at 10:00 a.m. The Unit Manager stated if the resident was wearing a device that restricts movement, there should be a physician order. The Unit Manager stated since this was a therapy related device, they [therapy department] should have put in the order. On 04/01/22 at 10:18 a.m., an interview was conducted with Staff N, Physical Therapist (PT). Staff N stated the resident was on case load for therapy post fall. Staff N stated Resident #90 broke her left hip. Staff N stated Resident #90 was discharged from the hospital with the abductor pillow to limit hip movement during healing. Staff N stated the abductor pillow was listed under therapy precautions. Staff N said, Since she came from the hospital, Nursing should have entered the order. On 04/01/22 11:49 a.m., Staff N stated he had called the doctor. Staff N stated the plan was to put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 5 of 24 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 04/01/2022 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 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an order to use abductor cushion as tolerated, pending clarification from the Orthopedic doctor. Staff N said, The order should have been in the chart. Staff N stated if a resident could not take off a device, it's a restraint. Staff N said, Yes, she should have an order. That's the standard of practice. An interview was conducted on 04/01/22 at 12:06 p.m. with the Regional Clinical Nurse. She stated Resident #90 was not able to independently move with or without the cushion. She said, That does not negate the fact that we should have an order in place. We have put it in now. Review of physician orders for Resident #90 dated 04/01/22 showed new orders for Abductor pillow as tolerated - perform skin integrity every shift. May remove for ADL care as required. (Every shift related to encounter for other orthopedic aftercare) Review of a facility policy titled, physician orders, with a revision date 03/03/21, showed the center will ensure that physician orders are appropriately and timely documented in the medical record. Under procedure for admission orders, the policy showed information received from the referring facility or agency is to be reviewed, verified with the physician, and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the orders during, or as soon as practicable after it is provided, to maintain an accurate medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 6 of 24 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 04/01/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one (Resident #97) out 43 sampled residents received care in accordance with professional standards of practices related to the staff not initiating written physician orders. Residents Affected - Few Findings included: Resident #97 was admitted on [DATE] and readmitted on [DATE]. The admission Record included diagnoses not limited to Type 2 Diabetes Mellitus, Acquired absence of left leg below knee, and End Stage Renal Disease (ESRD). An observation was made of a telephone order flagged in the hard copy of Resident #97's clinical record. The telephone order included the following: - Start patient (pt) on a Vitamin A containing Multivitamin. - Restart Tramadol 50 milligram (mg) by mouth (po) every 6 hours as needed (q6 prn), mod-severe pain. - Wound care consult - Left (L) knee, - Start a triple antibiotic three times a day (TID) to pustular skin lesions x 4 weeks. The telephone order was written and signed by the physician on 3/25/22. The order did not indicate the name of the nurse who had received the order or if the pharmacy was notified. A review of Resident #97's March Medication Administration Record (MAR), printed on 3/31/22 at 5:13 p.m. identified the order for Tramadol 50 mg q6 hours prn was included on the MAR and started at 7:45 a.m. on 3/25/22. The MAR did not include an order for a Multivitamin containing Vitamin A. The March Treatment Administration Record (TAR), printed on 3/31/22 at 5:13 p.m., did not include any treatment for the residents' left knee. On 3/31/22 at 12:27 p.m., Staff F, Licensed Practical Nurse (LPN), stated he had entered the order into the electronic medical record (EMR) for Resident #97's Tramadol then passed the other orders to the nurse who was assigned to the resident. On 3/31/22 at 12:29 p.m., Staff DD, Registered Nurse (RN), stated the process for taking off an order was to make sure the telephone order was legible and if legible, enter the order. The review of the Wound Care Advanced Practitioner Registered Nurse (APRN) progress notes from 3/30/22 identified the following wounds for Resident #97: - Wound #3: Right Heel, Diabetic Ulcer, - Wound #4: Right third toe, Arterial Ulcer, - Wound #5: Right plantar toe, Diabetic Ulcer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 7 of 24 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 04/01/2022 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 0684 The note did not include any information regarding a wound to the resident's left knee. Level of Harm - Minimal harm or potential for actual harm A progress note, dated 3/30/22 at 4:17 p.m., reported wound care rounds were done with the APRN and treatment was performed to Resident #97's right heel, right third toe, and right plantar foot. Will continue to follow current plan of care. The note did not indicate the area to the resident's left knee was observed or that a treatment was implemented. Residents Affected - Few A skin/wound note, dated 3/31/22 at 11:18 a.m., identified, Dressing to right heel clean dry and intact. Skin prep applied to right third toe. No complaint of (c/o) pain or discomfort noted during treatment. No signs/symptoms (s/s) of infection noted. Will continue to follow current plan of care. Call light in reach. The note did not indicate staff had identified the area to the residents' left knee. An interview was conducted, on 3/31/22 at 12:57 p.m., with the Regional Clinical Leader (RCL). The RCL reviewed the telephone order written on 3/25/22, and confirmed the orders for triple antibiotic ointment to pustular areas and the Multivitamin were not entered into the electronic record. She stated she had to check with the wound care nurse to see if the wound care provider had seen Resident #97 yesterday when they were in the building. A Non-Pressure Skin Condition, dated 3/31/22 at 1:18 p.m., identified an area on Resident #97's left knee (front) caused by a Trauma wound measuring 4.5 centimeter (cm) in length and 1.7 cm in width with no measurable depth. The evaluation identified there was no drainage, wound edges were Within Normal Limits (WNL), and the peri-wound was red. A progress note, dated 3/31/22 at 1:22 p.m., indicated, This nurse noted an area to the patient's left knee measuring 4.5 cm in length and 1.7 cm in width with no measurable depth. No drainage noted. Wound bed was dark brown in appearance. Received new order to apply oil emulsion and dry dressing every 3 days. No c/o pain or discomfort noted. Patient stated it happened during transfer from dialysis. The following orders were entered into the electronic record: - Order date, 3/31/22 at 1:33 p.m., LEFT KNEE: Cleanse area with Normal Saline (NS). Pat dry. Apply oil emulsion and dry dressing (DD) every (q) 3 days. - Order date, 3/31/22 at 2:30 p.m., Multivitamin-Minerals tablet - Give 1 tablet by mouth one time a day related to End Stage Renal Disease. Use house stock. A Nursing Progress Note, dated 3/31/22 at 2:28 p.m., indicated, Orders dated 3/25/22 were not transcribed. MD and resident are notified, orders are clarified and (&) entered in PointClickCare (PCC). The Facility Assessment 2021, identified that the facility provided the resident support/care needs which included Skin integrity: Pressure injury prevention and care, skin care, (and) wound care (surgical, other skin wounds). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 8 of 24 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 04/01/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one (Resident #51) of three residents sampled for positioning received services and equipment to prevent further decrease in range of motion. Findings included: On 03/29/2022 at 12:05 p.m., Resident #51 was observed in his room lying in bed. He was interviewable and his left hand appeared contracted. He was not wearing a splint/brace on his left hand. However, a blue and gray [hook and loop] splint/brace was observed placed on the left side of the bed, on the dresser, and out of his reach. He stated he did not receive therapy services. Photographic evidence obtained. On 03/30/2022 at 12:05 p.m., Resident #51 was observed sitting in his wheelchair. He was noted not wearing his left-hand brace and it was again observed positioned on the left side of the bed on the dresser. It was observed in the same exact position as from the observations the day before (03/29/2022). Photographic evidence obtained. On 03/31/2022 at 10:02 a.m., Resident #51 was observed sitting in the dining/tv room. He was not wearing his left- hand brace. An observation was made on 03/31/22 at 2:34 p.m., Resident # 51's left- hand brace was observed on the left side of the bed on the dresser. Photographic evidence obtained. On 03/31/2022 at 10:35 a.m., an interview was conducted with Staff T, Certified Nursing Assistant (CNA). She stated Resident #51 was able to tell staff if he wanted to wear the left- hand splint. She confirmed she had never seen him wearing the splint and had not observed it on his nightstand. 04/01/22 at 12:27 p.m., Resident #51 was observed sitting in his room, in his wheelchair. He was observed not wearing a splint/brace on his left hand. Review of Resident #51's medical record revealed he was admitted to the facility for long term care on 09/26/18. Review of the admission diagnosis sheet revealed Resident #51 was admitted with contractures of the left hand and wrist. Review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns revealed a Brief Interview for Mental Status score of 12, which indicated Resident #51 had moderately impaired cognition. Section G: Functional Status revealed Resident #51 required extensive assistance of one person for activities of daily living (ADL's) and was impaired on both sides of his upper and lower extremities. Review of the care plans with a last reviewed date of 03/04/22, revealed a focus area for ADL self-care performance deficit related to fatigue, hemiplegia, impaired balance, and limited mobility. Goals were to improve current level of function through the next review date. Interventions included but not limited to, left resting hand/wrist splint to be worn daily as tolerated. A focus area for a contracture of the left hand required him to wear a resting hand splint. Goals were to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 9 of 24 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 04/01/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few further contracture. Interventions included but not limited to monitor for skin redness or breakdown and passive range of motion to the left hand after cleansing with warm water and soap. On 04/01/2022 at 12:15 p.m., an interview was conducted with Staff U, Physical Therapist (PT). She confirmed Resident #51 was not on her caseload and his last day on her case load was 02/14/22. She confirmed she had previously worked with him on splint application. She stated he tolerated wearing the splint some days and not as well on others. On 04/01/22 at 12:17 p.m., an interview was conducted with Staff N, PT. He stated when Resident #51 was removed from their caseload, he was put on Restorative Therapy. The facility did not have a restorative aide. He stated the facility was supposed to hire a restorative aide, but it did not happen. When Resident #51 was on case load he was able to remove the splint independently. Staff N confirmed the last active order for splint application was dated 10/05/21 and that was the last time Resident #51 received services from the restorative program. Staff N confirmed the residents at the facility would benefit from having a restorative aide to assist with preventing further decline in functioning. A review of the facility policy titled Contractures and Prevention, revised on 08/22/17 revealed that each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Procedure: Residents with inactive extremities should have range of motion exercises done to those extremities as part of their daily care. Hand rolls may be placed in any hand that a resident cannot move. Some residents may have braces or splints to prevent or help release contractures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 10 of 24 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 04/01/2022 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 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** Based on observations, record reviews, and interviews, the facility 1. failed to ensure oxygen therapy equipment was stored in a sanitary manner for two (Residents #97 and #106) of three sampled residents and 2. failed to ensure physician orders were in place for the administration of oxygen therapy one (Resident #97) of three sampled residents Residents Affected - Few Findings included: On 3/30/22 at 10:38 a.m., an observation was conducted of Resident #97's room, between Resident #97's bed and the privacy curtain was an oxygen concentrator with tubing and nasal cannula attached. The nasal cannula was observed lying on floor in front of the concentrator. The resident stated the cannula had probably been there for 2 weeks. The observation identified a Continuous positive airway pressure (CPAP) machine with mask was sitting on top of the bedside dresser beside the resident's bed. The CPAP mask was lying on top of machine, uncovered and undated. On 3/31/22 at 12:51 p.m., an observation was conducted of Resident #97's room with the resident and family members in attendance. The CPAP mask was observed lying on top of the machine and the nasal cannula was observed lying across the oxygen concentrator uncovered and undated. On 4/1/22 at 10:46 a.m., Resident #97 admitted to using the CPAP every night and the oxygen concentrator was running at 3 liters per minute (lpm) while the nasal cannula laid next to the resident in bed. The CPAP mask was lying on top of the machine that was sitting on the bedside dresser. The resident reported using oxygen at times when lying down. A review of Resident #97's Order Summary Report, active as of 3/30/22 at 3:59 p.m., identified the resident did not have a physician orders for oxygen therapy including the use of the CPAP. The 5-day Minimum Data Set (MDS), dated [DATE] did not identify that the resident received oxygen therapy while being a resident. The care plan for the resident did not identify the resident's use of oxygen or CPAP. Resident #97 was admitted on [DATE] and recently readmitted on [DATE]. The admission Record for the resident included diagnoses not limited to End Stage Renal Disease, unspecified heart failure, and unspecified sleep apnea. The clinical record included a progress note, dated 12/23/21, that indicated the Director of Nursing (DON) requested the resident's CPAP to be checked due to not working and the machine was not to be touched by Respiratory Therapist (RT) at (@) the facility. The DON had visualized damage to the CPAP's power cord and included the recommendation for MD write order for CPAP to be set up (s/u) with (c) an appropriate pressure. On 4/1/22 at 10:50 a.m., Staff FF, Licensed Practical Nurse (LPN), reviewed the resident's electronic Medication Administration Record (MAR) and reported that there were no orders to do anything with the CPAP and said, it pains me to say this but I don't see an order for oxygen. The staff member further reviewed the residents' physician orders and stated there was not an order for the CPAP either and both should have an order. The Regional Clinical Leader (RCL) stated, on 4/1/22 at 11:00 a.m., that there should be an order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 11 of 24 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 04/01/2022 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 for Resident #97's CPAP and oxygen use. Level of Harm - Minimal harm or potential for actual harm The website medlineplus. gov (https://medlineplus.gov/oxygentherapy.html) identified that oxygen therapy It is only available through a prescription from your health care provider. The website cpaprx.com, located at https://cpaprx.com/cpap-prescriptions-everything-you-need-to-know, indicated that The law regulates the purchase of CPAP machines. The U.S. Food and Drug Administration classifies the machine along with the mask and humidifier as Class II Medical Device. The website identified that CPAP prescriptions also come with pressure settings based on the results of the sleep study. Residents Affected - Few During facility tours on 03/29/22 at 10:25 a.m., 03/30/22 at 11:43 a.m., 03/31/22 at 9:10 a.m., and 04/01/22 at 9:54 a.m., an observation was made of Resident #106's nebulizer stored on top of his nightstand. The nebulizer mask was positioned on top of the machine, exposed to the elements. The nebulizer tubing was hanging on the side of the nightstand, noted partly on the floor. Photographic evidence was obtained. Review of Resident #106 admission record revealed Resident #106 was admitted to the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease (COPD.) An MDS (minimum data set) dated 03/01/22 showed Resident #106 had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. An interview was conducted on 03/30/22 at 11:43 a.m., with Resident #106. He stated he used the nebulizer every day. He said, I use it to take my medicine. I have COPD. The resident stated he did not know who cleaned his nebulizer or when the mask and tubing were changed. Physician orders for Resident #106 dated 04/01/22, showed an active order dated 12/17/21, to change tubing, mask and / or nasal cannula weekly. May change sooner as needed. Check filter in back of concentrator for cleanliness as needed for hygiene, every night shift, every Friday. A review of the care plan dated 10/23/19, showed a focus area which indicated Resident #106 had COPD. The goal showed Resident #106 would display optimal breathing patterns daily through the review the next review date. Interventions included nebulizer treatments as ordered; Resident may self-administer nebulizer after nurse set up. On 04/01/22 at 09:54 a.m., an interview was conducted with Staff M, Licensed Practical Nurse (LPN.) Staff M observed the nebulizer in Resident #106's room on the nightstand. The mask was exposed to the element and tubing on the floor. Staff M said, The 11pm-7am nurse is supposed to change the cannula weekly. Staff M stated she would change it right away. Staff M said, It should be stored inside a bag, labeled and dated. An interview was conducted on 04/01/22 at 11:16 a.m. with the Regional Clinical. She stated the expectation was for the mask and tubing to be changed weekly and stored in a bag. She said the bag should be dated the day it was changed. The Policies and Procedures - Equipment Change Schedule, effective 11/30/14 and revised 8/28/17, indicated An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. Under procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 12 of 24 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 04/01/2022 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 Aerosol tubing and aerosol nebulizer to be changed once every seven days. Level of Harm - Minimal harm or potential for actual harm Nebulizer set up, once every seven days along with equipment bag, labeled with name, date and room number. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 13 of 24 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 04/01/2022 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #97 was admitted on [DATE]. The admission Record included diagnoses not limited to End Stage Renal Disease and Type 2 Diabetes Mellitus without complications. The 5-day Minimum Data Set (MDS), dated [DATE], indicated the resident had a Brief Interview of Mental Status (BIMS) score of 15, indicative of intact cognition. The MDS identified the resident received Dialysis treatments prior to being and while a resident of the facility. Residents Affected - Few On Wednesday 3/30/22 at 10:45 a.m., Resident #97 reported leaving for Dialysis on Tuesday, Thursday, and Saturdays at 10:00 a.m. and returned between 4:30 or 5 p.m. The resident stated the facility did not send a lunch or snack to Dialysis and there were times the lunch tray would still be sitting on the over-bed table when he returned from Dialysis. On 3/31/22 at 11:59 a.m., Resident #97 stated after Dialysis he removed the fistula dressing as leaving it on would compromise the site. A physician order indicated Resident #97 was scheduled for Hemodialysis on Tuesday, Thursday, and Saturday and was to be ready for pick up at 10:30 a.m. for a chair time of 11:45 a.m. The care plan for the resident identified the resident exhibited behaviors which included refusing paracentesis, refused Dialysis, did not follow prescribed/recommended diet and refused medications. The Policies and Procedures - Coordination of Hemodialysis Services, effective 11/30/2014 and revised 7/2/2019, indicated Residents requiring an outside End Stage Renal Disease (ESRD) facility will have services coordinated by the facility. There will be communication between the faciltiy and the ESRD facility regarding the resident. The procedure identified: - 1. The Dialysis Communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. - 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. - 3. The ESRD facility is to review the Dialysis Communication form and either: -- a. Complete the communication form and return with the resident OR -- b. Provide treatment information to the facility. - 4. Upon the resident's return to the facilty, nursing will review the Dialysis Communication form and information completed by the dialysis center OR the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. - 5. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's Clinical record. The review of Resident#97's Order Summary Report, active as 3/30/22 at 3:59 p.m., did not include a physician order to assess the resident's Dialysis access site or to remove any dressing from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 14 of 24 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 04/01/2022 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 0698 fistula. Level of Harm - Minimal harm or potential for actual harm A review of Resident #97's Dialysis binder included two recent Dialysis Communication forms: Residents Affected - Few - 3/8/22: the section that was to be completed by the facility prior to Dialysis did not indicate any vital signs, information regarding shunt site, or changes in resident condition since the last visit had been communicated to the center. The section completed upon the residents return from Dialysis which would have included vital signs, access site condition, and if the resident exhibited pain was not completed. The Dialysis Center had documented in the section of the Communication form reserved for them. - 3/12/22: The facility did not document vital signs, shunt condition, or any changes in condition prior to Dialysis or vital signs , pain, and access site condition upon the residents return from Dialysis. The Dialysis Center did complete the section reserved for their evaluation. The census for Resident #97 identified the resident was out of the facility from 3/3 to 3/4/22 and from 3/19 to 3/25/22. According to the census the resident was scheduled for Dialysis and in the facility on Tuesday 3/1, 3/8, 3/15, and 3/29/22, Thursday 3/3, 3/10, 3/17, and 3/31/22, and Saturday 3/5, 3/12, and 3/26/22. A review of the March 2022 Medication Administration Record (MAR) identified that on 3/3 and 3/5/22, the resident refused Dialysis and from 3/19 - 3/25/22 the resident was hospitalized . The MAR indicated that on 3/1, 3/8, 3/10, 3/12, 3/15, 3/17, 3/26, and 3/29/22, the resident received Dialysis, resulting in eight opportunities to complete Dialysis Communication forms. A review of progress notes identified that on 3/8/22 at 6:05 a.m., staff had completed a skilled note for Resident #97 which did not include an assessment of the residents' Dialysis access site. Further progress notes, dated 3/8/22, did not include a post Dialysis assessment of the resident. The progress notes on 3/12/22 did not include assessments for pre- or post- Dialysis condition. A review of progress notes indicated the following notations regarding Resident #97's Dialysis condition: - 3/1/22 at 2:17 p.m., the resident refused Dialysis (not identified on MAR). - 3/2/22 at 5:21 a.m., vascular access was present and Dialysis status was hemodialysis with Left upper extremity shunt and present bruit/thrill. - 3/2/22 at 12:52 p.m., educated on need for Dialysis treatments. The note did not include an assessment of the residents' Dialysis site. - 3/2/22 at 9:21 p.m., Vascular access is not present and Dialysis status is not applicable. - 3/8/22 at 6:05 a.m., Vascular access is not present and Dialysis status is not applicable. - 3/8/22 Dietary notes regarding significant weight loss. - 3/13/22 at 7:02 p.m., Vascular access is not present and Dialysis status is hemodialysis bruit present thrill present. - 3/16/22 at 2:59 a.m., Vascular access is not present and Dialysis status is hemodialysis bruit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 15 of 24 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 04/01/2022 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 0698 present thrill present. Level of Harm - Minimal harm or potential for actual harm - 3/17/22 at 4:11 a.m., Vascular access is not present and Dialysis status is not applicable. Residents Affected - Few - 3/25/22 at 2:22 p.m., Vascular access is not present and Dialysis status is hemodialysis bruit present thrill present. - 3/29/22 at 7:11 p.m., Vascular access is not present and Dialysis status is not applicable. - 3/30/22 at 6:50 a.m., Vascular access is not present and Dialysis status is not applicable. - 3/31/22 at 1:58 p.m., identified vascular access was present and Dialysis status is not applicable. - 3/31/22 at 3:49 p.m., Fistula in his leg arm intact Felling(sic) bruit. (writer: Staff DD) On 3/31/22 at 2:42 p.m., Staff Member DD, Registered Nurse (RN), stated he had not documented on Resident #97's access site as he did not have time, you know with all the interruptions. The electronic and paper chart on the unit did not include any other Dialysis Communication forms or any other communication that was received from the Dialysis Center. On 3/31/22 at 10:58 a.m., an interview was conducted with the Registered Dietician (RD) and Certified Dietary Manager (CDM). The RD stated Dialysis Centers were not allowing residents to bring food in from the facilities. She said she had personally called all the centers to confirm food was not to be brought in. On 3/31/22 at 1:54 p.m., an interview was conducted with the Administrator of the Dialysis center where Resident #97 received Dialysis. She stated the resident was allowed to bring a snack due to the diagnosis of diabetes. The Administrator reported the center's policy was for everyone to wear a (face) mask while in the center but due to the diagnoses of diabetes they did allow snacks. She stated the facility usually did send the communication binder if they did not forget it. The Regional Clinical Leader (RCL) stated, on 3/31/22 at 2:26 p.m., the Dialysis center was not real good about filling out the Communication forms and thought the facility had stopped sending the forms. The RCL reported the expectation was if the Dialysis center did not send a printout of what happened during Dialysis the facility should call them and ask for it. On 3/31/22 at 4:30 p.m., the RCL provided Resident #97's Dialysis binder and confirmed the clinical record on the unit did not contain any information received from the Dialysis center. Based on observation, interviews, and record review, the facility, 1. failed to ensure two (Residents #64 and #97) of six residents on dialysis, received a meal and/or snack during Dialysis and 2. failed to ensure one (Resident #97) received pre-dialysis, and post dialysis assessments, which is a standard of care consistent with professional practices. The findings included: 1. On 03/29/22 at 10:30 a.m., an observation and interview were conducted with Resident #64, who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 16 of 24 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 04/01/2022 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the facility did not prepare snacks and/or meals to take to the dialysis center, and said, he was diabetic. Resident #64 revealed he would prefer the facility pack a snack and/or meal to keep his blood sugar stabilized during Hemodialysis. A record review for Resident #64 indicated he was initially admitted on [DATE] with multiple diagnoses that included End Stage Renal Disease and Type 1 Diabetes Mellitus. A review of the Order Summary Report for Resident #64 revealed an active order dated 12/28/2021 for Dialysis every Monday, Wednesday, and Friday, resident to be up and dressed by 09:00 a.m. for chair time at 10:00 a.m. An interview was conducted on 3/31/2022 at 11:00 a.m. with Registered Dietician (RD), and Certified Dietary Manager (CDM). During the interview, the RD revealed she called all the dialysis centers and due to COVID-19, they currently do not want any residents to bring snacks or food to the dialysis centers. On 03/31/2022 at 2:07 p.m., a telephone interview was conducted with the Dialysis Registered Nurse (RN). During the interview she revealed that if it was medically necessary and a resident was diabetic, the center would allow the resident to bring a snack and/or meal and eat it during Hemodialysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 17 of 24 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 04/01/2022 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure medications were stored appropriately in four of seven medication carts and in one of three medication rooms. 2. On [DATE] at 10:18 a.m., the 100-low medication cart was observed unlocked and unattended while Staff BB, Licensed Practical Nurse (LPN) was in a resident room. The staff member returned to the medication cart and confirmed the cart was unlocked and unattended. A review of the medication cart located on the 300-hall was conducted with Staff AA, Registered Nurse (RN). An unopened and undated bottle of Latanoprost 0.005% eye drops were observed in the cart. One of the labels on the bottle instructed that the medication Refrigerate Until Opened. The other label instructed staff to discard 42 days after opening. On [DATE] at 12:55 p.m., an observation was conducted with Staff M, LPN, of the 200-high medication cart. The bottom drawer was disorganized and cluttered, the drawer contained an aerosol can of Sanitizing Spray stored in same compartment with tubing, boxes of Albuterol Sulfate Inhalation solutions, box of Triamcinolone Acetonide 0.025% cream, and box of Diclofenac Sodium 1% topical gel. Another drawer of the cart had layers of substances on the bottom of it. The drawer contained over-the-counter medications, an envelope of a medication underneath bottles of liquid medication, and the bottle of Iron Supplement liquid had residual substances on the outside of the bottle. The same compartment contained a box of Pain Relief Lidocaine 4% patches and a box of 1% Hydrocortisone Anti-Itch cream stored with liquid medications. Staff M would leave the medication cart at times and enter the resident room across from the cart. The cart contained an almost empty, undated bottle of Cherry-flavored Sugar Free Pro-Stat. The label of the Pro-Stat indicated that it should be discarded 3 months after opening. Staff M confirmed one Kwikpen of Basaglar insulin was opened and it did not have an opened date, and the label instructed users to Discard 28 days after opening. A bottle of Ofloxacin 0.3% Ophthalmic Solution eye drops was opened, undated, and confirmed by Staff M, The label for Ofloxacin had an area to note the date opened and the date expired. On [DATE] at 1:13 p.m., an observation was conducted with Staff FF, agency LPN, of the Rehab-low medication cart. A review of the cart revealed a container of [brand name]sanitizing wipes stored amongst oral medications, an Insulin Aspart FlexPen was observed in a clear plastic bag without a pharmacy label and the pen was not labeled with an open date, an opened Insulin Aspart FlexPen was undated and the label indicated that the pen was to Discard 28 days after opening. An opened Tresiba Flextouch insulin pen did not have an open date or expiration date and the label instructed users to Discard 56 days after opening. Staff FF confirmed the findings. On [DATE] at 1:18 p.m., an observation of the Rehab unit Medication Preparation Room was conducted with Staff F, LPN. In a top cabinet that had an attached locking mechanism, which was not locked, was a sealed Narcotic Emergency Kit (E-kit) received from the pharmacy on [DATE]. Staff F confirmed that the E-kit had been stored in an unlocked cabinet. On [DATE] at 4:37 p.m., during a telephone interview, the Pharmacist said, Eye drops should be dated, Latanoprost has a shortened life, good practice is to date all eye drops, especially Latanoprost. Medication carts should be organized, clean, and should be locked when unattended . Sanitizing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 18 of 24 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 04/01/2022 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 should not be stored in the same compartment with medications. Level of Harm - Minimal harm or potential for actual harm The Pharmacy Services and Procedures - Storage and Expiration Dating Medications, Biologicals, effective [DATE], revised [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], indicated the following: Residents Affected - Few - 2: Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. - 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. - 3.2: Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals. - 3.3: Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart of locked medication room that is inaccessible by residents and visitors. - 3.5: Topical (external) use medications or other medications should be stored separately from oral medications when infection control issues may be a consideration. - 5: Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication ha a shortened expiration date once opened or opened. -9: Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items. - 13.2: After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 19 of 24 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 04/01/2022 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review, the facility did not ensure the kitchen was maintained in a clean and sanitary manner, related to sanitation, food storage, and equipment cleaning and maintenance. Findings included: An initial kitchen tour was conducted on 03/29/22 from 9:30 a.m. to 9:57 a.m. with the Certified Dietary Manager (CDM). The CDM stated there were two staff working today, The Dietary Manager in Training (MIT) and Staff R, Dietary Aide. During the tour observations were made of: Ceiling vents noted with dirt, debris in the cooking areas and the dish room. Walls were observed with dust, dirt, and stains. The kitchen floors were observed with food residue, dirt, dust, and debris. Tiles were noted missing by the dish machine with water collected in the hole. The kitchen equipment (stove) was noted with food spills and oil splatters. A vent was noted on the floor with caked-in food remains, dust, dirt, and debris. Kitchen equipment - dish machine, microwave, blender, and dough mixer were noted with brown matter on the surfaces. The CDM stated the kitchen equipment should be cleaned and covered when not in use The ice machine was noted with dust and the vent and filter with debris. Refrigerator surfaces were noted with food marks and food debris. The clean dishes rack was observed with debris and dust. The clean cooking pans were noted resting on the dirty surfaces. The CDM said, That is not sanitary. Cooking spices were observed on a shelf next to the stove, some undated, opened, and exposed to the elements. The CDM stated they should be wiped off after each use, caps should be closed to keep dust off. The CDM stated their policy was to date spices once opened. Three plastic bins were observed stored next to the stove. One of the bins was noted labeled flour the date was illegible. The CDM stated the date on the bin looked like July 2020. The CDM said, It should be changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 20 of 24 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 04/01/2022 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 - Some The bin in the middle was labeled thickener with a date, 9/22/20. The CDM stated they use up the thickener often. The CDM stated they just keep refilling the bin. The CDM said, The bin should be cleaned out before refilling, new date, and label applied. A third bin did not have any date or label. CDM stated the product was sugar. The CDM stated it should be dated and labeled. An observation was made of the deep fryer with dark brown liquid. The MIT stated he was not sure how often the cooking oil should be changed. The MIT said, No, that does not look good. The MIT stated he did not know how old the oil was. The MIT said, We do not keep track of that. The CDM stated their expectation was to change the oil after each use because they fry different types of food. During a tour of the walk- in cooler, bio growth was observed on the door frame. The surfaces were observed with dirt and dust. The floor surface was observed with food remains, dirt, and debris. The CDM said, It [walk-in cooler] should be maintained in a clean manner. A tour of the freezer was conducted. The freezer was observed with excessive condensation, surfaces covered with ice and icicles. The floor had dirt and ice on it. The CDM stated they were aware there was a problem with condensation. In the dry goods storage area, a blue grocery bag was noted with a food item, unlabeled and undated. The MIT stated the food item was rice. The MIT stated the expectation was to make sure foods were stored in a sealed container and properly dated and labeled. The floors in the dry goods storage area were noted with bio growth around the corners. The CDM stated she did not notice it before. The CDM said, It should be cleaned. An observation was made of a broken sink cabinet in the food service station and water leaking under the sink. The CDM stated this was on the maintenance work order. (Photographic evidence was obtained) An interview was conducted on 03/29/22 at 9:48 a.m. with Staff R, Dietary Aide. Staff R stated they were all expected to clean the kitchen as they go. Staff R stated it did not look good today because they were short staffed. Staff R said, The expectation was for the kitchen to be maintained in a clean manner, all the time. On 03/29/22 at 9: 58 a.m., an interview was conducted with the CDM. The CDM stated she was aware of the identified concerns. The CDM said, I have the same concerns. I agree, the kitchen should not look like that. We will get it cleaned. When asked how they schedule cleaning, the CDM stated that she did not have a cleaning checklist. The CDM stated there was an old checklist that the previous CDM was using, but it was not appropriate. The CDM stated the maintenance department had been notified that the freezer had issues. The CDM stated she thought parts had been ordered. The CDM stated the nursing home administrator (NHA) was aware of the maintenance concerns. The CDM stated the maintenance department was short staffed and they had been told to prioritize what they should address first. On 03/31/22 at 11:35 a.m., an interview was conducted with Staff S, Dietary aide / Cook. Staff S (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 21 of 24 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 04/01/2022 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 - Some stated everyone was responsible for cleaning and sometimes they used checklists. Staff S said, The problem with the build-up ice in the freezer has been there a long time, probably 2 years. The problem is that the fan is not working, creating a problem with condensation. Staff S stated maintenance had been notified. Staff S stated the facility had switched management many times and there was inconsistency with staffing. Staff S stated that they had been trained to ensure all food items were dated and labeled. Staff S stated maintenance was responsible for cleaning the vents. An interview was conducted on 03/31/22 at 12:05 p.m. with the regional district manager. He stated a vendor had been contacted for the dish machine. The regional manager stated the dish machine needed to be rewrapped to address the rust. The dish machine fan was not working, and this had increased condensation. The regional manager stated the vents would be cleaned today and the tiles in the dish room would be repaired the following day. An interview was conducted on 03/31/22 at 2:50 p.m. with the registered dietician (RD) and CDM. The RD said, The expectation is for all kitchen surfaces to be maintained in a sanitary manner. The RD stated they should have everything on a cleaning schedule to make sure they were reaching all surfaces. The CDM said, The plan is to have a cleaning schedule, we implemented it yesterday. We will conduct daily checks. The RD stated all items in the fridge should be labeled and dated and discarded when out of date. The RD stated they had been addressing the freezer on an on-going basis. The ice build -up had been discussed. The RD said, We have been trying to fix it up. I have discussed it with the [NHA], at least monthly. The RD stated the issue had been documented in her monthly audits. The ice- built up on foods could cause freezer burns and bacteria growth. The RD said, It is not acceptable food storage practice. The CDM stated a vendor had been contacted to fix the bio growth issues and a vendor was coming to install a new gasket. The CDM stated the issues in the kitchen had been discussed with the NHA. Review of a monthly audit form conducted by the RD dated 02/08/22, showed the concerns of significant ice build-up in the walk-in freezer and broken tiles on the floor in the dish room were discussed with the NHA, CDM and Director of Nursing. An interview was conducted on 04/01/22 at 10:37 a.m., with the NHA, the Director of Maintenance (DOM) and the Regional Operations [NAME] President (VP.) They were notified of the concerns noted during the survey. The DOM stated the vents should be cleaned monthly. The VP stated the kitchen equipment had been cleaned. The VP said, the dishwasher needs to be wrapped. The electrician will be out tomorrow. It is not venting out which is causing condensation issues. The VP stated the freezer had been pulled out and the ice was cleaned out, but it was a temporary fix until the root cause could be addressed. The NHA stated he would make sure the cleaning and maintenance orders were completed per their policy and standards. Review of a facility policy titled, Food storage: dry goods, revised 09/17, showed all dry goods will be appropriately stored in accordance with the food and drug administration (FDA) food code. (5) All packaged items will be kept clean, dry, and properly sealed. (6) Storage areas will be neat, arranged for easy identification, and date marked as appropriate Review of a facility policy titled, Food storage: cold foods, revised 04/18, showed all time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with the guidelines of the FDA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 22 of 24 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 04/01/2022 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 Review of a facility policy titled, Equipment, revised 09/17, showed all food service equipment will be clean, sanitary and in proper working order. Procedures indicated that (1) all equipment will be routinely cleaned and maintained in accordance with the manufacturer's direction. Residents Affected - Some (3) All food contact equipment will be cleaned and sanitized after every use. (4) All food contact equipment will be clean and free of debris. Review of a facility policy titled, Environment, revised 09/17, showed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 23 of 24 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 04/01/2022 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure garbage and refuse receptacles were covered, the garbage area was maintained in a sanitary manner and the garbage was disposed of in a timely manner. Residents Affected - Few Findings included: During a facility tour on [DATE] at 9:59 a.m., an observation was made of the facility's trash area with a large size dumpster, noted overflowing with trash and refuse. The garbage was not in a covered receptacle. Piles of bags of garbage were observed on the ground next to the dumpster. (Photographic evidence was obtained) An interview was conducted on [DATE] at 9:59 a.m. with the Director of Maintenance (DOM). He stated their contract with the compactor had expired and that was why they rented a dumpster. He stated he had been calling the vendor and the vendor was not responding. Their agreement was that they would pick up every 7 days. The last time trash was picked up was on [DATE]. He expressed frustration with the process and said, Of course this is not acceptable, it is a health hazard. I will keep calling. He stated he was expected to make sure that garbage was picked up in a timely manner. The trash area should be kept clean to keep animals and rodents away. Review of a document titled, open top container timeline, dated [DATE], authored by the DOM showed the container (dumpster) was received on [DATE] with an expectation of a weekly pick up, dump and return. The document showed the trash was last emptied on [DATE]. On [DATE], the DOM documented the container (dumpster) had not been emptied because the hauler was unavailable. An interview was conducted on [DATE] at 11:57 a.m. with the Nursing Home Administrator (NHA). He stated it had been challenging. The vendor had been canceling on them. The NHA said, I know the trash is overflowing, it's a public health concern. I would not disagree with you. He stated he had observed the trash area. He said, I have seen it. It is not okay. An interview was conducted on [DATE] at 10:37 a.m. with the NHA, the DOM, and the Regional Operations [NAME] President (VP.) They were notified of concerns noted during survey. The NHA stated the issue with the trash was addressed. The contract had been renewed with a different company. Review of a facility policy titled, Environment, revised 09/17, showed (6) All trash will be in covered, leak proof containers that prevent cross contamination. (7) All trash will be properly disposed of on external receptacles (dumpsters) and the surrounding area will be free of debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 24 of 24