Inspection·February 28, 2024

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility was not responding. For the past two months, we were supposed to have a food committee meeting, but we did not. On 02/28/2024 at approximately 9:55 a.m., an interview was conducted with Resident #6, he stated food served does not match the meal ticket sometimes. It was industrial food, poor quality, and a lot of the same things. He said We have resident council, but it is a waste of time. Nothing comes of it. On 02/28/2024, a resident who wished to remain anonymous stated, for call bell light response, he/she stated, the 2nd and 3rd shift are the worst. It can take 90 minutes for them to help you. I sit here and I watch the clock. They have been shorthanded FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 2 of 12 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 02/28/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interviews and photographic evidence, the facility failed to ensure the provision of a therapeutic diet for one (Resident #2) of eleven sampled residents. Residents Affected - Few Findings included: On 02/28/2024 at 9:27 a.m., Resident #2 was observed in her bed, eyes open, clean, groomed, and comfortable. She agreed to an interview. She stated she had resided in the facility for more than one year. She stated she ate her meals in her room. She confirmed she received three meals a day. She said the food taste was ok, there was just not enough. She stated, Yes, I have had weight loss. I eat independently. Sometimes not enough, sometimes I go hungry. A review of Resident #2's clinical record, the admission Record, documented an admission of 05/03/2023 with readmission of 02/19/2024. Her diagnosis information included: Chronic obstructive pulmonary disease, unspecified severe protein-calorie malnutrition, and ulcerative colitis. A review of Resident #2's Minimum Data Set, a 12/18/2023 PPS (Prospective Payment System) Part A Discharge assessment, Section C, documented a Brief Interview for Mental Status score of 13 out of 15, which meant the resident's cognition was intact. A review of a Nutrition Evaluation, dated 02/21/2024, documented Resident #2 had significant weight change, weight loss is significant, unplanned, and undesirable within x 3, and x 6 months. A review of Resident #2's weight history reflected the following: 08/09/2023, 77 pounds (lbs) 09/28/2023, 74 lbs. 10/09/2023, 72.2 lbs. 11/13/2023, 79.8 lbs. 12/27/2023, 69.2 lbs. 01/18/2024, 67.2 lbs. 02/26/2024, 67.5 lbs. A review of Resident #2's Care Plan, reflected a Focus area: Resident has potential nutritional problem .Weight: severely underweight, initiated 05/09/2023, last revised, 02/21/2024. Interventions included: Provide, serve diet as ordered. An observation was conducted on 02/28/2024 at approximately 12:22 p.m. of Resident #2's meal delivered to her room with her meal ticket. (Photographic evidence obtained). Review of the meal ticket, documented the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 3 of 12 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 02/28/2024 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 0692 Regular-Dysphagia Advanced Level of Harm - Minimal harm or potential for actual harm #8 SCP (scoop)-ground homestyle meatloaf with ketchup glaze. 2 OZ (ounces)-brown gravy Residents Affected - Few ½ cup-seasoned green peas ½ cup-fortified mashed potatoes, extra gravy ½ cup chocolate pudding 1-dinner roll/bread 1-margarine 1 square-caramel apple upside down cake 6 OZ-juice of choice 6 OZ-tea of choice An observation of the meal provided to the resident, revealed she had a portion of meatloaf with ketchup glaze, no brown gravy was observed on the meatloaf; a scoop of mashed potatoes, no gravy was observed on the potatoes; and a portion of peas. A dinner roll, but no margarine was present; a small dish of fruit with cinnamon sprinkled on top. No chocolate pudding was observed. An interview was conducted with Resident #2 at this time, she confirmed her meal had not included brown gravy, chocolate pudding, or margarine. She stated she did want those products. She stated the fruit in the cup looked like apples and not an upside-down cake. She stated no tea had been provided, but that was ok, she did not want the tea. A review of the facility's cycle menu for the 02/28/2024 lunch meal, documented the following meal products to be served: Homestyle meatloaf with ketchup glaze, 4 OZ (ounces) Au Gratin potatoes, ½ cup. Seasoned [NAME] Peas, ½ cup. Dinner Roll/ Bread, 1 each. Carmel Apple Upside Down cake 1 square. On 02/28/2024 at 12:37 p.m. an interview was conducted with the facility's Registered Dietitian. He reported Resident #2 had just come back from the hospital. He stated his goal for her was to maintain her weight and if possible, to increase. Her current weight was about 67.5 lbs. He confirmed Resident #2 was at risk for weight loss. He stated, yes, it was the expectation the resident would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 4 of 12 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 02/28/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm receive the menu items that corresponded to the menu. During the interview, he reviewed the photo of Resident #2's lunch meal. He confirmed a brown gravy was to be served over the meatloaf and the potatoes. In addition, the resident should have received chocolate pudding and margarine. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 5 of 12 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 02/28/2024 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 0800 Level of Harm - Minimal harm or potential for actual harm Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, record review, and interview, the facility failed to ensure each resident received a diet that met their dietary needs for four (#2, #7, #9, #10) of eleven sampled residents. Residents Affected - Few Findings included: A review of the food committee meeting minutes for the past 6 months revealed that each meeting minutes recorded the date and time but did not record the names of the residents in attendance and did not record any concerns. An interview on 2/28/24 at 10:44 a.m. with the Certified Dietary Manager (CDM) revealed there was a food committee meeting the 1st Friday of each month. He said there were a variety of concerns, with ongoing concerns from some of the residents wanting double and triple portions. When asked why residents were asking for double and triple portions, the CDM reported Because people like to eat. He said they (the dietary department) try to accommodate resident's requests. Observations on 2/28/24 at 11:31 a.m., of the midday meal tray-line, revealed Staff A, [NAME] cutting the meat loaf into small squares using a flat spatula and then started plating each dish with Staff B, Dietary Aide, calling out each resident's food order per meal ticket and placing dessert and liquids on tray. Review of the menu revealed that the following was to be served: Meal for regular diet Homestyle meatloaf with ketchup glaze 4 oz (ounces) Au gratin Potatoes (substituted with Mashed potatoes) ½ cup Seasoned [NAME] Peas ½ cup Dinner Roll/Bread 1 each Caramel Apple Upside Down Cake (Substituted with steamed cinnamon apple) 1 square During continued observations of the tray line, the following serving utensils were noted to be in use: Green scoop #12 (2.66 oz)- Rice, mashed potatoes Yellow scoop #20 (1.63 oz)-Puree meat, Mech meat, puree bread Red scoop #24 (1.33 oz)-, puree vegetables Yellow ladle (1.0 oz)-ketchup Green ladle (4.0 oz)- Spinach, Soup (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 6 of 12 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 02/28/2024 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 0800 White Ladle (3.00 oz)- [NAME] peas Level of Harm - Minimal harm or potential for actual harm Resident #2's tray was noted to be plated per the meal card -Regular-Dysphagia Advanced -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) Residents Affected - Few -Should have received ½ cup of green peas-actually received white ladle (3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz plus extra brown gravy- Actually received no gravy. Resident #7's tray was noted to be plated per the meal card-Regular Double Protein & Vegetable -Should have receive 4 oz of meatloaf x 2-actually received 2 visibly small squares of meatloaf. -Should have received ½ cup vegetable x 2-actually received 1 heaped green ladle (4.0 oz) Resident #9's tray was noted to be plated per the meal card -Regular-Dysphagia Puree -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received #10 scoop (3.25 oz) of green peas-actually received white ladle(3.0 oz) -Should have received #8 scoop (4.0 oz) of mashed potatoes-Actually received #12 scoop (2.66 oz) -Should have received #16 scoop (2.00 oz) of pureed dinner roll-Actually received #20 (1.63 oz) scoop. -Resident was to receive 2.0 oz of brown gravy- Actually received no gravy. Resident #10, tray was noted to be plated per the meal Card-Consistent Carbohydrate (CCD) Dysphagia Advanced -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received ½ cup of green peas-actually received white ladle(3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz brown gravy- Actually received no gravy. An interview with Staff A, [NAME] at this time revealed she was providing each resident with the appropriate amount of food. Staff A was unable to verbalize how much each scoop was and reported she did not know the amount. Staff A left the tray-line and went to a posting on the wall and provided posting and said these are the scoop sizes. Staff A continued to verbalize she did not know if she was using the right scoops and continued plating. Staff A was asked how much each square of meatloaf weighed, Staff A reported she did not know how much each slice was, that she just cut it into squares to serve. She was unable to verbalize how she could determine the weight of each slice of cooked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 7 of 12 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 02/28/2024 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 0800 meatloaf. Level of Harm - Minimal harm or potential for actual harm An interview with the CDM at this time revealed that all the serving ladles and scoops have different sizes and could be found on the utensils, additionally they were color coded which was universal and each scoop color represented a number and the measurement that it held. He provided the scoop chart off the wall. He confirmed the wrong scoops and ladles were in use. He reported he did not know how much each slice of meat loaf weighed because he did not have a scale, so the staff just estimate. Residents Affected - Few During a continued observation of the tray-line on 2/28/24 at 11:51 a.m., the CDM obtained a gray scoop and a white ladle from the draw and placed the gray scoop into the mashed potatoes and white ladle in the rice. At this time, it was noted the first 100 hall cart minus 4 trays was full. No attempts were made at supplementing the trays that were already plated including trays for residents #2, #7, #9, #10. An interview on 2/28/24 at 12:05 p.m. with the CDM revealed there were three cooks and all cooks should know the measurements of all scoops and ladles and should use them accordingly. He reported the cooks should be independent in the use of the appropriate scoops and ladles when plating resident meals to ensure that each resident receives the meals as ordered. He said he was not sure if Staff A, Cook, had been trained in the use of the appropriate scoops and ladles. The CDM said for those residents who were requesting double and triple portions he encouraged heftier portions. He reported that today's, 2/28/24, meatloaf portion was average but could not be sure because the kitchen had no scale. During an interview on 2/28/24 at 12:37 p.m., the Registered Dietician (RD) revealed he was at the facility 32 hours weekly 4 days a week. He reported he monitored for accuracy of meals and appropriate substitutes. He reported he did not do anything in the kitchen and that he only did the clinical side, completed assessments, and reviewed for weight loss. He reported the residents should get their meals as ordered. Review of the facility policy titled Therapeutic Diets with an original date of 5/2014 and a revised date of 9/2017 revealed the following: All residents have a diet order, including regular, therapeutic, and texture modifications, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 8 of 12 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 02/28/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observations, record review, and interview, the facility failed to employ dietary staff that displayed appropriate competencies to meet the resident's nutritional needs related to one (Staff A) of three cooks and the Certified Dietary Manager. Findings included: Review of the Dining Services Director/Account Manager job description revealed the following: -Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. -Training, quality control and in-servicing staff to HCSG standards is an essential part of the Manager's responsibility and includes touring kitchen several times per day to assess work quality using QCIs for documentation purposes. Review of the [NAME] job description revealed the following: -Plates appropriate foods to resident meal trays. -Inspect special diet trays to ensure that the correct diet is served to the resident. -Adhere to menus and portion control standards, including those for special diets when preparing and serving meals. -Review tray card to assure that current food information is consistent with foods served. An interview on 2/28/24 at 10:44 a.m. with the Certified Dietary Manager (CDM) revealed there was a food committee meeting the 1st Friday of each month. He said there were a variety of concerns, with ongoing concerns from some of the residents wanting double and triple portions. When asked why residents were asking for double and triple portions, the CDM reported Because people like to eat. He said they (the dietary department) try to accommodate resident's requests. Review of the food committee meeting minutes for the past 6 months revealed that each meeting minutes recorded the date and time but did not record the names of the residents in attendance and did not record any concerns. Observations on 2/28/24 at 11:31 a.m., of the midday meal tray-line, revealed Staff A, [NAME] cutting the meat loaf into small squares using a flat spatula and then started plating each dish with Staff B, Dietary Aide, calling out each resident's food order per meal ticket and placing dessert and liquids on tray. Review of the menu revealed that the following was to be served: Meal for regular diet Homestyle meatloaf with ketchup glaze 4 oz (ounces) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 9 of 12 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 02/28/2024 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 0801 Au gratin Potatoes (substituted with Mashed potatoes) ½ cup Level of Harm - Minimal harm or potential for actual harm Seasoned [NAME] Peas ½ cup Dinner Roll/Bread 1 each Residents Affected - Few Caramel Apple Upside Down Cake (Substituted with steamed cinnamon apple) 1 square During continued observations of the tray line, the following serving utensils were noted to be in use: Green scoop #12 (2.66 oz)- Rice, mashed potatoes Yellow scoop #20 (1.63 oz)-Puree meat, Mech meat, puree bread Red scoop #24 (1.33 oz)-, puree vegetables Yellow ladle (1.0 oz)-ketchup Green ladle (4.0 oz)- Spinach, Soup White Ladle (3.00 oz)- [NAME] peas Resident #2's tray was noted to be plated per the meal card -Regular-Dysphagia Advanced -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received ½ cup of green peas-actually received white ladle (3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz plus extra brown gravy- Actually received no gravy. Resident #7's tray was noted to be plated per the meal card-Regular Double Protein & Vegetable -Should have receive 4 oz of meatloaf x 2-actually received 2 visibly small squares of meatloaf. -Should have received ½ cup vegetable x 2-actually received 1 heaped green ladle (4.0 oz) Resident #9's tray was noted to be plated per the meal card -Regular-Dysphagia Puree -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received #10 scoop (3.25 oz) of green peas-actually received white ladle(3.0 oz) -Should have received #8 scoop (4.0 oz) of mashed potatoes-Actually received #12 scoop (2.66 oz) -Should have received #16 scoop (2.00 oz) of pureed dinner roll-Actually received #20 (1.63 oz) scoop. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 10 of 12 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 02/28/2024 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 0801 -Resident was to receive 2.0 oz of brown gravy- Actually received no gravy. Level of Harm - Minimal harm or potential for actual harm Resident #10, tray was noted to be plated per the meal Card-Consistent Carbohydrate (CCD) Dysphagia Advanced Residents Affected - Few -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received ½ cup of green peas-actually received white ladle(3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz brown gravy- Actually received no gravy. An interview with Staff A, [NAME] at this time revealed she was providing each resident with the appropriate amount of food. Staff A was unable to verbalize how much each scoop was and reported she did not know the amount. Staff A left the tray-line and went to a posting on the wall and provided posting and said these are the scoop sizes. Staff A continued to verbalize she did not know if she was using the right scoops and continued plating. Staff A was asked how much each square of meatloaf weighed, Staff A reported she did not know how much each slice was, that she just cut it into squares to serve. She was unable to verbalize how she could determine the weight of each slice of cooked meatloaf. An interview with the CDM at this time revealed that all the serving ladles and scoops have different sizes and could be found on the utensils, additionally they were color coded which was universal and each scoop color represented a number and the measurement that it held. He provided the scoop chart off the wall. He confirmed the wrong scoops and ladles were in use. He reported he did not know how much each slice of meat loaf weighed because he did not have a scale, so the staff just estimate. During a continued observation of the tray-line on 2/28/24 at 11:51 a.m., the CDM obtained a gray scoop and a white ladle from the draw and placed the gray scoop into the mashed potatoes and white ladle in the rice. At this time, it was noted the first 100 hall cart minus 4 trays was full. No attempts were made at supplementing the trays that were already plated including trays for residents #2, #7, #9, #10. An interview on 2/28/24 at 12:05 p.m. with the CDM revealed there were three cooks and all cooks should know the measurements of all scoops and ladles and should use them accordingly. He reported the cooks should be independent in the use of the appropriate scoops and ladles when plating resident meals to ensure that each resident receives the meals as ordered. He said he was not sure if Staff A, Cook, had been trained in the use of the appropriate scoops and ladles. The CDM said for those residents who were requesting double and triple portions he encouraged heftier portions. He reported that today's, 2/28/24, meatloaf portion was average but could not be sure because the kitchen had no scale. During an interview on 2/28/24 at 12:37 p.m., the Registered Dietician (RD) revealed he was at the facility 32 hours weekly 4 days a week. He reported he monitored for accuracy of meals and appropriate substitutes. He reported he did not do anything in the kitchen and that he only did the clinical side, completed assessments, and reviewed for weight loss. He reported the residents should get their meals as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 11 of 12 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 02/28/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Professional Staffing with an original date of 5/2014 and a revised date of 9/2017 revealed the following: The Dining Services department will employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the resident population. Event ID: Facility ID: 106116 If continuation sheet Page 12 of 12