Inspection·October 24, 2025

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code. A review of Resident #5's social service progress note dated [DATE] showed .patient wishes to continue with full code status . A review of Resident #5's progress notes showed the following:On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified. - On [DATE] at 7:30 p.m. authored by Staff A, LPN, [Resident #5] was seen and admitted to hospice today. Code changed to DNR waiting for paperwork . - On [DATE], showed a BIMS summary score of 15 During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's electronic health record (EHR) for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the Director of Nursing (DON) about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/Unit Manager (UM) because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events. During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when EMS was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code. During a telephone interview on [DATE] at 11:00 a.m. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. On [DATE] at approximately 3:15 a.m. Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She there was, Confusion about the code status. During an interview on [DATE] at 11:46 a.m. Staff H, LPN/UM, said on [DATE] at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 2 of 19 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 10/24/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 4:05 a.m. Staff B, LPN, called and told her Resident #5, Expired 45 to 50 minutes ago. Staff H, LPN/UM, said two nurses are expected to review the residents' orders and check the chart for a DNR form. If there is a discrepancy staff are expected to follow physician's orders. We expect the Code Blue Documentation Tool [form] to be completed and signed by all the staff members who participated. Nurses have been instructed to complete a progress and/or a change in condition note. During an interview on [DATE] at 12:08 p.m., the NHA said she contacted the emergency medical service (EMS) provider who responded to Resident #5's emergency event on [DATE]. She said, according to their report, on [DATE] at 4:17 a.m. the facility notified EMS, at 4:25 a.m. EMS arrived at the facility, and at 5:05 a.m. Resident #5 was pronounced onsite. On [DATE] at 4:01 p.m., an interview was conducted with the NHA, Assistant NHA, DON and RNC. The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form and MD order they are to initiate CPR, and he should notify the doctor and hospice. A review of the facility policy titled Advanced Directives, effective [DATE] and a revision date of [DATE], showed the following: Policy: The center will abide by state and federal laws regarding advanced directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. 4. Upon completion of the Advanced Directives Discussion Document, Social Services or nurse will notify the Physician of the resident's wishes and procure a state approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record. 5. Any changes to Advanced Directives will require a new Advanced Directives Discussion Document to be completed and place in the medical record. The previous document to be filed in the thinned record. 5. Upon notification from resident and/or resident representative of the desire to change or revoke an advance directive, or any issue concerning the capacity, the physician will be notified, and the medical record will be modified accordingly. The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending the facility's investigation.An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the recommendations made from the root cause analysis. The team members in attendance were the medical director, executive director, director of nursing, and the assistant administrator.- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses are 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 3 of 19 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 10/24/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D. Event ID: Facility ID: 106116 If continuation sheet Page 4 of 19 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 10/24/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the resident's right to be free from deprivation of goods and services by failing to ensure timely Cardiopulmonary Resuscitation (CPR) was provided, per the resident's wishes, and failed to notify the physician of a change in condition for one resident (#5) out of three residents sampled for advance directives.On [DATE] at 1:09 a.m., Staff B, Licensed Practical Nurse (LPN) obtained Resident #5's oxygen saturation level (Sp02) which was 84% with supplemental oxygen by nasal cannula. According to emedicinehealth oxygen saturation levels below 95% are considered abnormal, and the brain may be affected when SpO2 levels drop below 80 to 85 percent. https://www.emedicinehealth.com/what_is_a_good_oxygen_rate_by_age/article_em.htm retrieved on [DATE]. Staff B, LPN did not notify the medical provider or document interventions regarding the change in condition. At approximately 3:15 a.m., Staff B, LPN found Resident #5 pulseless and not breathing. The staff member summoned Staff I, Certified Nursing Assistant (CNA) and Staff C, LPN to the resident's room. Staff C, LPN assessed Resident #5 and confirmed the resident did not have a pulse or respirations. Staff B, LPN and Staff I, LPN reviewed Resident #5's electronic health record (EHR) for resuscitation orders and the paper chart for a Do Not Resuscitate (DNR) form. Staff C, LPN stated Resident #5 had an order for full code and confirmed there was no DNR form in the chart. Staff B, LPN reviewed the full code order and failed to act on it. Staff B, LPN said he was confused because on [DATE], when Resident #5 was readmitted from the hospital, the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Agency for Healthcare Administration (AHCA) form, 3008), documented DNR status for the resident. Staff B, LPN called the administration, hospice, and Resident #5's medical team, which delayed chest compressions and ventilation for approximately 45-60 minutes. This failure created a situation in which Resident #5's wishes for CPR were not honored, resulting in death, which resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #5's admission record showed an initial admission date of [DATE], and a readmission of [DATE], with diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension. A review of Resident #5's order summary report showed the following:- As of [DATE] Full Code order, dated [DATE].- Pulse oximetry (ox) every shift for monitoring, dated [DATE].- Respiratory: Oxygen-via Nasal Canula (NC) continuous every shift for (oxygen) 02 dated [DATE].A review of Resident #5's care plan showed a focus area of advanced directive full code, initiated on [DATE], created by the Social Worker. The intervention for this care plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed.A review of Resident #5's annual minimum data set (MDS), dated [DATE], section C-cognitive pattern, showed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Section B- hearing, speech, and vision shows the resident can express ideas and wants. Section Q- participation in assessment and goal setting showed active participation in the assessment process.A review of Resident #5's progress notes showed the following:- On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified.- On [DATE] at 7:30 p.m. authored by Staff A, LPN, [Resident #5] was seen and admitted to hospice today. Code changed to DNR waiting for paperwork .- On [DATE], showed a BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 5 of 19 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 10/24/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few summary score of 15.- On [DATE] showed Resident #5 was admitted to the facility from a local hospital.On [DATE] social service progress note showed, .patient wishes to continue with full code status .A review of Resident #5's AHCA form, 3008, section H, advanced care planning section showed Resident #5's had DNR status. Review of Resident #5's orders did not show physician orders for DNR status. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code.A review of Resident #5's hospice patient care notes, dated [DATE], showed, Bedside visit with patient, [family member] on speaker phone. Pt [patient] is unresponsive s/s [signs and symptoms] [of] imminence per [doctor].A review of Resident #5's hospice protocol for, Patients Enrolled in Hospice Medicare Benefit form, showed the following, .please notify [name] Hospice if .changes occur in the patient's physical or mental status.During an interview on [DATE] at 12:25 p.m., Staff A, LPN said on [DATE] at approximately 7:00 p.m., during the shift change report, she told Staff B, LPN Resident #5 was a full code until a signed DNR form was received.During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's EHR for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the DON about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/Unit Manager (UM) because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events.During a telephone interview on [DATE] at 3:20 p.m., Staff D, LPN, said when she entered Resident #5's room on [DATE] Staff B, LPN, was performing chest compressions and asked if someone, Would take over. Staff D, LPN said she assisted with compressions until the Emergency Medical Technicians (EMT) arrived. On [DATE] at 4:01 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Assistant NHA, DON, and Regional Nurse Consultant (RNC) to review the facility's initial investigation of the reported event for Resident #5. The NHA reviewed three witness statements provided by Staff C, LPN on [DATE], [DATE]. and [DATE]. The NHA reported, Staff C, LPN reported on [DATE] at approximately 3:50 a.m., Staff B, LPN said there was a change in Resident #5's condition and requested her to check the resident. Staff C, LPN verified there was breathing or a heartbeat, checked the EHR for an order and the paper chart for a DNR form, and determined Resident #5 was a full code. Staff C, LPN told Staff B, LPN, We needed to start a code blue, and Staff B, LPN was argumentative. Staff B, LPN, told Staff C, LPN, Resident #5's code status was DNR because it was on the AHCA 3008 form, dated [DATE], sent from the hospital. Staff C, LPN told Staff B, LPN, to call the DON and later Staff H, LPN/UM because she would know Resident's 5's code status. Staff C, LPN overhead paged code blue in Resident #5's room, called 911, and entered the resident's room to start compressions. At approximately 4:20 a.m., she left Resident #5's room to prepare for EMS's arrival. Staff C, LPN reported a code blue documentation tool was not completed for Resident #5. The NHA reported, Staff B, LPN reported on [DATE] at 2:00 a.m., during rounds, Resident #5 was awake, breathing and receiving oxygen by nasal cannula, and no abnormality was observed. At (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 6 of 19 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 10/24/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 3:55 a.m., Staff B, LPN, found Resident #5's body lifeless and asked Staff C, LPN to evaluate Resident #5. After evaluating Resident #5, Staff C, LPN told him Resident #5 was a full code and to start CPR. Staff B, LPN called the DON because a DNR form was not found in Resident #5's chart. After the call with the DON, Staff B, LPN called Staff H, LPN/UM because he was confused about Resident #5's code status. He reported Staff H, LPN/UM said Resident #5 was a full code and to start CPR. Staff C, LPN called 911 while Staff D, LPN assisted with chest compressions and Staff G, CNA provided ventilation. The NHA reported, Staff G, CNA reported on [DATE] at 4:00 a.m. there was an overhead page to go to Resident #5's room. Resident #5 was not responsive, and staff was trying to find out if she was a full code. Staff G, CNA reported she asked Staff I, CNA, who was assigned to Resident #5, to assist with postmortem care. Staff C, LPN said they must start a code and Staff B, LPN, gave her the Ambu bag to provide ventilatory support. Staff G, CNA reported compressions were started between 4:15 a.m. and 4:45 a.m. Staff G, CNA said postmortem care was provided for 10-15 minutes before CPR was started.During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted, and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when EMS was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code.During a telephone interview on [DATE] at 11:00 a.m., Staff I, CNA said on [DATE] at approximately 11:15 p.m. she checked on Resident #5. She said she offered Resident #5 water and emptied the urine bag. At 1:00 a.m., Staff I, CNA said, She [Resident #5] was asleep, her chest was moving, she was breathing. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. She said at approximately 3:15 a.m., Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She said there was, Confusion about the code status. During this time Staff I, CNA said another CNA, she could not recall their name, assisted with checking Resident #5's oxygen saturation level and temperature.On [DATE] at 4:01 p.m., an interview was conducted with the NHA, Assistant NHA, DON and RNC. The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form and MD order they are to initiate CPR, and he should notify the doctor and hospice.During an interview on [DATE] at 11:46 a.m., Staff H, LPN/UM said on [DATE] at 4:05 a.m. Staff B, LPN, called and said Resident #5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 7 of 19 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 10/24/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few had expired 45 to 50 minutes earlier. Staff H, LPN/UM said she screamed and told Staff B, LPN, Resident #5 was a full code and to start CPR. Staff H, LPN/UM said two nurses are expected to review the residents' orders and check the chart for the DNR form. She said if there was a discrepancy, staff are expected to follow physician's orders. In reference to Resident #5's oxygenation saturation level of 84%, Staff H, LPN/UM said staff are expected to stabilize the oxygen level, call the doctor, and make changes as ordered. She said Staff B, LPN did not follow the process. Staff H, LPN/UM said a Code Blue Documentation Tool [form] is expected to be completed and signed by all the staff members who participated, and the nursing staff should complete a progress and/or a change in condition note. Staff H, LPN/UM confirmed they did not follow this process.During an interview on [DATE] at 12:08 p.m., the NHA said she contacted the Emergency Medical Services (EMS) provider who responded to Resident #5's emergency event on [DATE]. She said, according to their report, EMS was called on [DATE] at 4:17 a.m. EMS arrived at the facility at 4:25 a.m. On [DATE] at 5:05 a.m. Resident #5 was pronounced onsite. During an interview on [DATE] at 2:15 p.m., Staff A, LPN said on [DATE] at approximately 7:00 p.m., she told Staff B, LPN, Resident #5 was on hospice service, and the hospice staff said the resident representative had signed a DNR form. Staff A, LPN said they were waiting for the physician to sign the order. She stated, Resident #5 is full code until the signed DNR form is received.During a telephone interview on [DATE] at 2:30 p.m., Resident's #5's physician said he was her provider for a long time. He said the resident had been declining and chose to be a full code as a, Last ditch effort. During the interview and a review of Resident #5's physician orders, to include discontinued and completed, showed Resident #5 had full code status. The physician said, That's interesting. The physician did not address why there was confusion regarding code status for Resident #5. When asked about Resident #5's oxygen saturation level of 84% on [DATE] at 1:09 a.m., Resident #5's physician said a member of his team or hospice should have been notified. He said as an expectation DNR forms can be completed by the resident's physician or the hospice physician. Resident #5's physician could not confirm if he had signed a DNR form for Resident #5.A review of the facility policy titled, Abuse, Neglect, Exploitation, & Misappropriation, with an effective date of [DATE] and a revision date of [DATE], showed the following: Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. No employee may at any time commit an act of physician, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Neglect is the failure of the center, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to; . Failure to notify a resident's legal representative in the event of a significant change in the resident's physical, mental or emotional condition that a prudent person would recognize. Procedure: . Non-action, results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and humane care and treatment of the resident. A review of the facility's policy and procedure titled Notification of Change in Condition, with a revision date of [DATE], showed the following: Policy: The Center to promptly notify the Patient/ Resident, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 8 of 19 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 10/24/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few attending physician, and the resident representative when there are changes in status or condition. Procedure: The nurse to notify the attending physician and the resident representative (RR)when there is a(n):- significant change in the patient/resident's physical, mental, or psychosocial status. - In the event of an emergency situation, 911 to be called and the attending and the RR to be notified as soon as possible. The nurse to complete an evaluation of the patient/resident. Document evaluation in the medical record. Document resident/ patient change in condition on 24-hour report.- Complete SBAR as indicated. A review of the facility policy titled Medical Care/Standards of Practice, with an effective date of [DATE] and a revision date of [DATE], showed the following: Procedure: . Significant changes in medical status are reported to the attending physician. Nursing Services will be responsible for notifying the appropriate physicians, giving emergency care within the scope of their license, . and when appropriate, calling emergency medical services. Basic life support and/or first aid measures needed to minimize any deterioration of the resident's condition will be provided prior to transferring to an acute care hospital.A review of the facility's policy and procedure titled oxygen therapy, with a revision date of [DATE], showed the following: Policy: Oxygen therapy is the administration of a Fi02 (fraction of inspired oxygen) greater than 21% by means of various administration devices to: Raise the resident's PaO2 (partial pressure of oxygen) to an acceptable baseline using the lowest Fi02 . Procedure: Physician's orders for oxygen therapy shall include- Administration modality, Fi02 or liter flow, and Continuous or PRN .Documentation shall include: . Liter flow or Fi02 .A review of the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE], showed the following: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) Order.Procedure:1. In event of cardiac arrest, immediately call for assistance. a. Two licensed nurses are to verify: Resident identificationb. Fully executed Florida Do Not Resuscitate Order (DH1896), located in the advanced directive section of the medical record. e to 2. Use the paging system to call Code Blue to Room Number or location of the event three times. 3. In the absence of a fully executed Florida Do Not Resuscitate Order (DH1896), the facility will immediately begin CPR. 4. Will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: a. The resident responds b. Notify the physician and the resident representative/ legal representative. c. Document in the medical record. A review of the facility policy titled Advanced Directives, effective [DATE] and a revision date of [DATE], showed the following: Policy: The center will abide by state and federal laws regarding advanced directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. 4. Upon completion of the Advanced Directives Discussion Document, Social Services or nurse will notify the Physician of the resident's wishes and procure a state approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record. 5. Any changes to Advanced Directives will require a new Advanced Directives Discussion Document to be completed and place in the medical record. The previous document to be filed in the thinned record. 5. Upon notification from resident and/or resident representative of the desire to change or revoke an advance directive, or any issue concerning the capacity, the physician will be notified, and the medical record will be modified accordingly. A review of the facility policy titled Resident Rights, effective [DATE], showed the following: Policy: It is the policy of The Company to: 1. Make residents and their legal representatives aware of residents' rights. 2. Ensure that residents' rights are known to staff. 5. Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations. The facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 9 of 19 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 10/24/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending the facility's investigation. - An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the recommendations made from the root cause analysis. The team members in attendance were the medical director, executive director, director of nursing, and the assistant administrator.- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses are 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.- From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D. Event ID: Facility ID: 106116 If continuation sheet Page 10 of 19 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 10/24/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, interviews and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR), was implemented in a timely manner and failed to ensure the residents' wishes were honored related to full code status for one resident (#5) of three residents sampled. Resident #5 had active physician orders for full code status and had expressed wishes to be resuscitated. On [DATE] at 1:09 a.m., Staff B, Licensed Practical Nurse (LPN) obtained Resident #5's oxygen saturation level (Sp02) which was 84% with supplemental oxygen by nasal cannula. According to emedicinehealth oxygen saturation levels below 95% are considered abnormal, and the brain may be affected when SpO2 levels drop below 80 to 85 percent. https://www.emedicinehealth.com/what_is_a_good_oxygen_rate_by_age/article_em.htm retrieved on [DATE]. Staff B, LPN did not notify the medical provider or document interventions regarding the change in condition. At approximately 3:15 a.m., Staff B, LPN found Resident #5 pulseless and not breathing. The staff member summoned Staff I, Certified Nursing Assistant (CNA) and Staff C, LPN to the resident's room. Staff C, LPN assessed Resident #5 and confirmed the resident did not have a pulse or respirations. Staff B, LPN and Staff I, LPN reviewed Resident #5's electronic health record (EHR) for resuscitation orders and the paper chart for a Do Not Resuscitate (DNR) form. Staff C, LPN stated Resident #5 had an order for full code and confirmed there was no DNR form in the chart. Staff B, LPN reviewed the full code order and failed to act on it. Staff B, LPN said he was confused because on [DATE], when Resident #5 was readmitted from the hospital, the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Agency for Healthcare Administration (AHCA) form, 3008), documented DNR status for the resident. Staff B, LPN called the administration, hospice, and Resident #5's medical team, which delayed chest compressions and ventilation for approximately 45-60 minutes. This failure created a situation in which Resident #5's wishes for CPR were not honored, resulting in death, which resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #5's admission record showed an initial admission date of [DATE], and a readmission of [DATE], with diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension. A review of Resident #5's order summary report showed, as of [DATE], Full Code order, dated [DATE]. A review of Resident #5's annual minimum data set (MDS), dated [DATE], section C-cognitive pattern, showed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Section B- hearing, speech, and vision shows the resident can express ideas and wants. Section Q- participation in assessment and goal setting showed active participation in the assessment process. A review of Resident #5's care plan showed a focus area of advanced directive full code, initiated on [DATE], created by the Social Worker. The intervention for this care plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code. A review of Resident #5's social service progress note dated [DATE] showed .patient wishes to continue with full code status . A review of Resident #5's progress notes showed the following: On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified. During a telephone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 11 of 19 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 10/24/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interview on [DATE] at 11:00 a.m. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. On [DATE] at approximately 3:15 a.m. Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She there was, Confusion about the code status. During an interview on [DATE] at 11:46 a.m. Staff H, LPN/Unit Manager (UM), said on [DATE] at 4:05 a.m. Staff B, LPN, called and told her Resident #5, Expired 45 to 50 minutes ago. Staff H, LPN/UM, said two nurses are expected to review the residents' orders and check the chart for a DNR form and if there was a discrepancy, staff are expected to follow physician's orders. She said the Code Blue Documentation Tool [form] should be completed and signed by all the staff members who participated. Staff H, LPN/UM said nurses have been instructed to complete a progress and/or a change in condition note. During an interview on [DATE] at 12:08 p.m., the Nursing Home Administrator (NHA) said she contacted the Emergency Medical Services (EMS) provider who responded to Resident #5's emergency event on [DATE]. She said, according to their report, EMS was called on [DATE] at 4:17 a.m. EMS arrived at the facility at 4:25 a.m. On [DATE] at 5:05 a.m. Resident #5 was pronounced onsite. During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's EHR for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the Director of Nursing (DON) about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/UM because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events. During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted, and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when EMS was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code. On [DATE] at 4:01 p.m., an interview was conducted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 12 of 19 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 10/24/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few NHA, Assistant NHA, DON and Registered Nurse Consultant (RNC). The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form follow the MD order to initiate CPR and notify the doctor and hospice. A review of the facility's Policy and Procedure titled Florida Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE], showed the following: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) Order.Procedure: 1. In event of cardiac arrest, immediately call for assistance. a. Two licensed nurses are to verify: Resident identification. b. Fully executed Florida Do Not Resuscitate Order (DH1896), located in the advanced directive section of the medical record. e to 2. Use the paging system to call Code Blue to Room Number or location of the event three times. 3. In the absence of a fully executed Florida Do Not Resuscitate Order (DH1896), the facility will immediately begin CPR 4. Will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: a. The resident responds. b. Notify the physician and the resident representative/ legal representative.c. Document in the medical record. The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending the facility's investigation.- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the incident, discuss corrective actions and provide recommendations. The team members in attendance were the medical director, executive director/NHA, director of nursing, and the assistant administrator/ANHA .- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses work 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.- From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 13 of 19 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 10/24/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D. Event ID: Facility ID: 106116 If continuation sheet Page 14 of 19 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 10/24/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility documentation and policy review, the facility failed to ensure nursing staff were competent in identifying resident's code status, providing timely Cardiopulmonary Resuscitation (CPR) and responding to a Change in Condition (CIC) for one resident (#5) out of three residents sampled. On [DATE] at 1:09 a.m., Staff B, Licensed Practical Nurse (LPN) obtained Resident #5's oxygen saturation level (Sp02) which was 84% with supplemental oxygen by nasal cannula. According to emedicinehealth oxygen saturation levels below 95% are considered abnormal, and the brain may be affected when SpO2 levels drop below 80 to 85 percent. https://www.emedicinehealth.com/what_is_a_good_oxygen_rate_by_age/article_em.htm retrieved on [DATE]. Staff B, LPN did not notify the medical provider or document interventions regarding the change in condition. At approximately 3:15 a.m., Staff B, LPN found Resident #5 pulseless and not breathing. The staff member summoned Staff I, Certified Nursing Assistant (CNA) and Staff C, LPN to the resident's room. Staff C, LPN assessed Resident #5 and confirmed the resident did not have a pulse or respirations. Staff B, LPN and Staff I, LPN reviewed Resident #5's electronic health record (EHR) for resuscitation orders and the paper chart for a Do Not Resuscitate (DNR) form. Staff C, LPN told Staff B, LPN that Resident #5 had an order for full code and a there was no DNR form in the chart. Staff B, LPN reviewed the full code order and failed to act on it. Staff B, LPN said he was confused because on [DATE], when Resident #5 was readmitted from the hospital, the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Agency for Healthcare Administration (AHCA) form, 3008, documented DNR status for the resident. Staff B, LPN called the Director of Nursing (DON), Staff H, LPN/Unit Manager (UM), paged hospice, and Resident #5's medical team which delayed chest compressions and ventilation for 45-60 minutes. This failure created a situation in which Resident #5's wishes for CPR were not honored, and resulted in death, and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #5's admission record showed an initial admission date of [DATE], and a readmission of [DATE], with diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension. A review of Resident #5's order summary report showed the following:- As of [DATE] Full Code order, dated [DATE].Pulse oximetry (ox) every shift for monitoring, dated [DATE].- Respiratory: Oxygen-via Nasal Canula (NC) continuous every shift for (oxygen) 02 dated [DATE].A review of Resident #5's care plan showed a focus area of advanced directive full code, initiated on [DATE], created by the Social Worker. The intervention for this care plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed. A review of Resident #5's Treatment Administration Record (TAR), dated [DATE], showed the pulse ox reading was documented for two out of five opportunities.A review of Resident #5's annual minimum data set (MDS), dated [DATE], section C-cognitive pattern, showed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Section B- hearing, speech, and vision shows the resident can express ideas and wants. Section Q- participation in assessment and goal setting showed active participation in the assessment process. A review of Resident #5's progress notes showed the following:On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified.- On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 15 of 19 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 10/24/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [DATE] at 7:30 p.m. authored by Staff A, LPN, [Resident #5] was seen and admitted to hospice today. Code changed to DNR waiting for paperwork .- On [DATE] showed a BIMS summary score of 15.- On [DATE] showed Resident #5 was admitted to the facility from a local hospital.- On [DATE] social service progress note showed, .patient wishes to continue with full code status .A review of Resident #5's AHCA form, 3008, section H, advanced care planning section showed Resident #5's had DNR status. Review of Resident #5's orders did not show physician orders for DNR status. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code.A review of Resident #5's hospice patient care notes, dated [DATE], showed, Bedside visit with patient, [family member] on speaker phone. Pt [patient] is unresponsive s/s [signs and symptoms] [of] imminence per [doctor].A review of Resident #5's hospice protocol for, Patients Enrolled in Hospice Medicare Benefit form, showed the following, .please notify [name] Hospice if .changes occur in the patient's physical or mental status.During an interview on [DATE] at 12:25 p.m., Staff A, LPN said on [DATE] at approximately 7:00 p.m., during the shift change report, she told Staff B, LPN Resident #5 was a full code until a signed DNR form was received.During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when Emergency Medical Services (EMS) was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code.During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's EHR for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the DON about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/UM because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events.During a telephone interview on [DATE] at 11:00 a.m., Staff I, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 16 of 19 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 10/24/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few CNA said on [DATE] at approximately 11:15 p.m. she checked on Resident #5. She said she offered Resident #5 water and emptied the urine bag. At 1:00 a.m., Staff I, CNA said, She [Resident #5] was asleep, her chest was moving, she was breathing. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. She said at approximately 3:15 a.m., Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She said there was, Confusion about the code status. During this time Staff I, CNA said another CNA, she could not recall their name, assisted with checking Resident #5's oxygen saturation level and temperature.On [DATE] at 4:01 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Assistant NHA, DON and Regional Nurse Consultant (RNC). The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form follow the MD order, initiate CPR, and notify the doctor and hospice.On [DATE] at 8:27 a.m., an interview was conducted with the Human Resource Director of Training (HRDT), RNC, NHA, and the DON to review employee records for training/education and competency validation about advanced directives, code blue status, and change in condition. A review of a facility orientation form for Staff B, LPN, titled, new hire orientation, all staff mandatory/information to be provided form, dated [DATE], revealed an incomplete form. The orientation form did not show Staff B, LPN received education/training for topics to include: advanced directives/state specific DNR orders, hospice and end of life, respiratory care (oxygen therapy), vital signs and complete change in condition and situation background assessment recommendations (SBAR). The form showed a signature and date area which was left blank. The DON said she did not know why the orientation form was blank as it was prior to her employment and she could not speak to the process at that time. The NHA said the expectation was for all spaces on the orientation form to be checked and initialed to indicate training was completed.On [DATE] at 12:59 p.m., a follow-up interview was conducted with the HRDT and the NHA. The NHA said the facility could not locate the orientation form for Staff C, LPN in the employee file. They could not confirm if Staff C had received training.During an interview on [DATE] at 11:46 a.m., Staff H, LPN/UM stated not knowing how to confirm if nursing staff had received CPR/advanced directive competency/training. Staff H, LPN/UM, said before [DATE] the training did not include code blue drills.A review of the facility's onboarding action items, completed during new hire orientation, showed topics to include: - understanding resident rights facilitated by the executive director -abuse and neglect facilitated by self-paced modules - resident rights essentials facilitated by self-paced modules - advanced directives and state specific do not resuscitate orders (DNRO) facilitated by director of nursing - change in condition SBAR facilitated by director of nursing. A review of the facility policy and procedure titled, Notification of Change in Condition, with a revision date of [DATE], showed the following: Policy: The Center to promptly notify the Patient/ Resident, the attending physician, and the resident representative when there are changes in status or condition. Procedure: The nurse to notify the attending physician and the resident representative (RR)when there is a(n):- significant change in the patient/resident's physical, mental, or psychosocial status. - In the event of an emergency situation, 911 to be called and the attending and the RR to be notified as soon as possible. - The nurse to complete an evaluation of the patient/resident. Document evaluation in the medical record. - Document resident/ patient change in condition on 24-hour report.- Complete SBAR as indicated.A review of the facility policy titled, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 17 of 19 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 10/24/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Medical Care/Standards of Practice with a revision date of [DATE], showed the following: Procedure: . Significant changes in medical status are reported to the attending physician. Nursing Services will be responsible for notifying the appropriate physicians, giving emergency care within the scope of their license, . and when appropriate, calling emergency medical services. Basic life support and/or first aid measures needed to minimize any deterioration of the resident's condition will be provided prior to transferring to an acute care hospital.A review of the facility's policy and procedure titled oxygen therapy, with a revision date of [DATE], showed the following: Policy: Oxygen therapy is the administration of a Fi02 (fraction of inspired oxygen) greater than 21% by means of various administration devices to: Raise the resident's PaO2 (partial pressure of oxygen) to an acceptable baseline using the lowest Fi02 . Procedure: Physician's orders for oxygen therapy shall include- Administration modality, Fi02 or liter flow, and Continuous or PRN .Documentation shall include: . Liter flow or Fi02 .A review of the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE], showed the following: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In event of cardiac arrest, immediately call for assistance. a. Two licensed nurses are to verify: Resident identification b. Fully executed Florida Do Not Resuscitate Order (DH1896), located in the advanced directive section of the medical record. e to 2. Use the paging system to call Code Blue to Room Number or location of the event three times. 3. In the absence of a fully executed Florida Do Not Resuscitate Order (DH1896), the facility will immediately begin CPR.4. Will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: a. The resident responds. b. Notify the physician and the resident representative/ legal representative. c. Document in the medical record. A review of the facility policy titled Resident Rights, effective [DATE], showed the following: Policy: It is the policy of The company to 1. Make residents and their legal representatives aware of residents' rights. 2. Ensure that residents' rights are known to staff. 5. Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations.The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending investigation.- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the recommendations made from the root cause analysis. The team members in attendance were the medical director, executive director, director of nursing, and the assistant administrator.- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses are on 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106116 If continuation sheet Page 18 of 19 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 10/24/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - The Human Resource Director will ensure during new hire orientation, newly hired nurses and CNAs are educated on the facility policy related to advanced directives, CPR and the completed road map from orientation will be signed acknowledging the education received.Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D. Event ID: Facility ID: 106116 If continuation sheet Page 19 of 19