Aviata At Central Park

F 0655 Level of Harm - Minimal harm or potential for actual harm

admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Central Park

702 S Kings Ave Brandon, FL 33511

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 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

checked for a pulse and then I jumped in and continued started compressions. Staff F said, I requested to switch. Staff C, LPN checked for a pulse, then Staff H, CNA started compressions. Another female was in

the room and was going to switch with Staff H, CNA but just froze up (stood there). I therefore jumped back

in and continued with compressions. Staff F, CNA stated not remembering who the female who froze up was as being new to the facility. EMS arrived and took over care of the resident. Staff F, CNA confirmed being certified in CPR. During an interview on [DATE REDACTED] at 10:37 a.m. Staff A, LPN stated Staff B, CNA, yelled to come to Resident #1's room. Staff A said, I immediately went to the room, noted Resident #1 not responding. I ran out of the room to get the blood pressure machine, called a rapid response, and verified code status. Staff A, LPN stated taking the crash cart back to Resident #1's room. Staff H, CNA was providing compressions when I arrived back to Resident 1's room. Staff C, LPN was directing everyone and Staff F, CNA took over from Staff H, CNA. Staff A, LPN confirmed being certified in CPR. During an

interview on [DATE REDACTED] at 11:55 a.m. Staff D, LPN stated Staff A, LPN came to the nurse station and stated Resident #1 was unresponsive. Staff D said, I immediately checked Resident #1's code status. Resident #1 was a Full Code. Staff A, LPN and I grabbed the crash cart and headed to Resident #1's room. Staff C, LPN was already performing compressions on Resident #1 when we arrived at the room. Staff F, CNA and Staff H, CNA were standing next to the bed. I ran back to the nurse station and contacted 911 and began preparing the paperwork. Staff D, LPN confirmed being certified in CPR. During an interview on [DATE REDACTED] at 2:18 p.m. Staff E, RN stated they called code blue over the speakers. Staff E, RN stated headed to Resident #1's room and upon arrival noted Staff C, LPN was working with Resident #1. The staff were not yet performing CPR; they determined Resident #1 was too heavy to move to the floor. Staff C, LPN asked me to get the crash cart and back board. Upon returning with the backboard and cart, Staff C, LPN was performing chest compressions. Staff C, LPN stopped and checked Resident #1 while Staff F, CNA and Staff H, CNA placed the backboard under Resident #1. Staff E, RN stated leaving the room since Staff C, LPN and Staff A, LPN were in the room. Staff E, RN confirmed being certified in CPR. Multiple attempts were made to reach Staff H, CNA via phone on [DATE REDACTED] and [DATE REDACTED] with no response. Staff H, CNA did not have a CPR certification located in the facility employee record. During an interview on [DATE REDACTED] at 10:53 a.m. the Nursing Home Administrator stated during the review of Resident #1's code it was determined Staff H, CNA admitted to performing chest compressions on Resident #1 although not being certified in CPR. The NHA stated licensed nurses certified in CPR are the expected staff members to perform CPR in

the facility. The NHA stated CPR is not in the CNA's job description and Staff H, CNA should not have performed chest compressions on Resident #1. Review of the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR) dated [DATE REDACTED] revealed: 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 the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: * Resident identification * Fully executed Florida Do Not Resuscitate order (DHI 896), located in the advanced directive section of the medical record 3. Use the paging system and call Code Blue to Room Number or location of the event three times. 4. In the absence of a fully executed Florida Do Not Resuscitate order (DHI 896) the facility will immediately begin CPR. 5. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: The resident responds. 6. Notify the physician and resident representative/ legal representative 7. Document in the medical record.

Event ID:

Facility ID:

If continuation sheet