Aviata At Lakeside Oaks

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

services. Resident #10's diagnoses including diabetes mellitus with foot ulcer, cognitive communication deficit, difficulty walking, and need for assistance with personal care and chronic pain.Review of Resident #10's physician order dated 7/29/25 showed Resident to discharge with 20 in wheelchair and PT/OT [Physical Therapy/Occupational Therapy] eval and treatReview of Resident #10 Discharge Plan and Instructions, signed on 8/1/25 revealed Resident #10 discharged to home with family member. The care plan goal is continue wound care is documented. Skin condition is described Right planter [NAME] 3.8 cm x1.5cm x 0.3 cm collagen, calcium alginate. The social service discharge summary .resident will receive HHS (home health services) for wound and PT/OT (physical therapy/occupational therapy). Discharge home with home health is selected for Resident #10. Resident #10's discharge plan and instructions did not list the name or contact phone number for HHS provider. Documentation regarding post discharge follow-up phone call is blank.Review of the medical record did not reveal discharge follow up communication was performed, and the facility did not provide documentation after two requests.During an interview on 8/27/25 at 10:51 AM Staff O, RN said the SSD starts the discharge documentation and notifies the nurses.

Regarding discharging residents with controlled medications Staff O, RN said sometimes they will send the resident's remaining controlled medications and/or a prescription for the medication. She said depending on

the provider orders for controlled medications they send enough for three days or what is on hand.During

an interview on 8/27/25 at 12:03 PM, Staff U, Licensed Practical Nurse (LPN) for discharges the DON gives him the resident's packet. He checks the residents' orders, review the discharge packet with the resident and if ordered, gives the remaining medications to the resident. Staff U, LPN said the resident signs the paperwork. He is told in advance of DME delivery for the resident and wheelchairs are usually delivered to

the facility before discharged . If the provider approves controlled medications to be sent with the resident

he verifies with the DON. He sends whatever [number of pills] is on the card.During an interview on 8/27/25 at 12:58 PM, the DON said the facility follows physician orders. If a resident is discharging with controlled medications and does not have the number of pills ordered a prescription will be sent at the time of discharge. During an interview on 8/28/25 at approximately 1:30 PM with the SSD and the Regional SSD (RSSD), the RSSD said it is the company's policy to call the resident within three days of facility discharge to confirm HHS providers showed up and DME was delivered. He confirmed the three-day post discharge phone calls were not completed for Resident #1 or Resident #10.Review of facility's policy and procedure, titled Discharge of Resident to Home or Other Center, revised 8/3/2018 showed Procedure: 1. Upon determination by the Interdisciplinary team that resident is appropriate for discharge, the Nurse will obtain a physician's order for discharge to include:-Place of discharge-Community resources or referrals required-Status of medications on discharge (i.e. May discharge home with med)2. Complete the Discharge Plan.3. The list of medications may be printed from pharmacy for resident or legal representative review and signature. Signed copy of the pharmacy discharged Resident Medication Transfer Record is to be faxed to the number indicated on the discharge resident medication transfer record printed from the pharmacy and filed in the clinical record.5.Provide resident a copy of the Discharge Plan, and the pharmacy Medication list.6. Document final disposition in the resident's clinical record.-Resident's goals for admission and desired outcomes, as well as preferences and potential for future discharge- Individualized interventions that honor the resident's preferences and promote achievement of the resident's goal-Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths and desired outcomes.

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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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Lakeside Oaks

1061 Virginia St Dunedin, FL 34698

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

hasn't been wanting to wear it. I don't even know if Resident #2 still needs it. Therapy or the doctor would make that decision. I haven't been able to discuss this with the doctor because I am only here once a week.

An interview was conducted with the Medical Records Coordinator (MRC) on 8/27/25 at 4:20 p.m. The MRC said she schedules all residents' physician appointments. She says Resident #2 doesn't have any appointments coming up and hasn't had an appointment outside the building since March. A telephone

interview was conducted with Resident #2's PCP on 8/28/25 at 9:50 a.m. The PCP stated treatment of this comminuted fracture often does not include surgery, but the orthopedic surgeon would make that determination. The PCP was not aware that the resident has not seen orthopedic surgery yet. The PCP said treatment with a sling is mainly for comfort, but it may continue to be used until the arm is re-X rayed.

The orthopedic surgeon would need to re-Xray to determine healing even if surgery is not performed.

During an interview on 8/28/25 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that post injury, Resident # 2, was placed in a sling and with instructions to follow up with orthopedics. The resident has not seen orthopedics yet. I will have to check with the MRC about an appointment. The resident refuses

the sling often and will not wear it. At this point, there is no follow up about his refusal. The normal process

on post-acute care orders is that the primary nurse admitting the patient back from the hospital would put

the orders in or the DON or Assistant Director of Nursing could place the orders. The facility staff would verify the orders with our physician as well. Review of a Facility Policy titled 'Admissions Procedure' revised 8/19/18 revealed: Any new information or changes noted during the collection of data from resident and/or Responsible Party will be communicated as necessary.

Event ID:

Facility ID:

If continuation sheet

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Lakeside Oaks

1061 Virginia St Dunedin, FL 34698

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

the locked medication cart and counted every shift. Narcotics are reviewed at the management level at least every week. An audit is performed 10 times a month. If a discrepancy is reported, then he will try to figure out how it happened. If there was a diversion found, then one of the regional supervisors would be involved in the investigation. The DON revealed that there have not been any investigations into narcotic discrepancies in the last six months. He also has never reported narcotic discrepancies to the state board, Drug Enforcement Administration (DEA), or law enforcement. He related that training is completed during

the narcotic auditing and during employee onboarding training. Discontinued medications are placed in a two-drawer locked file cabinet until destruction. Destruction of narcotics is completed with the Pharmacy Consultant during the monthly review. On 8/28/2025 at 10:35 a.m., an interview was conducted with the Pharmacy Consultant. He stated that he monitors the controlled substances in this facility. He tracks what is coming into the facility, checks the logs, and ensures there are two nurses' signatures. He disposes of the pulled narcotics with the DON every month. The audit review and disposals usually occur on the first Thursday of the month. He provides a monthly report for the facility that includes any discrepancies. He notes discrepancies such as scratch marks, missing numbers, and missing signatures. When discrepancies are identified, he also talks to the DON. He is not aware of any diversion during narcotic handling. His last audit and report was on August 1, 2025.On 8/28/2025 at 10:50 a.m., a follow up interview was conducted with Resident #3. The resident confirmed that she only had an issue with not receiving pain medication on that one day. Resident #3 takes pain medication every eight hours. The resident stressed that the medication is never refused because it is needed. The night nurses may run late with medications, but the resident usually gets it sooner or later.On 8/28/2025 at 11:43 a.m. an interview with the DON was conducted. The discrepancies found in the sampled residents records were discussed. The DON stated that

the staff should be signing the medication narcotics sheet and the MAR. The staff did not sign them out as given, and that is an error. He provided a copy of the monthly report. He stated actions would be planned in reference to the monthly report and education would be provided for the staff.A review of the Monthly Medication Unit Review completed on 8/1/2025 by the Consultant Pharmacist revealed a no under sections titled: Controlled substance documentation is accurate and complete, and Controlled substance inventory is reconciled according to facility procedures.A review of the facility policy and procedure titled Medication-Oral Administration of with a revision date of 08/15/2019, revealed: on page 2, when documenting in the EMAR, the nurse will document immediately prior to administration and immediately post administration based on individual professional practice of the nurse.A review of the facility pharmacy policy and procedure titled 4.0 Schedule II Controlled Substance Medication with no listed effective date, revealed: on page 4-8, Section H (5), When a controlled dangerous substance medication is administered,

in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials.

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