Aviata At Lakeside Oaks

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

the determination on whether a grievance should be made or not. The SSD stated that he, doesn't really know who does or does not know about the grievance process. When asked if a grievance is filed when there is an allegation of abuse, the SSD explained that a grievance and reportable should be completed in reference to the allegation, as the situation needs to be rectified. The SSD explained that any concerns about residents being handled roughly during care should be addressed with the nursing department, and

a grievance should be made and processed. A review of the facility's grievance policy revealed: The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee.

Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The resident should have reasonable expectations of care and services, and the center should address those expectations in a timely, reasonable, and consistent manner.

An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. Original grievance forms are then submitted to the Grievance Officer/designee for further action. The Grievance Officer/designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame, this should not exceed 14 days. The Grievance Officer will log complaints/grievances in Monthly Grievance Log. The individual voicing the grievance will receive follow-up communication with the resolution, a copy of the grievance will be provided to the resident upon request.

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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

10/21/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

health in relation to [family member]. Resident denies physical contact. She remains at her psychosocial baseline. Resident states that she feels safe in facility. Psych eval [evaluation] completed on 7/3/25. Abuse, neglect, and exploitation education initiated. Staff statements initiated. Interviewed Res [residents] with BIMS of 10 or greater. Skin sweeps of residents with BIMS of 9 or below. Witness statements initiated.

Employee suspended pending investigation. A review of witness statements provided by the facility revealed a statement from Staff Q, RN, with no date documented. No other witness statements, from staff and residents, were provided by the facility regarding the investigation of Resident #2's allegation of a sexual/verbal adverse event. The NHA and DON said they did not interview other residents as it was a conversation between a staff member and one resident. The NHA said she felt it was an isolated event, and no other residents were present. The NHA and DON said no other staff members were present except for Staff Q, RN. The DON said no skin sweeps were completed because of the delay in reporting and confirmed there was no documentation in the investigation file about skin sweeps that were completed. He confirmed the FEDREP information included the facility conducted skin sweeps on residents with a BIMS of 9 and below as part of their investigation. The DON confirmed skin checks are typically done weekly at the facility and the unit manager is expected to ensure they are being completed. He said the wound care provider documents in the non-pressure versus (vs) pressure assessment. He confirmed the wound care provider is not completing the weekly skin evaluations during their wound care, as it is specific to the wound for that resident. Review of the facility's policy titled abuse, neglect, exploitation and misappropriation, dated 11/16/22, revealed the following under investigation, The Abuse Coordinator and/ or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Further review of the policy, under reporting/response, revealed the following, . The Abuse Coordinator will endeavor to protect the rights of resident and employees. The Administration recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened.

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

10/21/2025

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 0699 Level of Harm - Actual harm Residents Affected - Few

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

outside. She reports that she is journaling and that it is helping her cope. Patient is not experiencing anxiety. No mood swings and behavioral outbursts noted. Patient has fair sleep and appetite. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .On 10/21/25 at 3:55 p.m., an interview was conducted with Staff S, LPN. She said she had not recently been the nurse assigned to Resident #1 as she, Floats all over the place. She said she was not aware of where to look for the resident's PTSD triggers. She said the nurse that is usually assigned to Resident #1 was not working today.On 10/21/25 at 4:00 p.m., an interview was conducted with Staff E, CNA. She said she floats and does not have a set assignment. Staff E, CNA said she had not worked with Resident #1 long enough to determine what her PTSD triggers were. She said Resident #1 showed signs of frustration if care was not done her way and could seem overwhelmed at times. Staff E, CNA said she was not aware if Resident #1 preferred a male or female to care for her. She said there was a place to document behaviors in the electronic health record.On 10/21/25 at 4:59 p.m., an

interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON).

The DON said there were changes made as a result of the investigation of Resident #1's allegation of sexual abuse made on 9/6/25. He said the change they made was to make sure Resident #1 did not have a male caregiver, per her request. He said nursing staff were made aware of the change. The DON stated, It's not written down anywhere, it's verbal. He said he was not sure if changes or updates were made to Resident #1's care plan.A review of Resident #1's nurse aide reference information, known as the Kardex, dated 10/21/25, revealed no information about a preference for a female caregiver or no male care givers.

On 10/21/25 at 6:28 p.m., the DON provided an assignment sheet for the east back hall that had handwritten documentation of, no male caregivers. review of other documents revealed no documented reference of the resident's caregiver preferences.A review of the facility's, trauma-informed care, dated 10/24/22, revealed the following, Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization. Further review of the policy, under procedure, revealed the following, .3. Develop a care plan and add interventions to the nurse aid Kardex.

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If continuation sheet