Aviata At The Palms

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

She said she called and let her manager know about the incident. Staff D, Nurse Supervisor confirmed Staff B, LPN was his assigned nurse. She stated, She [Staff B, LPN] was on the floor, not in the dining room. She said she does not know Resident #3 well but knows he was on a pureed diet and assumed he had a swallowing difficulty. She confirmed she assisted with educating staff after the incident. She said immediately after the incident, they started making sure a nurse and/or management is in the dining room

during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating. On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds.

She confirmed she documented her assessment in the electronic health record. Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed. Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when she was told about what happened. She confirmed she would have expected to be notified and would have evaluated him sooner since she was his assigned nurse. Staff B, LPN said lunch in the dining room is around 11:00 am. When asked what time she assessed Resident #3 she stated, Pretty much whatever time I documented is when I evaluated him, it was probably a few minutes before. Staff B,

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at the Palms

2600 Highlands Blvd N Palm Harbor, FL 34684

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

NHA to review their response to the incident with Resident #3. The NHA said the incident happened on 11/9/25. She said she was made aware during the morning meeting on 11/10/25 that Resident #3 choked

in the dining room. The NHA said Staff D, Nurse Supervisor notified her Resident #3 had the wrong lunch tray and choked on a small piece of ham. The NHA said Resident #3 was fine, he had no change in condition, was at baseline, and the physician was notified who ordered a chest x-ray. She said Staff K, receptionist who was assisting with passing meal trays gave the resident the tray. The NHA said Staff D, Nurse Supervisor told her she did not see the tray provided to Resident #3 due to her being with two other resident emergencies. The NHA said she asked the dietary team about Resident #3's meal ticket that day and she was advised it was the right ticket on the tray. She said the dietary staff confirmed they provided

the right tray, meal, and verified the meal before the tray exited the kitchen area. She said through her

interview with Staff K, receptionist she confirmed she did not verify the meal before giving it to Resident #3.

The NHA said after the Heimlich was performed, Resident #3's tray was taken back to the kitchen and confirmed he had the wrong tray. The NHA said he was provided a regular diet to include regular consistency of ham, black eyed peas, and greens. She said through their investigation they are not sure if it was the dietary staff or the staff passing trays that provided the wrong meal to Resident #3. The NHA stated

it is, Still unknown where the error and confusion happened. She said Resident #3 was assessed again on 11/10/25 and had no signs of distress and labs completed showed he did n

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at the Palms

2600 Highlands Blvd N Palm Harbor, FL 34684

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

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

F 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

facility's immediate actions to remove the Immediate Jeopardy included:- On 11/10/2025, the Nursing Home Administrator, educated unlicensed staff that served the wrong diet consistency tray was suspended and educated on abuse and neglect.- On 11/10/25 dietary employee that prepared the wrong diet consistency tray was suspended and educated on abuse and neglect as well as tray accuracy by the CDM district dietary manager.- On 11/10/25 an ADHOC Quality Improvement Performance Committee meeting was held to review the recommendations made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing (via telephone), and management staff.- On 11/10/25, a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis (RCA) as determined by Quality Assurance Performance Improvement committee (QAPI). Root cause analysis identified as dietary staff prepared the incorrect diet consistency for Resident #3 and an unlicensed staff member served the incorrect meal tray.- On 11/10/25

The ADHOC QAPI Committee approved the following recommendations:1. Resident was assessed, MD was notified & chest x-ray was ordered.2. Current residents in the facility diet orders in [electronic health

record vendor] were checked against meal tickets in the kitchen to ensure all were accurate.3. Education was completed for dietary employees on following the correct diet when preparing resident meal trays.4.

Nursing staff were educated on checking the meal tickets with diet being served.5. Nursing staff completed competencies on meal tray serving.6. Current facility staff were

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at the Palms

2600 Highlands Blvd N Palm Harbor, FL 34684

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

management is in the dining room during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating.On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds. She confirmed she documented her assessment in the electronic health record.

Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed.

Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when

she was told about what happened. She confirmed she would have expected to be notified and w

Event ID:

Facility ID:

If continuation sheet