Aviata At Beneva

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

9/11/25, 9/12/25, 9/20/25, and 9/29/25, N/A was entered for the evening shift.On 9/10/25, N/A was entered for the night shift. On 10/13/25 at 3:17 p.m., in an interview related to answering call lights, CNA Staff G said I don't know what the expected time is to answer a call light. If I'm in a room or if I go on break, I can't see if the light is on. I really don't know.On 10/14/25 at 9:19 a.m., an interview was held with the Administrator related to the failure of staff to respond timely to residents' call lights and the failure to provide incontinent care to meet the needs of the residents. The Administrator said the facility had no policy on call light response time or incontinent care. All staff can answer the call lights. If they are not able to assist the resident, they are to leave the call light on and find someone who can assist help. The Administrator said

they held a Quality Assurance and Performance Improvement meeting on 9/18/25 to address call light response time. She said they were also auditing call light response. The expectation was to answer the call lights within 5 minutes.Review of the Ad Hoc (unplanned) Quality Assurance and Performance Improvement Meeting dated 9/18/25 revealed there had been an increase in Resident grievances related to call light response time within the past 2 weeks. During staff rounds call lights were not always within reach.

Call lights should be answered as timely as possible preferably within 5 minutes.Review of the call light audits revealed on 9/23/25 from 1:00 p.m. to 2:30 p.m., the call light response was not within 10 minutes for 6 of 10 rooms. The observer conducting the audit documented the CNA was there, but no one answered in time. She wrote, I told CNA that they need to answer light faster. I told nurses when they hear the light if CNA not around for them to answer lights.On 9/26/25 the observer answered: No for Call light answered timely and call lights are within reach upon rounds for one room. The observer documented, . Action was taken for one room audited. CNA was told that her light was on for 10 min [minutes] and that was to [sic] long. She understood and did apologize.The Administrator did not provide audits conducted on the evening shift or the night shift.

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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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Beneva

741 South Beneva Road Sarasota, FL 34232

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to report an allegation of physical abuse to the Agency for Health Care Administration within the specified timeframe for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of the facility provided Abuse, Neglect, Exploitation & Misappropriation Policies and Procedures with an effective date of 11/30/2014 and a revision date of 11/16/2022 revealed, Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse . to a resident, is obligated to report such information immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . to the Administrator and to other officials in accordance with State law .

Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .Review of the clinical record revealed Resident #1 had an admission date of 7/9/25 with diagnoses including Parkinson's Disease with dyskinesia (involuntary, uncontrolled muscle movements), and anxiety.Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 9/30/25 revealed Resident #1 scored a 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition.Review of the Care Plan initiated on 10/1/25 for Alteration in Usual Functional Performance in Mobility/Transfer revealed Resident #1 required supervision or touching assist with 1 staff for bed to chair transfer and toilet transfers.On 10/13/25 at 10:55 a.m., in an interview Resident #1 said that the Certified Nursing Assistant (CNA) who was assigned to her the night of 10/5/25 hurt her arm while assisting her to the bathroom. She reported the incident to CNA Staff H on 10/6/25.On 10/13/25 at 12:16 p.m., in an interview the Assistant Director of Nursing (ADON) said on 10/6/25, Licensed Practical Nurse (LPN) Staff I reported to her that Resident #1 alleged during the night of 10/5/25 the CNA who was assigned to her hurt her arm while assisting her to the bathroom. The ADON said she reported the allegation to the Administrator on 10/6/25 at approximately 9:00 a.m., during morning meeting.On 10/13/25 at 12:31 p.m., in an interview LPN Staff I said on 10/6/25 she was doing rounds when CNA Staff H reported to her that Resident #1 said during the night shift of 10/5/25, CNA Staff J hurt her arm while assisting her to

the bathroom. LPN Staff I said she immediately reported the allegation to the Director of Nursing (DON) on 10/6/25 at approximately 8:30 a.m. Review of the facility provided investigation revealed the resident informed the ADON that during the night shift, the CNA came into the room to answer the light. The Resident informed the CNA that she needed assistance with toileting. The CNA grabbed the resident by the right hand and pulled her up. The resident stated that the CNA pulled her arm hard and it hurts from the wrist to the shoulder.The investigation noted the incident occurred on 10/5/25 at 8:00 p.m., and staff became aware of the incident on 10/6/25 at 12:00 p.m. The incident investigation noted the Administrator was notified of the incident on 10/6/25 at 2:07 p.m.Review of the incident reporting history revealed that the allegation of abuse was not reported to the Agency for Health Care Administration within 2 hours after the allegation was made as required. The report was submitted to the Agency for Health Care Administration

on 10/7/25 at 1:07 p.m.On 10/14/25 at 12:59 p.m., in an interview the Administrator said the allegation of physical abuse should have been reported to the Agency for Health Care Administration within 2 hours and

it was not.

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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Beneva

741 South Beneva Road Sarasota, FL 34232

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, resident and staff interviews, the facility failed to provide assistance with showers as outlined in the resident's care plan and according to residents' preferences for 2 (Residents #900 and #800) of 3 dependent residents reviewed.The findings included:Review of the clinical record revealed Resident #900 had an admission date of 9/9/25. Diagnoses included weakness, hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) affecting the right side.Review of

the admission Minimum Data Set (MDS) with an assessment reference date of 9/15/25 revealed Resident #900 was dependent for toileting, dressing and bathing and was always incontinent of bowel and bladder.

The MDS noted the resident scored 13 on the Brief Interview for Mental Status, indicating of intact cognitive skills for daily decision.On 10/13/25 at 10:42 a.m., in an interview Resident #900 said he doesn't get his scheduled showers on Wednesdays and Sundays. He has gone days, even weeks without a shower. When

he asks for a shower, staff tell him they'll be back to shower him but they don't.The resident pointed to a sign on the wall that documented his showers were scheduled on Wednesday and Sunday during the 7:00 a.m. to 3:00 p.m., shift.Review of the Certified Nursing Assistant (CNA) documentation for September and October 2025 revealed Resident #900 was scheduled for showers on Thursday and Sunday during the 7:00 a.m. to 3:00 p.m., shift.On 9/11/25, 9/18/25, 9/25/25 and 9/28/25 on scheduled shower days, a bed bath was documented.On 9/16/25, 9/23/25 and 9/30/25 there was no documentation of care.On 10/5/25 and 10/9/25 on scheduled shower days, N/A (not applicable) was entered for shower.Review of the clinical

record for Resident #800 revealed an Annual MDS with an assessment reference date of 8/1/25. The MDS noted Resident #800 scored 15 on the BIMS, indicating intact cognition. The resident was dependent on staff for incontinent care, personal hygiene and bathing.Review of the Care Plan with a revision date of 9/25/24 revealed Resident #800 had an activities of daily living (ADL) self-care performance deficit related to decreased mobility, chronic pain, lymphedema (swelling of arms or legs), and lower extremities weakness. The goal with a revision date of 5/8/25 noted the resident would receive appropriate staff support with ADL's (Activities of Daily Living).On 10/13/25 at 12:00 p.m., in an interview Resident #800 said

she likes to shower and get her hair washed but has not received a shower in several weeks.Review of the CNA documentation for September 2025 and October 2025, revealed Resident #800's shower days were Mondays and Thursdays on the 7:00 a.m. to 3:00 p.m. shift.On 9/1/25, 9/4/25, 9/11/25, 9/15/25 and 10/9/25

the documentation showed Resident #800 received a bed bath.On 9/29/25, N/A was documented.On 10/14/25 at 12:04 p.m., in an interview the Administrator said the facility had no policy on ADL care or bathing. The staff are expected to follow the shower schedule.On 10/14/25 at approximately 12:35 p.m., in

an interview CNA Staff F said There is shower list at the desk, and you follow it. The residents will let you if

they want a shower.

Residents Affected - Some

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

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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Beneva

741 South Beneva Road Sarasota, FL 34232

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, review of facility's policy and procedure and staff interview, the facility failed to ensure medications were kept locked in 1 (300 hall) of 4 medications carts observed when not in use and under direct supervision. The findings included: Review of the facility policy 1.0 Medication Dispensing System (no effective date) documented Medication carts are always to be locked when out of sight or unattended.On 10/13/25 at 10:23 a.m., during a tour of the facility the 300-hall medication cart was observed unlocked, and unattended and unsecured for approximately 4 minutes. Residents and staff were observed passing by the unlocked medication cart.On 10/13/25 at 10:27 a.m., Licensed Practical Nurse Staff A was observed coming around the corner. She said she went to gather supplies for a resident and verified she left the medication cart unlocked and unattended for several minutes.

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If continuation sheet