Colonial Lakes Health Care

F-F692

Resident #1 was admitted to the facility on [DATE REDACTED] from an acute care hospital with diagnoses that included Parkinson's disease, dysphagia oropharyngeal phase (trouble swallowing in the mouth or throat), history of cerebral infarction (stroke), and unspecified dementia. Review of resident #1's physician orders for December 2024 revealed orders for a dysphagia mechanical soft texture diet since 8/29/23.

The Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had a Brief

Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. She had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs). She was not identified as having any symptoms of a swallowing disorder but was on a mechanically altered diet which required a change in food texture or liquids.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 Review of resident #1's care plan, with revision date 11/20/24, identified she had a potential nutritional problem related to the need for mechanically altered diet texture and past medical history of Parkinson's Level of Harm - Immediate disease, dysphagia, dementia, and Gastro Esophageal Reflux Disease. The interventions included staff to jeopardy to resident health or monitor/document/report as needed any signs or symptoms of dysphagia but failed to include interventions safety for staff to serve diet as ordered.

Residents Affected - Few According to the National Foundation of Swallowing Disorders, which followed the recommendations from

the American Dietetic Association, a dysphagia mechanical soft texture included foods such as soft pancakes, and pureed breads but all other bread textures should be avoided. Other foods that should be avoided included sandwiches and peanut butter, (retrieved on 1/23/25 from Swallowingdisorderfoundation. com).

On 1/13/25 at 1:56 PM, the facility's Reportable and Adverse incident log from December 2024 was reviewed with the Director of Nursing (DON) who was also the Risk Manager. She said that on 12/20/24 at around 11:00 AM, CNA A alerted staff that resident #1, who at the time was in the day room of the memory care unit, was choking on a snack. The Heimlich maneuver was performed, and the resident was suctioned but ultimately, was transferred via Emergency Medical Services (EMS) to the hospital. The DON recalled she responded to the scene along with two nurses, the Advance Practice Registered Nurse (APRN), and the Physician Assistant (PA). According to the DON, the root cause was staff not being familiar with the approved snack list based on diet texture orders and snacks being placed unsecured on a dementia unit.

On 1/14/25 at 9:24 AM, during a telephone interview, CNA A stated she had worked at the facility since July 2024 and had no prior CNA experience. She reported on 12/20/24 she was assigned to work on the secure memory care unit. She noted she had worked with resident #1 before and was aware she was on a dysphagia mechanical soft texture diet. She recalled at about 11:00 AM, she went to the nourishment room, located outside of the secured unit, to get snacks for the residents. She said she picked up a tray with labeled snacks with resident names and other snacks such as peanut butter sandwich and cookies, that had no resident names. She stated she went back to the memory care unit's dayroom where resident #1 was seated at a table by herself next to the door. She said she placed the tray of snacks on a table across from resident #1 and then saw the resident grab a peanut butter and jelly sandwich. She said she allowed the resident to have the sandwich because she had seen her eating bread before, and the sandwich was soft.

She remembered she was called away by another CNA that needed help and left the dayroom. She noted

she was called back to the dayroom by a hospice CNA a few seconds later as resident #1 didn't look good.

She said the resident was turning blue, had her mouth open and tongue sticking out. She recalled she immediately called for help and LPN C administered the Heimlich maneuver and LPN D assisted with suctioning the resident's airway. She reported resident #1 was unresponsive and was given supplemental oxygen until paramedics arrived and transferred the resident to the hospital. She said she was not trained on what foods were appropriate for a dysphagia mechanical soft diet and did not ask anyone if a peanut butter and jelly sandwich was appropriate for the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 Review of the nursing progress notes revealed a change in condition note entered on 12/20/24 at 1:30 PM, by an LPN that noted the resident went into respiratory arrest. The note revealed resident #1's vital signs at Level of Harm - Immediate the time of the incident were, blood pressure 85/56, pulse 44, respirations 0, oxygen saturation 71% on room jeopardy to resident health or air, and mental status was unresponsive. The LPN documented that she responded immediately and noticed safety the resident had something in her mouth and her face was discolored. She started the Heimlich maneuver and soggy bread material was expelled from her mouth. The note showed they lowered the resident on to Residents Affected - Few the floor on her side and suctioned. The note read that EMS arrived, applied oxygen and the APRN gave the order to transfer the resident to the hospital. At 2:34 PM the LPN noted she spoke with the resident's son who said he was at the hospital with the resident.

According to resident #1's hospital records with admitted [DATE REDACTED], noted she was seen due to the choking incident and resident being unresponsive. The admission summary showed the resident was having her meal, started to choke and became unresponsive. On arrival to the emergency room (ER), she remained unresponsive, was intubated for hypoxic respiratory failure and admitted to the ICU. The discharge summary dated 12/24/24 showed the discharge diagnosis of acute hypoxic respiratory failure and noted that speech and swallow tests were done, and diet was adjusted.

Review of resident #1's modified Quarterly MDS completed on 12/27/24, post readmission from an acute care hospital, revealed she required setup assistance for eating, had a new behavior of rejecting care, had difficulty swallowing due to coughing or choking during meals, and continued on mechanically altered diet.

Review of a physician progress note dated 12/29/24, noted resident #1 was evaluated for resumption of care

after hospitalization from [DATE REDACTED] to 12/24/24 due to choking resulting in intubation as per hospital record with administration of multiple intravenous antibiotics in the ICU setting. She returned to the facility on antibiotic therapy for five days.

Review of CNA A's personnel file revealed she was hired on 7/09/24 and had received her CNA certification

in 2024. The facility's Job Description for CNAs noted CNAs were entrusted to provide responsible healthcare and were responsible to provide each of their assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan. Other duties and responsibilities included providing direct care in accordance with treatment plans and attending scheduled facility in-services, orientations, and educational classes. According to the job requirements, CNAs must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.

On 1/14/25 at 4:34 PM, the Assistant Director of Nursing (ADON) was interviewed with the Regional Nurse Consultant (RNC) and DON present. The ADON confirmed she was the Staff Educator and stated staff received orientation with general nursing topics that included nutrition but not specific to diet types and appropriate food textures.

Review of CNA A's education file revealed she completed the new hire orientation packet and skills competency assessment for eating support on 7/10/24. There were no documented competencies or in-services related to caring for dysphagia residents, food textures, or appropriate foods/snacks for each diet type.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 On 1/15/25 at 12:43, CNA E said that prior to the choking incident she had not been educated on diet types or food textures. She worked with resident #1 regularly and said she preferred not giving resident #1 a snack Level of Harm - Immediate because she was at risk for choking. jeopardy to resident health or safety On 1/15/25 at 1:10 PM, CNA A stated she had not received training related to diet types or food textures when she was hired, and she did not remember attending any in-services prior to the choking incident. Residents Affected - Few

On 1/15/25 at 1:46 PM, LPN D reported he had worked at the facility for a total of two years. He said he had never received education during orientation related to diet types and food textures but had received education at a prior facility.

On 1/15/25 at 3:21 PM, interviews were conducted with five CNAs from the first and second shift, who said

they did not receive education regarding diet types or food textures prior to the choking incident. They confirmed they were responsible for passing out meal trays, handing out snacks, assisting with feeding residents, and monitoring residents during meals.

A review of the Facility Assessment revised 8/01/24, noted the facility provided resident services such as eating assistance and nutritional services including individualized dietary plans and specialized diets. The assessment lacked an explanation of how the facility would educate their staff to ensure these services were provided safely and appropriately. According to section 3.4, Staff training/education and competencies, in-service trainings for nursing aides must address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff.

According to the Consistency Census Report printed on 1/14/25 at 2:51 PM, 31 out of 175 residents in the facility required a mechanically altered texture diet (mechanical soft, pureed, thickened liquids) related to a dysphagia diagnosis. In the memory care unit six residents required a mechanically altered texture diet.

The resident sample was expanded to include seven additional residents who required dysphagia diets.

Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team:

*CNA A received a teachable moment regarding appropriate snacks according to diet texture with DON on 12/20/24.

* On 12/20/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to

review the action plan. The Medical Director reviewed and approved the plan.

* On 12/20/24 the RD completed a quality review on resident diet orders and validated with the Certified Dietary Manager (CDM) against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 * On 12/20/24 resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were Level of Harm - Immediate posted to dining rooms, nursing stations, and med carts. CDM validated that snacks were delivered to the jeopardy to resident health or secured pantry. safety * Education for staff started on 12/20/24 and continued through 1/3/25 with 98% trained. Education included Residents Affected - Few recognizing the different diet types and food textures, appropriate snacks for each diet type, and procedure to validate the resident's diet order as needed. Training also included Abuse/Neglect training and supervision

during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders.

* On 12/23/24 CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedure for snacks. New diet orders would be reviewed during morning clinical meeting.

*On 12/23/24 Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done 12/23/24, 12/30/24, and 1/6/25 with no discrepancies noted.

*On 12/24/24 a facility wide quality review began by Speech Language Pathologist verifying that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed on 1/14/25 with no discrepancies noted.

*Resident #1 returned to the facility on [DATE REDACTED] from the hospital with diet texture downgraded to puree. Orders and care plan were updated accordingly to reflect the texture change. Registered Diet (RD) followed up with resident on 12/26/24 with no new recommendations.

* On 12/24/24 the Administrator and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective.

*On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical

record matched the meal tracker. There were no issues noted.

Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks. Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 105440

F-F726

Resident #1 was admitted to the facility on [DATE REDACTED] from an acute care hospital with diagnoses that included Parkinson's disease, unspecified psychosis, dysphagia oropharyngeal phase, history of cerebral infarction (stroke), unspecified dementia, generalized anxiety disorder, and major depressive disorder. Review of resident #1's physician orders for December 2024 revealed an order for a dysphagia mechanical soft texture diet since 8/29/23.

Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed she had a Brief

Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. The assessment indicated resident #1 had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs). The assessment did not document any symptoms of a swallowing disorder but showed she was on a mechanically altered diet which required a change in food texture or liquids.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 Dysphagia is defined as difficulty swallowing that could, in some cases, make it almost impossible to swallow. Oropharyngeal phase dysphagia can be caused by neurological conditions such as Parkinson's Level of Harm - Immediate disease. Not being able to swallow correctly can lead to complications such as aspiration pneumonia due to jeopardy to resident health or food entering the lungs and choking due to food getting stuck in the throat. When food gets stuck in the safety throat it can block the airway and lead to death if not attended to promptly (retrieved on 01/21/25 from the mayoclinic.org). Residents Affected - Few

The National Foundation of Swallowing Disorders, following the recommendations of The American Dietetic Association, described dysphagia mechanical soft texture diet included foods such as pureed breads but advised all other bread textures should be avoided. The recommendations included other foods to be avoided included sandwiches and peanut butter, (retrieved on 1/23/25 from swallowingdisorderfoundation. com).

A progress note written by the Director of Nursing (DON) on 12/20/24 at 11:28 AM, revealed that at 11:10 AM, a hospice CNA and floor CNA were in the dining room of the memory care unit passing snacks. The floor CNA was called to assist on the floor and within seconds the hospice CNA alerted the floor CNA that

the resident didn't look like she felt well. The note described the floor CNA stated that the resident had her mouth open and tongue sticking out, so she called the nurse immediately. The DON documented the LPN started the Heimlich maneuver and soggy bread material came out, then she was laid on the floor on her side and suctioned. The APRN, Physician Assistant (PA), and another LPN also responded. She detailed the resident's oxygen saturation was 71% on room air so oxygen was applied, and the oxygen saturations came up to 92%. The DON detailed that Emergency Medical Service (EMS) arrived and used a laryngoscope (a small tool to look in your throat) to remove the remaining object from blocking the airway. Resident #1 was transferred to the hospital for possible aspiration and the family was notified.

Normal oxygen saturation levels should be between 95% and 100% for most people. Oxygen is essential to all body functions so low oxygen levels are concerning and may lead to many serious conditions and damage to individual organ systems, especially your heart and brain. If your level is lower than 88% you should get emergency treatment, (retrieved on 1/27/25 from www.myclevelandclinic.org).

Review of a nursing progress note revealed a change in condition note entered on 12/20/24 at 1:30 PM, that indicated resident #1 had respiratory arrest. The note revealed resident #1's vital signs at that time were, blood pressure 85/56, pulse 44, no respirations, oxygen saturation 71% on room air, and mental status was unresponsive. The LPN documented that she responded immediately and noticed the resident had something in her mouth and her face was discolored. She started the Heimlich maneuver and soggy bread material was expelled from her mouth, so they lowered her to the floor on her side and suctioned. EMS was called, oxygen was applied on the resident, and the APRN gave the order to transfer the resident to the hospital. At 2:34 PM, the LPN documented she spoke with the resident's son who said he was at the hospital with the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 A nursing progress note dated 12/24/24 at 11:02 PM, indicated resident #1 returned to the facility from the hospital with orders for a diet change. On 12/25/24 at 10:25 AM, the Respiratory Therapist (RT) assessed Level of Harm - Immediate the resident and documented she was awaiting orders from the APRN. The Registered Dietician (RD) jeopardy to resident health or evaluated the resident on 12/26/24 and noted resident #1's diet order was changed to a regular diet with safety pureed texture and thin liquids. She also documented the resident required supervision with meals due to her history of attempting to take food from others. On 12/26/24 a change in condition note was documented by a Residents Affected - Few nurse that the resident had abnormal lung sounds (rales, rhonchi, wheezing) and the doctor ordered a chest X-ray due to chest congestion.

Review of a physician progress note dated 12/29/24, revealed resident #1 was evaluated for resumption of care after a hospitalization from [DATE REDACTED] to 12/24/24 due to choking resulting in intubation (a tube in her throat to breath) as per hospital records with administration of multiple Intravenous antibiotics in the ICU setting. She returned to the facility on antibiotic therapy for five days.

Review of resident #1's hospital records with admitted [DATE REDACTED], revealed she was seen due to a choking incident where she was unresponsive. The admission summary indicated the resident choked on her meal and became unresponsive, so EMS were called. Upon arrival to the hospital emergency room (ER), she remained unresponsive, so they intubated her for hypoxic (low oxygen) respiratory failure and admitted her to the ICU. The discharge summary on 12/24/24 showed the discharge diagnosis of acute hypoxic respiratory failure and noted that speech and swallow tests had been done, and her diet was adjusted.

On 1/13/25 at 1:56 PM, the DON stated she served as the facility's Risk Manager. She confirmed that on 12/20/24 around 11:00 AM, CNA A alerted staff that resident #1 was choking on a snack in the memory care unit day room. The DON stated the facility found the root cause of the event was staff were not familiar with

the approved snacks per diet texture orders and snacks being placed unsecured in the dementia unit.

In a joint interview on 1/13/25 at 4:15 PM, with the Director of Rehabilitation (DOR) and the Speech Therapist (ST), the DOR stated resident #1's most recent Speech evaluation was completed on 8/27/24 and showed a decline in cognitive and swallowing function which required a mechanical soft/chopped textured diet. The DOR explained resident #1 also required supervision during meals and cues for swallowing. The ST stated their goal was for resident #1 to implement compensatory strategies to increase safety during meals. She explained that a mechanical soft diet consisted of foods like pudding, applesauce, Jello, and pureed bread but would not include peanut butter and jelly sandwiches.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 On 1/14/25 at 9:24 AM, in a telephone interview CNA A said she had worked at the facility since July 2024 and had no prior experience as a CNA. She recounted that on 12/20/24 she was assigned to work the Level of Harm - Immediate secure memory care unit and had worked with resident #1 before. CNA A stated she was aware resident #1 jeopardy to resident health or required a dysphagia mechanical soft texture diet and said around 11:00 AM she went to the nourishment safety room, outside of the secured unit, to get snacks for the residents. She recalled she grabbed a tray that contained labeled snacks with resident's names and other unlabeled snacks such as peanut butter Residents Affected - Few sandwiches and cookies. She returned to the memory care unit's dayroom and saw resident #1 sitting at a table by herself, next to the door. CNA A said she placed the tray of snacks on a table across from resident #1 and saw her grab the peanut butter and jelly sandwich from the tray. She confirmed she allowed resident #1 to have the sandwich because she had seen her eating bread before, thought the sandwich was soft, and ok for her to eat. CNA A explained she was then called away by another CNA that needed help and left the dayroom. She recalled there was a hospice CNA in the dayroom that was attending to another resident who called her back into the dayroom a few moments later to say that resident #1, didn't look good. CNA A explained she returned to the dayroom and saw resident #1, who was turning blue, had her mouth open and tongue sticking out. She said she immediately called for help and LPN C and LPN D arrived to provide emergency care for resident #1. CNA A remembered resident #1 was unresponsive and they gave her supplemental oxygen until EMS arrived and transferred her to the hospital. CNA A explained she had not been educated about which foods were appropriate for a dysphagia mechanical soft diet and had not asked anyone if a peanut butter and jelly sandwich was appropriate for resident #1.

On 1/14/25 at 9:35 AM, LPN C stated that she was assigned to the memory care unit on 12/20/24 and around the time of the incident she was out of the secured unit making copies at the nurse's station. She recalled at approximately 11:00 AM, CNA A came out of the secured unit saying she needed help right away. When she entered the dayroom, she saw resident #1 sitting up in a chair with her mouth open, tongue sticking out, and a creamy substance in her mouth. LPN C said she immediately started the Heimlich maneuver, and some food came out, but the resident was unresponsive. She recounted that LPN D came to

the room with portable suction and assisted her to lower resident #1 to the floor, place her on her side and suction her mouth. LPN C explained some food came out of resident #1's moth, but she was still unresponsive, and her oxygen saturation was low at 71%. She said at that time that they gave her supplemental oxygen and waited for EMS to arrive. LPN C said when EMS arrived they used the laryngoscope to get more food out of her mouth and then transported her to the hospital. She confirmed that resident #1 had known behaviors of grabbing food from others and ate very fast. LPN C stated resident #1 required a mechanical soft texture diet and therefore a peanut butter and jelly sandwich would not be appropriate for her because it was very sticky and hard to swallow.

On 1/14/25 at 9:40 AM, the Certified Dietary Manager (CDM) confirmed that resident #1 was prescribed a dysphagia mechanical soft texture diet on 12/20/24. He stated that prescribed snacks were served around 10:00 AM and 2:00 PM daily but resident #1 did not get a prescribed snack. The CDM explained resident #1 was offered a daily snack because she liked them so extra snacks were always added to the tray. He related that the dietary aides were directed to place the snack trays in the 400-hall nourishment room and not in the memory care unit's dayroom, to prevent memory care residents from grabbing foods not prescribed for their diet. He explained some of the snacks offered were peanut butter sandwiches, applesauce, pudding, and cookies. He confirmed that resident #1 had behaviors of grabbing foods from others, so trays should not be left unattended. The CDM said pureed bread was okay, but peanut butter and jelly sandwiches were not acceptable or safe for a resident who needed a dysphagia mechanical soft texture diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 On 1/14/25 at 1:46 PM, LPN D explained he had not worked on the secured memory care unit, but on 12/20/24 he was at the nurses' station outside the secured unit when he heard CNA A calling for help. He Level of Harm - Immediate recounted that when he entered the dayroom, resident #1 was sitting in a chair making gasping sounds and jeopardy to resident health or appeared to be having trouble breathing. He explained LPN C was administering the Heimlich maneuver to safety resident #1 when she went unconscious but had a pulse. He said they lowered her to the floor on her side and suctioned her mouth with some food coming out. Residents Affected - Few

On 1/14/25 at 2:24 PM, in a telephone interview CNA B confirmed she worked for an outside hospice and was at the facility on 12/20/24 to provide care to hospice residents in the building. She explained that on that day at approximately 11:00 AM, she was visiting a resident in memory care unit and was working with a resident in the dayroom when she noticed that resident #1 did not look good. Hospice CNA B said she did not see CNA A bringing the snack tray in to the room and had not seen resident #1 take the peanut butter and jelly sandwich. She explained that CNA A had left the room and CNA B ran out to get her back when she saw resident #1 looking ill. Hospice CNA B said CNA A arrived immediately and went to call for help. She reported that because she was not directly observing resident #1 when CNA A left the room, she could not say how long she had been choking before she noticed.

On 1/15/25 at 2:05 PM, the APRN said that around lunch time on 12/20/24, she was called to the memory care unit by a nurse who told her a resident was choking. She recounted when she arrived in the dayroom

she saw resident #1 sitting up in a chair and a nurse was behind her performing the Heimlich maneuver. The APRN described the resident as looking ashen and not responding but having a pulse. She said during the Heimlich some food came out, but the resident was still unresponsive. The APRN directed the staff to lower

the resident to the floor on her side and a male nurse started suctioning. She recalled that oxygen was applied until EMS arrived and proceeded with additional life saving measures. The APRN said the resident's color started improving and EMS transported her to the ER. She explained that prior to the incident she had not worked with resident #1 and was unaware of her dysphagia diagnosis or food texture order. but was told by staff that the resident had ingested some type of bread, and which caused her to choke. The APRN indicated she did not believe bread was part of a mechanical soft texture diet and it was her expectation for staff to be knowledgeable on the types of textures and foods appropriate for each diet. She said that a resident with swallowing difficulties could potentially choke, aspirate, or become unresponsive if they ingested food not suitable for their diet texture.

The Immediate Jeopardy was determined to be removed on 1/14/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy.

The resident sample was expanded to include seven additional residents who required dysphagia diets.

Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team:

*CNA A received a teachable moment regarding appropriate snacks according to diet texture with the DON

on 12/20/24.

* On 12/20/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to

review the action plan. The Medical Director reviewed and approved the plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 * On 12/20/24 the RD completed a quality review on residents diet orders and validated with the CDM against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders Level of Harm - Immediate were clarified as needed. jeopardy to resident health or safety * On 12/20/24 resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were Residents Affected - Few posted to dining rooms, nursing stations, and med carts. The CDM validated that snacks were delivered to

the secured pantry.

* Education for staff started on 12/20/24 and continued through 1/3/25. They educated staff on appropriate snacks based on resident diet texture order and the procedure to validate the resident's diet order if needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders.

* On 12/23/24 the CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedures for snacks. New diet orders would be reviewed during morning clinical meeting.

*On 12/23/24 Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done 12/23/24, 12/30/24, and 1/06/25 with no discrepancies noted.

*On 12/24/24 a facility wide quality review was begun by Speech Language Pathologist to verify that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed on 1/14/25 with no discrepancies noted.

*Resident #1 returned to the facility on [DATE REDACTED] from the hospital with diet texture downgraded to puree. Orders and care plans were updated accordingly to reflect the texture change. The RD followed up with resident #1 on 12/26/24 with no new recommendations.

* On 12/24/24 NHA and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective.

*On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical

record matched the meal tracker. There were no issues noted.

Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks. Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 105440 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105440 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

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 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49840 safety Based on interview, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had Residents Affected - Few the knowledge, skill sets, and competencies to provide foods/snacks to residents in accordance with their plan of care and physician orders for 1 of 8 sampled residents, (#1).

This failure resulted in the resident being allowed to consume the wrong consistency snack which resulted in

the resident choking and being transferred to a higher level of care where she was admitted to the Intensive Care Unit (ICU) and treated for acute respiratory failure with hypoxia.

On 12/20/24 at 11:00 AM, resident #1, who was on a mechanical soft consistency diet, was allowed to consume a peanut butter and jelly (PB&J) sandwich from a tray of snacks left on a table in the dayroom by CNA A. The CNA was aware resident #1 was on a mechanical soft diet but allowed the resident to eat the sandwich because she had seen her eat bread in the past. The CNA recalled she was called back into the dayroom by CNA B who told her resident #1 did not look good. CNA A said resident #1 was sitting up in a chair with her mouth open and tongue sticking out. Licensed Practical Nurse (LPN) C and LPN D immediately responded, and LPN C attempted to administer the Heimlich maneuver but the resident was unresponsive. The resident was lowered to the floor and suctioned with some food removed from her airway.

The resident remained unconscious with a pulse when the paramedics arrived and removed food from the back of the resident's airway. The resident was transported to the hospital and admitted to the Intensive Care Unit with admitting diagnoses of acute respiratory failure with hypoxia.

The facility's failure to follow the prescribed therapeutic diet resulted Immediate Jeopardy starting on 12/20/24. The facility implemented actions to remove the Immediate Jeopardy as of 1/14/25.

Findings:

Cross reference