Health inspection·August 28, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a safe and orderly discharge for one residents (#1) and failed to follow up post discharge for two residents (#1 and #10) out of three residents sampled.Findings included:1. Review of Resident #1's admission record showed he was admitted on [DATE] and discharged on 6/20/25 to Private home/apt.(apartment) with no home health services: Home. Resident #1's medical diagnoses including the following: Stage 3 pressure ulcer of sacral region, paraplegia, chronic pain and osteomyelitis of the spine. Review of Resident #1's physician order dated 6/20/25 revealed Resident to discharge 6/20/25, DME [durable medical equipment]: 18 in (inch) W/C (wheelchair) with leg rests; shower chair, bedside commode; hospital bed; slide board; recliner chair; large briefs; wound care; physical therapy/ occupational therapy eval (evaluation) and treat (treatment).Review of Resident #1's physician order summary report, showed orders including:An order dated 6/19/25 revealed, discharge on [DATE], send all non-controlled medications. Send three days of narcotics.Order dated 6/11/25, apply zinc [ointment] to left ischium daily and as needed.Order dated 6/1/25, Cleanse left ischium wound with Dakins sol 0.125%, apply collagen powder, Cal Alginate and cover with superabsorbent dressing daily and as needed.Order dated 4/11/25, Oxycodone 15mg every 4 hours as needed for non-acute pain.Review of Resident #1's Medication Administration Record (MAR) dated 6/1/25-6/30/25 showed Oxycodone 15mg every 4 hours as needed for non-acute pain was given 43 out of 56 opportunities, between five to six dosages daily. Review of Resident #1's wound care provider note, dated 6/18/25 showed the reason for the visit was a stage four sacral pressure ulcer follow-up. Treatment clean wound with Dankins solution 0.125%, cover with collagen, alginate, super absorbent and bordered dressing daily. Recommendations include off load wound, turn and reposition per facility policy. Review of Resident #1's pain management provider note, dated 6/19/25 showed current regimen is reported reasonable effective to maintain comfort and motivation with person Activities of Daily Living [ADL's] . Plan he had dc [discharge] plans in place; .will ok 3 days of opiates to go home with patient .he is concerned in regard to quantity of PRN meds; oxycodone 15 mg every 4 hours; have discussed with nursing/ADON.Review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section C, cognitive patterns revealed a Brief Interview for Mental Status (BIMS) summary score of 15 out of 15 indicating intact cognition. Section GG, Functional Abilities showed Resident #1 had impairments to bilateral lower extremities, uses a manual wheelchair for mobility, requires substantial to maximal assistance to get in and out of a tub or shower and needs full assistance with shower/bathe. Resident #1 requires partial to moderate assistance when positioned from sitting on the side of the bed to lying down, transferring from a bed to a chair and getting on and off the commode. Review of Resident #1's Social Service Progress notes showed the following:A note dated 6/16/25, Resident said he would like to be discharged from the current facility by 6/20/25. Social Service staff faxed a request for DME and Home Health (HH) and will request the resident's discharge Page 1 of 7 105132 105132 08/28/2025 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some address prior to facility discharge.A note dated 6/17/25 showed the facility called Resident #1's home care service provider and told the name of the home health provider and was informed DME had not been established with a vendor. The facility's social service staff will follow up with the home care service provider to see when a DME provider is chosen.A note created on 6/20/25, dated 6/19/25 showed, call placed to the home care service provider to inquire about the DME for Resident #1's 18 (inch) W/C (wheelchair). The home care provider services representative has not received insurance authorization.A note dated 6/20/25, Social Service staff was contacted that authorization for wheelchair had not been obtained and a request for the facility's social services to reach out to Resident #1's insurance to find out when authorization and be established. A review of Resident #1 Primary Care Physician (PCP) note dated 6/17/25 showed continue oxycodone for pain, on Naloxone (antidote) as directed . continue wound care management for pressure ulcers, .fall precautions and use of safety devices A review of Resident #1's discharge plans and instructions, with an effective date of 6/18/25, showed the following:The name of who will accompany Resident #1 was not listed. The disposition was home by car. Part 2; Physician information: Section EHome Health Services: Receiving Home Health Services is not marked, Section F- Medical Equipment Supplier: receiving medical equipment is not marked and Section K- Wound Care: Receiving Wound Care Services is not marked. Part 4- Functional Status Evaluation discharge: Section 3- shows Resident #1 usually needs setup or clean up assistance before and after voiding or having a bowel movement. The helper does all the task when transferring from a bed to a chair. The ability to transfer in and out of a car was not attempted. Resident #1 requires a helper to do all the task to get on and off the toilet or commode. Review of the Social Services Discharge Summary note revealed a Home Health Care agency was provided, and DME provided. The Medication Summary shows prescriptions and mediations were sent with Resident #1. The section to document the number for the president's post discharge follow-up phone call is not completed. The discharge disposition shows Resident #1 was discharged with home health services. Documentation regarding post discharge follow-up phone call is blank. Review of the medical record did not reveal evidence the facility followed up with Resident #1 after discharge.During an interview on 8/27/25 at 4:34 PM the Social Services Director (SSD) said his responsibilities include faxing referral orders to home health services (HHS) and Durable Medical Equipment (DME) providers. He said he has an established relationship with Resident #1's HHS provider. Regarding the process to verify HHS services had started, the SSD says he does not always know and relies on the HHS providers to contact him.During a telephone interview on 8/28/25 at 9:47 AM with Resident #1's Primary Care Physician (PCP) said the resident had chronic pain, he is also his patient in the community, and he knew him well. HHS providers are involved; they are the ones who help us deal with making sure that the patient receives the care they need. He said, I expect my orders to be followed. During a telephone interview on 8/28/ 25 at 9:10 AM with Resident #1's documented HHS provider. The HHS representative said there is no file [current record] for Resident #1 the last referral for services was on 7/19/24. On 8/28/25 at 9:30 AM during a telephone conversation with Resident #1's home care benefits manager company, a company representative said on 6/20/25 the facility was notified the home care benefits provider did not accept Resident #1's insurance for home care services. On 6/27/25 Resident #1 was notified the company could not process orders for shower chair. On 8/5/25 the home care benefits manager closed out orders for the commode and transfer device due to missing documentation from Resident #1's insurance company. The representative said according to Resident #1's records the referral needed to be sent directly to [Insurance Company] for authorization.2. Review of Resident #10's admission record showed an admission date of 7/1/25 and a discharge date of 8/18/2025 to a private home/apartment with home health 105132 Page 2 of 7 105132 08/28/2025 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 105132 Page 3 of 7 105132 08/28/2025 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure treatment and care were provided after an upper extremity fracture in accordance with professional standards of practice for one resident (#2) of three sampled residents.Findings included:On 8/27/25 at 10:05 a.m., Resident #2 was observed sitting up in bed wearing a hospital gown. Resident #2's left arm was observed to be without movement and laid straight at his side. He was not wearing a left arm sling. Review of Resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses to include: cerebral infarction due to thrombosis of right middle cerebral artery; muscle weakness (generalized); spastic hemiplegia affecting left nondominant side; other symptoms and signs involving cognitive functions and awareness; aphasia following cerebral infarction; other schizoaffective disorders and was updated to include unspecified fracture of upper end of left humerus on 7/23/25.Review of Resident #2's medical record showed he had a designated healthcare proxy.On 8/21/2025 Resident #2 had a Brief Interview for Mental Status (BIMS) score, of 15 indicating intact cognition. Review of Resident #2's Emergency Department (ED) Discharge (DC) instructions from an acute care facility dated 7/22/25 at 5:24 p.m. shows: See Orthopedic surgery within 3-5 days. Please call to arrange an appointment for your left humerus fracture. Review of Resident #2's facility orders on 7/23/25 showed: sling to left arm as allowed and tolerated every shift related to unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. There were no orders found for orthopedic surgery follow-up. Review of Resident #2's Treatment Administration Record (TAR) shows sling to left arm as allowed and tolerated every shift was checked off as performed for 8 of 9 days in July and 26 of 27 days in August. Review of Resident #2's progress notes dated 7/24/25 and 8/6/25 by the Resident's Primary Care Physician (PCP) stated: Plan includes: left arm sling, continue to monitor. Physician Progress notes dated 8/14/25 8:17 p.m. by the Resident's Nurse Practitioner stated: Left humerus fracture: continue immobilization and orthopedic follow-up per protocol. There were no progress notes stating the resident refused the left arm sling. Review of Resident #2's care plan initiated on 9/9/24 and revised on 5/15/25 shows: Alteration in usual functional performance in self-care related to CVA, use of psychoactive medication, communication impairment with a goal that stated the resident's functional performance in self-care will maintain at current functioning level through the next review target date of 11/26/25. The most recent intervention included: Apply sling to left arm as allowed and tolerated (initiated 7/23/25). There were no other interventions initiated since 7/23/25 including in other focus areas of the care plan. An interview was conducted with Resident #2 on 8/27/25 at 11:15 a.m. Resident #2 stated they put my arm in a sling after my injury. I don't need it anymore. My arm is better. During a phone interview on 8/27/25 at 1:24 pm with Resident #2's healthcare proxy, the healthcare proxy stated: He won't wear the sling for the left arm. The hospital ED said Resident #2 needed to see a bone doctor, but I was told by nursing at the facility that it was not recommended. During an interview on 8/27/25 at 2:00 p.m. with Staff Q, LPN, Staff Q stated if the staff makes a check mark in the TAR for an arm sling it means the sling is on. If the resident didn't have it on, I would chart ‘No' and then make a note about it. Or we can use the number codes to say ‘Other, refused', but I would make a note. During an interview on 8/27/25 at 2:20 p.m. with Staff P, CNA, Staff P stated I usually get Resident #2 out of bed every day. I know he used to have a left arm sling, but the resident is not wearing it anymore. The CNAs can put that on, but I haven't for a while. An interview was conducted with Staff O, RN on 8/27/25 at 2:25 p.m. Staff O said the left arm sling order is when needed (PRN). If there is a checkmark in the chart, it probably means it is on. Resident #2 Residents Affected - Few 105132 Page 4 of 7 105132 08/28/2025 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 105132 Page 5 of 7 105132 08/28/2025 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to maintain accurate records of controlled substances and ensure narcotics were reconciled as required for three residents (#2, #3, and #4) out of three sampled residents.Findings included:On 8/27/2025 at 10:03 a.m., an interview was conducted with Resident #3. Over a week ago the resident did not receive the prescribed oxycodone 10 mg during an evening shift. The resident stated the pain medication was due at 6:00 p.m. Staff U, Licensed Practical Nurse (LPN), was asked several times to administer the medication. The resident did not receive the medication until the next shift. Review of the Medication Administration Record (MAR) and the Medication Monitoring/Control Record, the Narc log, revealed administrations were present in the Narc log but the corresponding administrations were not documented in the MAR. The following findings detail the volume of administration not documented in the MAR:Review of the Medication Administration Record dated 7/1/2025 through 7/31/2025, revealed Resident #3's MAR was missing nine out of 56 doses of Oxycodone 10 mg recorded on the Narc log. Resident #2's MAR was missing five out of the 90 doses of Norco (hydrocodone / acetaminophen) 325 mg recorded on the Narc log. Resident #4's MAR was missing 10 out of the 62 doses of Oxycodone 10 mg recorded on the Narc log.Review of 8/1/2025 through 8/15/2025 MAR records, revealed Resident #3's MAR was missing 10 out of 31 doses of Oxycodone 10 mg recorded on the Narc log. Resident #4's MAR was missing 2 out of the 13 doses of Oxycodone 10 mg recorded on the Narc log.On 8/28/2025 at 9:25 a.m., an interview was conducted with Resident #4. The resident began to use pain medications when physical therapy started. Resident #4 said medication is required to improve the residents' pain tolerance during the physical therapy sessions. The pain medication is scheduled for every 4 hours now. The resident will request the medication before physical therapy and would like it to be coordinated with physical therapy more often.On 8/28/2025 at 10:11 a.m., an interview was conducted with Staff H, LPN. She described the facility's process for receiving and documenting controlled substances. The pharmacy brings the medications to the facility, and two nurses must sign to receive the medications. They record the medication information in the Narc book. She stated when the medications are scheduled then they are administered during that scheduled time. If the medication is PRN, as needed, then it is administered if the resident asks for it. The medications are supposed to be recorded in the MAR and on the narcotic count sheet. She revealed that if you forget to record a medication, then the medication can be back dated. She was unsure of a certain amount of time allowed to back date a medication, but she knows that documentation should be done immediately. She stated that if the narcotic count does not match the documentation, then they are required to flag it. They must then let the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) know about the error. She has received some training on the facility's controlled substance reconciliation policy. She was unsure about the date the training occurred. Her most recent training was in June 2025 regarding the facility's two-nurse system. The narcotics are stored in the medication carts, with a two-lock system. She has never encountered a narcotic discrepancy. During shift-to-shift narcotic count verification, the nurses look at the number of medications on the Narc Sheet and count it all together. If medication is not available in the cart, then the nurse must retrieve the medication from a medication dispensing system. They must call the Pharmacy Consultant and are given a code to retrieve the medication out of the medication dispensing system. A pharmacy representative performs monthly checks of the medication dispensing system.On 8/28/2025 at 10:23 a.m., an interview was conducted with the Director of Nursing (DON). The DON said the narcotic medications come from the pharmacy with a manifest slip. Two nurses are required to sign for the medications and log them into the Narc book. The medications are placed in 105132 Page 6 of 7 105132 08/28/2025 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 105132 Page 7 of 7