Health inspection·October 21, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the determination on whether a grievance should be made or not. The SSD stated that he, doesn't really know who does or does not know about the grievance process. When asked if a grievance is filed when there is an allegation of abuse, the SSD explained that a grievance and reportable should be completed in reference to the allegation, as the situation needs to be rectified. The SSD explained that any concerns about residents being handled roughly during care should be addressed with the nursing department, and a grievance should be made and processed. A review of the facility's grievance policy revealed: The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The resident should have reasonable expectations of care and services, and the center should address those expectations in a timely, reasonable, and consistent manner. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. Original grievance forms are then submitted to the Grievance Officer/designee for further action. The Grievance Officer/designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame, this should not exceed 14 days. The Grievance Officer will log complaints/grievances in Monthly Grievance Log. The individual voicing the grievance will receive follow-up communication with the resolution, a copy of the grievance will be provided to the resident upon request. Event ID: Facility ID: 105132 If continuation sheet Page 2 of 9 Printed: 05/28/2026 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility did not ensure two allegations of abuse were investigated thoroughly for two residents (#1 and #2) out of four residents with reportable incidents reviewed.Findings included: 1.) On 10/21/25 at 10:58 a.m., an interview was conducted with Resident #1. She said an event occurred at the facility on 9/4/25. She said she had a bowel movement and relied on the staff to change her. She said around 5:00 or 6:00 p.m., on 9/4/25, she requested a female staff to assist with changing her. Resident #1 said she was told by a male staff the female staff member was busy, and she could wait until about 7:30 p.m. She said she was not comfortable with a male staff member changing her. Resident #1 said her response was she was not waiting for two hours to be changed. She said Staff I, Certified Nursing Assistant (CNA) was the only person available to assisting with changing her soiled brief. She said she ambulated in the wheelchair to her room and waited. Resident #1 said Staff I, CNA came in and assisted her into bed. She said she rolled to the side to be changed. Resident #1 said she has a catheter and when Staff I, CNA was cleaning that area she felt a lot of pressure towards her anus. She said she asked him what he was doing and continued to feel more pressure. Resident #1 said she felt Staff I, CNA's fingers enter her genital area. She stated, I swatted him and told him to get me dressed. She said she felt embarrassed afterwards and called her family members. Resident #1 stated, I didn't want to do anything, and I wanted to act like it didn't happen. She said she felt she did not have anyone to talk to. She said she told Staff J, Licensed Practical Nurse (LPN) about the incident on 9/6/25 and the nurse reported it. A review of Resident #1's admission record revealed an admission date of 8/15/25 with diagnoses to include intraspinal abscess and granuloma, other bipolar disorder, need for assistance with personal care, muscle weakness (generalized), neuromuscular dysfunction of bladder, unspecified, other psychoactive substance use, unspecified, uncomplicated, other specified anxiety disorders, other recurrent depressive disorders, and chronic post-traumatic stress disorder (PTSD).A review of Resident #1's comprehensive minimum data set (MDS), section C-cognitive patterns, dated 8/18/25 revealed a brief interview for mental status (BIMS) score of 15, meaning cognitively intact.A review of Resident #1's care plan initiated on 9/2/2025 revealed the following a focus - [Resident name] has potential for re-traumatization due to past history of trauma kidnapped and raped by [family member], multiple family suicide, trigger---loud noise, Date Initiated: 09/02/2025, with a goal of, [Resident name] triggers will be avoided, and resident will not be re-traumatized. Date Initiated: 09/02/2025 . Target Date: 12/01/2025. Interventions to include, Announcing self before entering, avoiding sudden movements Date Initiated: 09/02/2025. Avoiding noises/noisy environment Date Initiated: 09/02/2025. Do not talk about the event unless the resident wants to/initiates the conversation about the event, Date Initiated: 09/02/2025 . Giving resident control and choices, Date initiated 09/02/2025. Other: Psych services as indicated Date Initiated: 09/02/2025. A review of Resident #1's nursing progress note dated 9/7/25 revealed - Writer knocked on resident door & introduced herself & resident said come in; Writer asked how she is doing and she got a little teary and said she is still quite emotional & said she should have spoken up sooner; provided her comfort and reassurance that staff are here to support her and make her stay here pleasant & safe. Reminded her not to blame herself but to focus on her healing & therapy & recovery so she can go home when ready; Reminded her if she wants to talk anytime just let me know and I will be right there.A review of Resident #1's nursing progress note dated 9/7/25 revealed, When writer went into resident's room to give resident IV [intravenous] writer asked how she was feeling resident stated, emotional that it was a long day resident started to cry very upset. Writer assured resident that she was safe resident applied for waiting so long to report the situation and started to cry again writer tried to comfort Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 3 of 9 Printed: 05/28/2026 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident, stating that it is understandable due to situation. Resident is in good spirits to see [family member] in morning.A review of Resident #1's nursing progress note dated 9/8/25 revealed a medication administration note, 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress notes . 5 resident crying off and on.A review of Resident #1's progress note dated 9/9/25 revealed an encounter note, Date of Service: 09/09/2025 . Today, I saw patient as it was reported to me that patient is unstable requiring psychiatric assessment. Due to acuity of the situation, I saw patient using Telepsych [telehealth psychiatry] . The facility requested a psychiatric assessment to evaluate for trauma following an abuse allegation involving a staff member. The resident was cooperative and engaged during interview. She endorsed a history of PTSD related to prior kidnapping and sexual assault and stated that the recent incident was triggering for her. She prefers to manage her reactions independently at this time and declined both medication changes and initiation of psychotherapy. Recommend documenting the allegation per facility policy, offering trauma-informed supports and crisis resources, and arranging supportive check-ins with the option to re-evaluate if symptoms emerge or worsen. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .A review of Resident #1's progress note dated 9/11/25 revealed an encounter note, Date of Service: 09/11/2025 . Psychiatry Subsequent Note . Reason for Today's Encounter: Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment . past psychiatric history of depression, anxiety, Bipolar and PTSD. Prior to last visit, patient was at baseline. The patient reported feeling a little depressed and having intermittent trouble sleeping. She was having mood swings and outbursts with the staff. During last visit, patient endorsed a history of PTSD related to a prior kidnapping and sexual assault. She stated that the recent incident was triggering her PTSD symptoms. No medication changes were done. As per collected information, observed patient lying in bed resting. Patient reports that she is still feeling depressed about the alleged incident with a staff member. She is not open to psychotherapy as she has her own therapist outside. She reports that she is journaling and that it is helping her cope. Patient is not experiencing anxiety. No mood swings and behavioral outbursts noted. Patient has fair sleep and appetite. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .A review of Resident #1's pain management note dated 9/9/25 revealed, Plan . per nrsg [nursing] she had verbal altercation w/ [with] male CNAs out of proportion w/ event. she can stand short period of time; she is able to move upper body freely and is now self-propelling WC [wheelchair] . A review of Resident #1's primary provider's note dated 9/8/2025 revealed, . Follow up with sexual harassment and abuse allegation - patient expresses of being violated - police already seen the patient and made their report 3. Patient expresses feeling fine at this time - no further report of abuse . Patient report to have abuse while being take care off with her personal care. Unable to tell specific time of event. Assessment and interaction with patient is limited and cut off. When patient verbalizes already that police already made the report and assessment was done, and she is feeling fine at this time. Unable to do thorough assessment at this time - will do if patient allows us. Patient is pretty much dependent with nursing care and services for personal care and ADLs. [activities of daily living] . 4. Physical abuse of adult, initial encounter Notes: Police report already filed Psychiatry consult to evaluate and manage patient's psychiatric needs No physical assessment done - patient done - She has already been assessed and done with it. Police already took pictures and filed report - we will conduct a thorough assessment with nurse as witness if needed or warranted - patient denies any complaints or discomfort at this time.On 10/21/25 at 4:27 p.m., an interview was conducted with the Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 4 of 9 Printed: 05/28/2026 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (DON). The DON said on 9/6/25 he was notified by Staff J, LPN, who was the resident's nurse that day, that an allegation was made about a staff member being sexually inappropriate with Resident #1. He said the incident date was 9/4/25 according to Resident #1. He said law enforcement, the Department of Children and Families (DCF), and the abuse hotline was contacted on 9/6/25. The DON said the statement from Resident #1 was that Staff I, CNA did incontinence care and put his finger in her genital area. He said Staff I, CNA was suspended pending their investigation. The DON stated a skin assessment was conducted on Resident #1 and, Found issue on backside, nothing else reported. He said the sexual assault nurse examiner (SANE) came on 9/7/25 to evaluate Resident #1. The DON said he found out about the results from the SANE evaluation from DCF after they completed their investigation on 9/30/25 and told them there were no findings. The DON said skin checks were completed on residents with a BIMS score of 9 and below. He said Resident #1 had a psych consult scheduled, but she declined. Staff statements were reviewed to include the following, Staff J, LPN (dated 10/6/25, however, the DON said it was an error), Staff I, CNA (dated 9/6/25), Staff K, CNA (dated 9/6/25), Staff L, Registered Nurse (RN) (dated 9/6/25), Staff M, CNA (dated 9/6/25), and Staff R, CNA (dated 9/6/25). The DON confirmed the staff who worked on 9/4/25, during the shift where the alleged incident occurred, were interviewed but the facility did not have documentation of their statements. The DON said he typically documented the staff's interviews during an investigation. The DON provided documentation of four residents that were interviewed on 9/7/25, regarding being treated with respect, abuse and neglect, feeling safe/comfortable and knowing who the NHA, DON, and ombudsman are. He said Resident #1's roommate was interviewed and said she was unaware of what happened. The DON said he did not have documentation of the roommate's statement, except for documented responses to questions that were not specific to the incident. When asked what changes were made after the investigation, for Resident #1, the DON said they made sure the resident does not have a male caregiver per her request. He stated it is not documented as it is, Verbal between nursing staff. He said he was not sure if changes had been made to her care plan to reflect her wishes of a male caregiver. When asked about documentation of skin assessments completed on the resident the DON confirmed the facility did not have documentation in the investigation file. He said the skin checks would have been completed under the weekly skin checks in their electronic health record. On 10/21/25 at 4:47 p.m., an interview with the Nursing Home Administrator (NHA) was conducted regarding the investigation for Resident #1. A review of the NHA's handwritten notes that were in the investigation file revealed, on 9/8/25 at 2 p.m., the DCF staff member told her, with the DON present, that Resident #1 had a new complaint, . stated new complaint received 9/8 re: anal penetration on Saturday. The NHA said she is not sure where that statement came from. The DON said he did not recall the DCF staff member saying that. The NHA said she did not do anything with the information, but she thinks the DCF staff member may have asked about it. The NHA said Resident #1 did not mention that information to her directly. 2.) A review of Resident #2's admission record revealed an original admission date of 3/7/24 and a re-admission date of 6/25/24. Further review of the admission record revealed diagnoses to include other cervical disc degeneration, unspecified cervical region, major depressive disorder, recurrent moderate, generalized anxiety disorder, other chronic pain, and post-traumatic stress disorder unspecified.A review of Resident #2's care plan revealed the following:- [Resident name] has potential for re-traumatization due to past history of trauma . Triggers---Nightmares, loud noises, flashbacks, gunshots, certain TV [television] shows Date Initiated: 07/04/2024 Revision on: 05/21/2025 . A review of the facility's investigation with the NHA and the DON on 10/21/25 at 5:13 p.m., revealed the following, [Resident #2] reported that several weeks ago, [staff member] made a personal comment regarding his reproductive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 5 of 9 Printed: 05/28/2026 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete health in relation to [family member]. Resident denies physical contact. She remains at her psychosocial baseline. Resident states that she feels safe in facility. Psych eval [evaluation] completed on 7/3/25. Abuse, neglect, and exploitation education initiated. Staff statements initiated. Interviewed Res [residents] with BIMS of 10 or greater. Skin sweeps of residents with BIMS of 9 or below. Witness statements initiated. Employee suspended pending investigation. A review of witness statements provided by the facility revealed a statement from Staff Q, RN, with no date documented. No other witness statements, from staff and residents, were provided by the facility regarding the investigation of Resident #2's allegation of a sexual/verbal adverse event. The NHA and DON said they did not interview other residents as it was a conversation between a staff member and one resident. The NHA said she felt it was an isolated event, and no other residents were present. The NHA and DON said no other staff members were present except for Staff Q, RN. The DON said no skin sweeps were completed because of the delay in reporting and confirmed there was no documentation in the investigation file about skin sweeps that were completed. He confirmed the FEDREP information included the facility conducted skin sweeps on residents with a BIMS of 9 and below as part of their investigation. The DON confirmed skin checks are typically done weekly at the facility and the unit manager is expected to ensure they are being completed. He said the wound care provider documents in the non-pressure versus (vs) pressure assessment. He confirmed the wound care provider is not completing the weekly skin evaluations during their wound care, as it is specific to the wound for that resident. Review of the facility's policy titled abuse, neglect, exploitation and misappropriation, dated 11/16/22, revealed the following under investigation, The Abuse Coordinator and/ or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Further review of the policy, under reporting/response, revealed the following, . The Abuse Coordinator will endeavor to protect the rights of resident and employees. The Administration recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened. Event ID: Facility ID: 105132 If continuation sheet Page 6 of 9 Printed: 05/28/2026 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Actual harm Based on observation, record review, and interviews, the facility did not ensure the care plan was updated and individualized interventions were in place after a reportable adverse event, that resulted in re-traumatization, for one resident (#1) out of one resident reviewed.Findings included: On 10/21/25 at 10:58 a.m., an interview was conducted with Resident #1. She said an event occurred at the facility on 9/4/25. She said she had a bowel movement and relied on the staff to change her. She said around 5:00 or 6:00 p.m., on 9/4/25, she requested a female staff to assist with changing her. Resident #1 said she was told by a male staff the female staff member was busy, and she could wait until about 7:30 p.m. She said she was not comfortable with a male staff member changing her. Resident #1 said her response was she was not waiting for two hours to be changed. She said Staff I, Certified Nursing Assistant (CNA) was the only person available to assisting with changing her soiled brief. She said she ambulated in the wheelchair to her room and waited. Resident #1 said Staff I, CNA came in and assisted her into bed. She said she rolled to the side to be changed. Resident #1 said she has a catheter and when Staff I, CNA was cleaning that area she felt a lot of pressure towards her anus. She said she asked him what he was doing and continued to feel more pressure. Resident #1 said she felt Staff I, CNA's fingers enter her genital area. She stated, I swatted him and told him to get me dressed. She said she felt embarrassed afterwards and called her family members. Resident #1 stated, I didn't want to do anything, and I wanted to act like it didn't happen. She said she felt she did not have anyone to talk to. She said she told Staff J, Licensed Practical Nurse (LPN) about the incident on 9/6/25 and the nurse reported it. A review of Resident #1's admission record revealed an admission date of 8/15/25 with diagnoses to include intraspinal abscess and granuloma, other bipolar disorder, need for assistance with personal care, muscle weakness (generalized), neuromuscular dysfunction of bladder, unspecified, other psychoactive substance use, unspecified, uncomplicated, other specified anxiety disorders, other recurrent depressive disorders, and chronic post-traumatic stress disorder (PTSD).A review of Resident #1's comprehensive minimum data set (MDS), section C-cognitive patterns, dated 8/18/25 revealed a brief interview for mental status (BIMS) score of 15, meaning cognitively intact.A review of Resident #1's care plan initiated on 9/2/2025 revealed the following a focus - [Resident name] has potential for re-traumatization due to past history of trauma kidnapped and raped by [family member], multiple family suicide, trigger---loud noise, Date Initiated: 09/02/2025, with a goal of, [Resident name] triggers will be avoided, and resident will not be re-traumatized. Date Initiated: 09/02/2025 . Target Date: 12/01/2025. Interventions to include, Announcing self before entering, avoiding sudden movements Date Initiated: 09/02/2025. Avoiding noises/noisy environment Date Initiated: 09/02/2025. Do not talk about the event unless the resident wants to/initiates the conversation about the event, Date Initiated: 09/02/2025 . Giving resident control and choices, Date initiated 09/02/2025. Other: Psych services as indicated Date Initiated: 09/02/2025.Another focus in the same care plan revealed [Resident name] is at risk for behaviors r/t [related to] use of psychoactive medication, Bipolar, PTSD, history of drug abuse Date Initiated: 09/02/2025.Another focus in the same care plan revealed - [Resident name] has a mood problem r/t Admission/bipolar, PTSD Date Initiated: 09/02/2025 Revision on: 09/02/2025.Review of the care plan and the electronic medical record (EMR) revealed no documentation about Resident #1's preference of no male caregivers. A review of Resident #1's progress note dated 8/21/25 revealed, encounter, Date of Service: 08/21/2025 . Psychiatry Evaluation Note . Chief Complaint: Depression, anxiety, Bipolar and PTSD. Reason for Today's Evaluation: I was consulted for psychiatric evaluation and treatment of depressed mood. History of Present Illness: . Past psychiatric history of depression, anxiety, Bipolar and PTSD . Patient reports she's Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 7 of 9 Printed: 05/28/2026 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Actual harm Residents Affected - Few a little depressed and having intermittent trouble sleeping. She has been having mood swings and outburst with the staff. Patient does not want to change or adjust any medications at this time, however she is open to psychotherapy. According to PHQ9 [patient heath questionnaire-9] score is 11 that is moderate depression and BIMS score of 15, which is cognitively intact. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 . Assessment and plan for trauma: History of trauma: Kidnapped and raped by [family member], multiple family suicide. Current triggers if any: Loud noise, PTSD status: No PTSD diagnosis Care plan if trauma and triggers present: Continue ability, refer to psychotherapy . Added PTSD dx [diagnosis] and care plan in the chart: As pt. (patient) has active symptoms of PTSD such as flashbacks, nightmares, hypervigilance causing distress, .A review of Resident #1's nursing progress note dated 9/7/25 revealed - Writer knocked on resident door & introduced herself & resident said come in; Writer asked how she is doing and she got a little teary and said she is still quite emotional & said she should have spoken up sooner; provided her comfort and reassurance that staff are here to support her and make her stay here pleasant & safe. Reminded her not to blame herself but to focus on her healing & therapy & recovery so she can go home when ready; Reminded her if she wants to talk anytime just let me know and I will be right there.A review of Resident #1's nursing progress note dated 9/7/25 revealed, When writer went into resident's room to give resident IV [intravenous] writer asked how she was feeling resident stated, emotional that it was a long day resident started to cry very upset. Writer assured resident that she was safe resident applied for waiting so long to report the situation and started to cry again writer tried to comfort resident, stating that it is understandable due to situation. Resident is in good spirits to see [family member] in morning.A review of Resident #1's nursing progress note dated 9/8/25 revealed a medication administration note, 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress notes . 5 resident crying off and on.A review of Resident #1's progress note dated 9/9/25 revealed an encounter note, Date of Service: 09/09/2025 . Today, I saw patient as it was reported to me that patient is unstable requiring psychiatric assessment. Due to acuity of the situation, I saw patient using Telepsych [telehealth psychiatry] . The facility requested a psychiatric assessment to evaluate for trauma following an abuse allegation involving a staff member. The resident was cooperative and engaged during interview. She endorsed a history of PTSD related to prior kidnapping and sexual assault and stated that the recent incident was triggering for her. She prefers to manage her reactions independently at this time and declined both medication changes and initiation of psychotherapy. Recommend documenting the allegation per facility policy, offering trauma-informed supports and crisis resources, and arranging supportive check-ins with the option to re-evaluate if symptoms emerge or worsen. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .A review of Resident #1's progress note dated 9/11/25 revealed an encounter note, Date of Service: 09/11/2025 . Psychiatry Subsequent Note . Reason for Today's Encounter: Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment . past psychiatric history of depression, anxiety, Bipolar and PTSD. Prior to last visit, patient was at baseline. The patient reported feeling a little depressed and having intermittent trouble sleeping. She was having mood swings and outbursts with the staff. During last visit, patient endorsed a history of PTSD related to a prior kidnapping and sexual assault. She stated that the recent incident was triggering her PTSD symptoms. No medication changes were done. As per collected information, observed patient lying in bed resting. Patient reports that she is still feeling depressed about the alleged incident with a staff member. She is not open to psychotherapy as she has her own therapist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105132 If continuation sheet Page 8 of 9 Printed: 05/28/2026 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 105132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete outside. She reports that she is journaling and that it is helping her cope. Patient is not experiencing anxiety. No mood swings and behavioral outbursts noted. Patient has fair sleep and appetite. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .On 10/21/25 at 3:55 p.m., an interview was conducted with Staff S, LPN. She said she had not recently been the nurse assigned to Resident #1 as she, Floats all over the place. She said she was not aware of where to look for the resident's PTSD triggers. She said the nurse that is usually assigned to Resident #1 was not working today.On 10/21/25 at 4:00 p.m., an interview was conducted with Staff E, CNA. She said she floats and does not have a set assignment. Staff E, CNA said she had not worked with Resident #1 long enough to determine what her PTSD triggers were. She said Resident #1 showed signs of frustration if care was not done her way and could seem overwhelmed at times. Staff E, CNA said she was not aware if Resident #1 preferred a male or female to care for her. She said there was a place to document behaviors in the electronic health record.On 10/21/25 at 4:59 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON said there were changes made as a result of the investigation of Resident #1's allegation of sexual abuse made on 9/6/25. He said the change they made was to make sure Resident #1 did not have a male caregiver, per her request. He said nursing staff were made aware of the change. The DON stated, It's not written down anywhere, it's verbal. He said he was not sure if changes or updates were made to Resident #1's care plan.A review of Resident #1's nurse aide reference information, known as the Kardex, dated 10/21/25, revealed no information about a preference for a female caregiver or no male care givers. On 10/21/25 at 6:28 p.m., the DON provided an assignment sheet for the east back hall that had handwritten documentation of, no male caregivers. review of other documents revealed no documented reference of the resident's caregiver preferences.A review of the facility's, trauma-informed care, dated 10/24/22, revealed the following, Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization. Further review of the policy, under procedure, revealed the following, .3. Develop a care plan and add interventions to the nurse aid Kardex. Event ID: Facility ID: 105132 If continuation sheet Page 9 of 9