Health inspection·November 24, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that he didn't know her very well and was not aware that she required a one to two person staff assist with turning and repositioning. He said before she fell, he hadn't been trained to look up how to find specific information about residents in the Kardex (Computer program accessible by CNA's to access patient information).On 11/24/2025 at 12:30 p.m., during an interview the APRN (Advanced Practice Nurse Practitioner), said he was not present when Resident #1 fell out of bed, but the nurse immediately came and got him. When he saw the resident, she was lying on her back and bleeding from her head. He said Staff A, CNA, was providing care when the resident rolled out of bed. The resident was on blood thinners, so they transferred her out immediately to a higher level of care. She was in the hospital for a couple of days and then returned to the facility. She had a diagnosis of non-surgical subdural hematoma.On 11/24/2025 at 3:48 p.m., the Director of Nursing (DON) said that Staff A, CNA, was performing incontinent care when he went to dispose of a brief and wash his hands. She said Staff A, CNA left the patient laying on her side on the edge of the bed and staff are supposed to ensure residents are in safe position prior to leaving bedside. The Resident was not left in a safe position and this is when Resident #1 fell out of bed. The DON could not verify that Staff A, CNA, had received training for the Kardex prior to Resident #1's fall. She said, I did the training after the fall.On 11/24/2025 at 3:55 p.m., the facility Administrator said he was aware that Resident #1 had received an injury during care but the staff member followed the residents care plan. Event ID: Facility ID: 105452 If continuation sheet Page 2 of 4 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on record review, and staff interviews, the facility failed to provide adequate supervision to prevent falls with major injury for 1 (Resident #5) of 3 residents reviewed for falls.The findings included: Facility policy titled Falls Management Revision Date 7/29/2019 indicated: Fall mitigation strategies included developing resident centered interventions based on resident risk factors.Record Review of the facility provided incident log revealed Resident #5 had 5 falls between 12/14/25 and 1/6/26.Review of Resident #5's progress notes reveal on 12/14/25 resident was found on the floor and assisted back to bed with no change in condition noted at that time. On 12/16/25 resident was noted in nursing progress note to have inverted left lower extremity and shortening of the left lower extremity. An order was obtained to send Resident #5 out to the emergency room (ER). Resident returned from the ER the same day with a diagnosis of pubis ramus fracture. Nursing progress note on 12/20/25 indicated Resident #5 was found on the floor, half in and half out, of his bathroom. Head to toe assessment revealed no injuries.Nursing progress note on 12/25/25 indicated Resident #5 had an unwitnessed fall and hit his head. No other injuries and no complaint of pain. Order received to send to ER due to being on blood thinner medication. Resident #5 returned from the ER later that same day with no new orders.Nursing progress note on 12/27/25 indicated Resident #5 had an unwitnessed fall and was found lying on his right side on the floor in his room. Resident said he stood up to straighten his bedside table, lost balance and slid down to floor. No injuries at that time.Nursing progress note on 1/6/25 indicate Resident #5 was found sitting on floor in front of his door. Resident said he was trying to close door and ended up sliding down to the floor. Resident #5 sustained a small skin tear to his left knee.Provider's progress note on 1/7/26 indicated Resident #5 had complaints of hip and groin pain. A stat x-ray was ordered and revealed a complete fracture of the left femoral neck with superior lateral displacement. Additionally, a pubis ramus fracture was identified on the imaging. Due to the displacement and complete fracture an order was placed to transfer to the ER. Nursing progress note on 1/10/26 indicated resident was readmitted to the skilled nursing facility following left hip surgery with 38 staples in place.Provider progress note on 1/13/26 indicated Resident #5 had returned to the facility on 1/10/26 following a left hip repair secondary to a mechanical fall. Resident #5's orders included: physical therapy, fall mats, low bed when in bed, and scoop mattress.Certified Nurse Assistant (CNA) Kardex indicated under safety to ensure resident is wearing appropriate footwear/nonskid socks when ambulating or mobilizing in wheelchair and ensure the resident has unobstructed path to the bathroom. Kardex also indicated under bed mobility: bed in low position.Resident #5's care plan addresses fall risk with interventions including bed in low position, appropriate footwear, physical therapy, fall mats, frequent checks every 15 minutes, hand bell to assist with calling staff, offer toileting every 2 hours. On 1/14/26 at 2:59 p.m., Staff F (CNA) said she was taking care of Resident #5. She said she watches for falls and checks on him every 2 hours, but that was not documented anyplace. She said he was a fall risk, and his bed was kept low. On 1/14/26 at 3:01 p.m., Staff G (CNA) said he has worked with Resident #5, and he was an assist to the restroom. Staff G said earlier that day he found Resident #5 standing at the side of his bed. Staff G said Resident #5 hadn't fallen, but he gets on the side of the bed sometimes, he did his own thing. Staff G said Resident #5 hadn't been incontinent. Staff G said he had seen him in bed when he passed his lunch tray and when he went back in to pick it up was when he found him standing at the side of the bed. On 1/14/25 at 1:56 p.m., the Physical Therapist (PT) said they began working with Resident #5 when he came back from the 12/14/25 pelvic fracture. PT said she doesn't think Resident #5 remembers he can't get up by himself anymore. She said he needed assistance, but he tries (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105452 If continuation sheet Page 3 of 4 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 105452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Englewood 1111 Drury LN Englewood, FL 34224 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to get up by himself and doesn't call for help. She said they have tried to educate him as much as possible, did the low bed, added fall mats and several other interventions, but he had a habit of doing what he wanted to do. Saying Resident #5 was very independent minded. PT said they continue to work with him, both Occupational and Physical therapy, trying to reinforce safety awareness. On 1/14/26 at 1:25 p.m., the Director of Nursing (DON) said she was aware of Resident #5's multiple falls. She said all his falls have been unwitnessed and they have placed gripper socks, 15-minute checks, 2-hour toileting, fall mats, scoop mattress, bed in low position, a hand bell to ring, but he gets up and walks on his own. The DON said Resident #5 had dementia, poor safety awareness, was forgetful, had confusion, and was non-compliant. On 1/14/26 at 3:30 p.m., the Administrator said, I don't know what you want us to do, we can't tie him down. Event ID: Facility ID: 105452 If continuation sheet Page 4 of 4