Health inspection·March 17, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and review of the medical record, the facility failed to notify the Physician of behaviors and behavioral changes for one of nineteen sampled residents, (#7). Following admission, the resident presented with refusal of care, hitting, and yelling behaviors, in which the Physician was not notified. Findings included: On 3/15/2021 at 12:30 p.m., while standing outside resident #7's room, staff went in to set up and serve the meal tray. Resident #7 was first observed in her room and in bed since 9:10 a.m. While staff were serving resident #7 her meal, Resident #7 was overheard telling staff, I don't want it, leave me alone. The staff member was overheard to ask if she wanted to order something else, and Resident #7 was overheard, get the ____out, leave me alone. After leaving Resident #7's room, an interview was conducted with Employee A, who was asked why resident #7 was yelling out. Employee A indicated that Resident #7 had been presenting with behaviors since her admission and that she just likes to stay in her room, in bed, and wants to be left alone. Employee A was asked if she and other staff tell the nurse of these behaviors. She indicated that she had. On 3/15/2021 at 1:30 p.m., the unit nurse, Employee B, was asked if she knew about Resident #7 presenting with behaviors of calling out and yelling. She said that she was aware and believed the Physician was aware. Employee B indicated that Resident #7 mostly wants to be left alone and had been exhibiting yelling out, screaming and attempting to hit staff since her admission. On 3/16/2021 review of Resident #7's medical record found she was admitted to the facility on [DATE]. Review of the advance directives determined Resident #7 was her own decision maker. Review of the admission diagnoses sheet revealed diagnoses to include but not limited to: Anxiety and Depression. Review of the current Minimum Data Set (MDS) 5 day assessment, dated 3/7/2021, revealed a Cognition/Brief Interview Mental Status (BIMS) score of 13 of 15; which indicated Resident #7 was cognitively intact, interviewable and able to make her own decisions. The mood/behavior section of the MDS revealed Resident #7 did not present with any behaviors during the five days assessed. Review of the dated electronic progress notes found: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105587 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 105587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Countryside 3825 Countryside Blvd N Palm Harbor, FL 34684 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)