Inspection visit

Health inspectionSeptember 22, 2022

AVIATA AT COUNTRYSIDECMS #1055878 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor resident rights to privacy for all residents, by not ensuring that residents quality of life was enhanced on two of three (100 Hall, 300 Hall) resident hallways related to staff knocking and waiting to be invited into resident rooms. Findings included: Review of the facility policy titled Privacy with an effective date of 11/30/2014 revealed the following: It is the policy of The Company to give all residents the opportunity for privacy. 2. Residents' privacy will always be respected. 1. Observations on 09/19/22 at 11:55 A.M., during the delivery of midday meal trays on the 300 hall, revealed multiple staff members were noted to deliver meal trays to multiple residents on the 300 hall. At that time, multiple staff persons were noted to enter multiple resident rooms without knocking on the room doors and did not wait to be invited into the rooms by the residents. An interview on 09/19/22 at 11:58 A.M., with Staff E, Registered Nurse (RN), Assistant Director of Nursing (ADON), confirmed she entered a resident room on the 300 hall without first knocking or being invited into the resident's room. She stated she was in a rush. She said the process was to first knock on the door and wait for the resident to respond to entry into the room. Observations on 09/19/22 at 12:03 P.M., during the delivery of midday meal trays on the 100 hall, revealed multiple staff members were noted to deliver meal trays to multiple resident rooms. At that time, multiple staff persons were noted to enter multiple resident rooms without knocking on the room doors and did not wait to be invited into the rooms by the residents. On 09/19/22 at 12:08 P.M., Staff K, RN was observed to enter into room [ROOM NUMBER] without first knocking. Staff K acknowledged she entered the room without the residents permission and said she was in a rush as the resident was going out on an appointment. On 09/19/22 at 12:11 P.M., Staff L, Certified Nursing Assistant (CNA) was observed to enter into two rooms on the 100 hall without knocking to deliver meal trays. In an interview at this time with Staff L, she acknowledged she did not knock on the residents' doors before entering the rooms. She said she knew she was supposed to knock and wait for the residents to respond before entering the (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 13 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 09/22/2022 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)

F 0550 rooms. Level of Harm - Minimal harm or potential for actual harm On 09/19/2022 at 11:45 A.M., a brief tour of the facility was conducted and staff were observed interacting with residents. Staff were observed in multiple hallways delivering meal trays. Observations were made of Staff I, CNA, delivering food trays to rooms in hallway 300 and not knocking prior to entry. When interviewed, Staff I said she typically knocked on the residents' doors before entering but failed to knock during the observation because the residents were expecting her to deliver their meals. Residents Affected - Few On 09/19/2022 at 11:49 A.M., Staff H was observed assisting with delivering food trays to residents in hallway 300 and entering rooms without knocking. An interview was conducted, and staff member H was asked about the facility protocol as it pertains to resident's rights and entering rooms. CNA H stated that the staff are taught to knock before entering a room but that she just was not thinking at the time of the observation. On 09/19/2022 at 11:52 A.M. Staff J, CNA was observed delivering food trays to several residents in hallway 100 and failing to knock before entering the residents room. In an interview with Staff J, after the observation, she said she did not knock because she was expected. She said all the staff were expected and trained to knock before entering a residents room. On 09/22/2022, the Director of Nursing provided a copy of the facility's policy and procedure for resident's rights with an effective date of 11/30/2014. The policy stated: It is the policy of the company to give all residents the opportunity for privacy. Procedure: 1. Nursing home staff will recognize that residents and their families need a place of privacy. 2. Residents Privacy will always be respected. 3. Facility will provide time and space for privacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 2 of 13 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 09/22/2022 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)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure two (Residents #71, #92) of three residents sampled for Beneficiary Notice, received the correct Beneficiary Notice when discharged from a Medicare covered Part A stay and remained in the facility. Residents Affected - Few Findings Included: Review of documentation provided by the facility's Director of Social Services related to Beneficiary notification for Resident #71 revealed his last covered Medicare Part A day was 8/12/22 and he remained in the facility. Documentation on the SNF Beneficiary Protection Notification Review form revealed a SNF ABN Form CMS -10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN)) form was not provided to the resident. Continued review of the form revealed a hand written note under Other Explain which indicated Resident is LTC [Long Term Care] here. No DC [Discharge]/Transfer Review of documentation provided by the facility's Director of Social Services related to Beneficiary notification for Resident #92 revealed her last covered Medicare Part A day was 6/16/22 and she remained in the facility. Documentation on the SNF Beneficiary Protection Notification Review form revealed a SNF ABN Form CMS -10055 form was not provided to the resident. Continued review of the form revealed a hand written note under Other Explain which indicated Resident is LTC here. No DC/Transfer An interview on 09/22/22 at 2:18 p.m., with the Social Service Director, revealed she did not provide Resident's #71 and #92 with a CMS-10055 form, and did not realize that the CMS form 10055 should have been issued to the resident. She reported she was unaware that for residents who stay long term care were to receive both forms. Review of the facility policy titled Advance Beneficiary Notice-ABN with an effective date of 11/30/2014 and a revision date of 1/10/2015 revealed the following: 1. The facility will give a completed copy of the ABN far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 3 of 13 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 09/22/2022 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan related to interventions for the use of compression stockings for one (Resident #31) of a sample of 34 residents. Findings included: A review of the medical record for Resident#31 revealed a physician's order dated 9/2/2022 for Compression Stockings at HS (evenings) for dependent bi-lateral feet swelling. Remove stockings before bed. Encourage resident to elevate feet as tolerated. Start date 9/2/2022 and on 9/3/2022 Compression stockings in a.m. for depended bilateral feet swelling APPLY STOCKINGS IN THE AM and remove in PM before bed. Encourage resident to elevate feet as tolerated-Start ate 9/3/2022. Resident #31 was admitted to the facility on [DATE] and had a re-admission date of 10/31/2022 with multiple diagnoses including but not limited to edema, ataxia following cerebral infarction, and Alzheimer's Disease. On 09/20/2022 at 12:58 p.m., an observation was made of Resident #31. His legs appeared very swollen and red. The Resident did not have any compression stockings on during this observation. On 9/20/2022 at 1:05 p.m., an interview with Staff A, Licensed Practical Nurses (LPN), was conducted. She said, The resident has an order for support stockings to be applied on the resident in the evenings and off during the day, I make sure I document that he doesn't have any on during the day, but you would think he should wear them during the day. An observation was made of Resident #31 on 09/20/22 at 2:26 p.m. in his room. Resident #31 was sitting up in his wheelchair near his bed. He was observed with red non-skid socks on. He was observed with edema on his lower bilateral extremities. When asked about his compression stockings he looked at his feet and stated he had on his red socks. An observation on 09/20/22 at 3:08 p.m. revealed Resident #31 sitting on the side of his bed with red non-slip socks on but with no compression stockings. On 09/21/22 at 9:29 a.m. an observation of Resident #31 was made. The resident was sitting at his doorway in his wheelchair sleeping; the resident was observed with a pair of red non-slip socks. No compression stockings were observed on the resident or in his room. On 09/21/22 at 9:48 a.m. an interview with the Director of Nursing (DON) was conducted in regard to the resident not having his compression stockings on or refusal of any care. The DON said any refusals must be documented in the care plan and nursing notes. On 09/21/22 at 10:20 a.m., the DON and surveyor made an observation of Resident #31 in his room, the resident did not have on his compression stockings. The DON asked permission to search his chest of drawers for the stockings. They were not found. The resident stated he had not seen them. Although he did refuse to wear them at times, there should be documentation in his medical record under nursing notes. The DON said the nurse had read the order wrong and believed that the order read: No compression stockings in the A.M. and only in the evening. She was documenting the resident was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 4 of 13 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 09/22/2022 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)

F 0656 wearing the compression stockings. Level of Harm - Minimal harm or potential for actual harm On 9/21/2022 at 10:54 a.m., an interview with the DON and review of the resident's care plan was conducted. The DON confirmed a plan of care had not been developed for the use compression stockings for Resident #31. Residents Affected - Few The facility provided their policy for Plans of Care with an effective date of 11/30/2014 and revision date of 9/25/2017 which reads: The interdisciplinary team shall ensure that the plan of care addressees any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 5 of 13 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 09/22/2022 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)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to make aggressive attempts to ensure that one (Resident #23) of 34 sampled residents received appropriate treatment and assistive devices to maintain their hearing abilities. Residents Affected - Few Findings included: On 09/19/22 at 11:53 a.m., an observation and interview with Resident #23 was conducted. The resident was sitting up in bed watching TV. The resident said he was hard of hearing and reported he were bilateral hearing aids and the left hearing aide needed new batteries. He reported he told a staff person last week and they said they would take care of it but nothing had been done. Review of #23's current physician orders revealed there were no orders related to hearing aid use, maintenance of hearing aids, or storage or monitoring of hearing aids. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: -Adequate hearing with hearing aid or hearing appliances -Hearing aid not used Review of the admission assessment dated [DATE] revealed the following -hearing difficulty R and L Review of Resident #23's care plan dated 1/4/22 with revision date on 2/9/22 related to Has a communication problem r/t Hearing deficit, B/L hearing aids. Continued review of the care plan revealed the interventions related to this care plan included the following: -Ensure hearing aid to bilateral ears -Monitor/document/report PRN any changes in : ability to communicate, Potential contributing factors for communication problems, Potential for improvement. An interview on 09/21/22 at 12:25 p.m., with Resident #23 revealed he did not have any issues with hearing today as his wife (Resident of the facility and shares a room with him) was able to change his batteries to his hearing aid. He reported that he could not change his own batteries as he had Parkinson and his hands were not steady. An interview on 09/21/22 at 12:27 p.m. with Staff M, Registered Nurse (RN) revealed she was the nurse assigned to Resident #23 and she did not know if the resident wore hearing aids. Staff M reviewed the electronic record via the computer mounted on top of her medication cart and was unable to verbalize if the resident required the use of hearing aids to communicate. An interview on 09/21/22 at 1:11 p.m. with the Director of Nursing (DON) revealed the use of hearing aids would be on the residents care plan which should pull over onto the [NAME]. She reported nurses were able to see the care plan and the Certified Nursing Assistants (CNA) could see the [NAME]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 6 of 13 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 09/22/2022 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)

F 0685 Level of Harm - Minimal harm or potential for actual harm She reported some residents kept their hearing aids others did not, depending on their abilities. The DON reported hearing aids were monitored by CNA's and nurses. At this time, the DON reviewed the resident's record and confirmed the hearing aid was not on the [NAME] which would not allow the CNA's to know to monitor for the hearing aides. She confirmed there was no physician order to monitor the use of the hearing aids and said the nurse should have known even though there was no order to monitor the hearing aid. Residents Affected - Few Review of the facility policy titled Care of Hearing Aid with an effective date of 11/30/2014 and a revision date of 9/1/17 revealed that as part of the procedure staff are to Check batteries, if hearing aid is not functioning, replace with new battery. Spare battery should always be available. Batteries should last 1 to 2 weeks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 7 of 13 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 09/22/2022 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, and record review, the facility failed to provide appropriate respiratory services for one (Resident #14)of two residents sampled for respiratory care. Residents Affected - Few Findings included: Observations of Resident #14 on 09/19/22 at 2:40 p.m. revealed the resident in bed in her room with a nebulizer treatment in progress. The resident was noted with her oxygen tubing in her nasal cannula with oxygen running and nebulizer face mask over mouth but away from the nose. The nurse was not in the vicinity of the resident's room and was noted to be four rooms down the hall and past the double doors. While standing down the hall on 09/19/22 at 2:45 p.m. the nurse announced she needed to go check on her treatment, then walked down the hall and entered Resident #14's room. The nurse was noted to fix the mask over the resident's nose. During an interview with Staff A, Licensed Practical Nurse (LPN), she confirmed she fixed the nebulizer mask on the residents face. She reported she did not stay with the resident during the treatment as she was used to the resident and knew she did not have any adverse reactions to her respiratory treatment. She reported she usually followed up when the resident was done with the treatment. She reported the treatment usually took 10-15 minutes and she did not stay with the resident during that time. Observations on 09/20/22 at 7:26 a.m., of Resident #14 revealed the resident lying in bed actively receiving a nebulizer treatment. The resident was noted to have her oxygen mask on via nasal cannula. The resident was noted to lift the nebulizer mask up to her forehead scratch her face and replace the mask. An interview on 09/20/22 at 7:30 a.m., with the resident revealed she breathed through her nose. While in the room, the resident's nebulizer machine fell to the floor from her nightstand. A Certified Nursing Assistant (CNA) in the room, assisting the residents roommate, picked up the nebulizer machine and placed it on the night stand. She checked the nebulizer and told resident she was finished with the treatment. The CNA removed the nebulizer mask from the resident's face and placed it face down on top of the nebulizer machine. An interview with Staff F, CNA at this time, revealed she took the nebulizer mask off of the resident because the treatment was finished. Observations on 09/20/22 at 7:32 a.m., revealed Staff A, LPN entered the resident's room and stood by doorway. Staff F, CNA told the nurse she had taken off the resident's nebulizer mask as the resident was done with her treatment, the nurse responded by saying ok and told the CNA that she would be back and proceeded to leave Resident #14's room. At this time, the nurse did not check on the status of the resident after her nebulizer treatment. Review of the residents physician orders revealed current orders for the following -Ipratropium-Albuterol Sol 0.5-2.5 (3) MG/3 ml 3 ml inhale orally four times daily related to Dyspnea -Oxygen -5 L/min via NC continuous as tolerated -Budesonide inhalation Suspension 0.5 mg/2 ml-2 ml inhale orally every 12 hours for COPD ok to mix (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 8 of 13 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 09/22/2022 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)

F 0695 with duoneb per MD Level of Harm - Minimal harm or potential for actual harm -Change tubing, mask and / or nasal cannula weekly. may change sooner as needed. Residents Affected - Few Review of the resident's care plan dated 7/2/21, related to behaviors of taking oxygen off at times had interventions that included, Administer medication as ordered. Monitor/document for side effects and effectiveness. An interview on 09/20/22 at 3:03 p.m., with the Director of Nursing (DON) revealed the use of oxygen via nasal cannula while receiving a nebulizer treatment via a nebulizer mask would be dependent on the resident. She reported for Resident #14, she would struggle without the oxygen, so she would stay on it during the nebulizer treatment. She said the nurse should be within eyesight to monitor the resident throughout the whole treatment. She reported the nurse should be removing the mask, not the CNA. She should have orders to listen to the lungs. The DON reported the nebulizer mask should be put into the bag and not left face down on the nebulizer machine. Review of the facility policy titled Nebulizer (small volume nebulizer) with and effective date of 11/30/2014 and a revision date of 3/20/2018 revealed the following: Evaluate the resident's response and effectiveness of treatment by evaluating breath sounds, pulse rate, oxygen saturation and respiratory rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 9 of 13 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 09/22/2022 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and four errors were identified for two (Residents #247 and #68) of four residents observed. These errors constituted a 13.33% medication error rate. Residents Affected - Few Findings included: 1. On 9/20/22 at 9:42 a.m., an observation of medication administration with Staff B, Registered Nurse (RN), was conducted with Resident #247. Staff B dispensed the following medications: - Acetaminophen 325 milligram (mg) - 2 tablets - Loratadine 10 mg tablet - Meclizine 25 mg tablet - Diltiazem 60 mg tablet - Polyethylene Glycol 3350 - 17 grams - Folic Acid 1 mg tablet - Montelukast 10 mg tablet - Potassium Chloride Extended Release (ER) 20 milliequivalent (meq) tablet - Spironolactone 25 mg tablet - Torsemide 20 mg tablet The RN identified the resident was to receive a 100 microgram (mcg) tablet of Vitamin B12 but the medication cart had 1000 mcg tablets and she would have to check with central supply for the correct dosage. The RN also stated Resident #247 was to receive Linzess but will have to come back as the medication was not located in the medication cart. Staff B confirmed she was administering 10 tablets/capsules to Resident #247. A review of the September Medication Administration Record (MAR) indicated that staff member ljd documented the dispensed medications had been administered and AM96 had administered Resident #247's Vitamin B12 and Linzess (linaclotide). 2. On 9/20/22 at 10:02 a.m., an observation of medication administration with Staff B was conducted with Resident #68. The staff member dispensed the following medications: - Zofran 4 mg tablet - Celecoxib 200 mg capsule (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 10 of 13 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 09/22/2022 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)

F 0759 - Atenolol 25 mg tablet Level of Harm - Minimal harm or potential for actual harm - Multi-Vitamin tablet - Ofev 150 mg tablet Residents Affected - Few - Venlafaxine 37.5 mg tablet After obtaining the requested Zofran from the electronic dispensary the staff member popped the medication onto the top of medication cart, missing the medication cup. She used a spoon to pick up the Zofran tablet and placed it into a medication cup, then the staff member began to dispense a Celecoxib capsule into the medication cup. The staff member was stopped and confirmed that the top of the medication cart was not clean and that the Zofran tablet should be discarded. Staff B removed the tablet and obtained another Zofran tablet from the cart. She reported Resident #68 was to be administered Ipratropium Bromide nasal spray but guess they ran out of it, going to have to call pharmacy. The review of Resident #68's MAR identified that Resident #68 was ordered by the physician: - Multiple Vitamin with (w/) minerals - one tablet by mouth daily. The MAR indicated that Staff B had administered the Multi Vitamin with mineral versus the observed Multi Vitamin which did not include minerals. The MAR did not identify the resident's Ipratropium nasal spray had been administered. An interview was conducted at 2:27 p.m. on 9/22/22 with the Director of Nursing (DON). She confirmed the findings that AM96 had signed the MAR indicating that Resident #247's Linzess and Vitamin B12 had been administered. She stated that AM96 was her designated initials and that she had not administered any medications on 9/20/22. She was unsure of why the MAR identified that she had administered the medications. On 9/22/22 at 2:46 p.m., the DON provided Resident #247 and #68's MAR's and stated she had struck out the documentation that she had given the medications and would be doing a medication error report. The policy, General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10, 1/1/13, and 1/1/22, indicated that Facilty staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. The policy identified: - 3.5 If a medication which is not in a protective container is dropped, Facility staff should discard it according to Facility policy. - 3.7 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 11 of 13 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 09/22/2022 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure prescribed medications and biologicals were appropriately stored for one (Resident #95) of twenty-three sampled residents and one of two treatment carts left unlocked and unattended. Findings included: 1. An observation of Resident #95 was conducted on 09/19/22 at 11:34 a.m. A bottle of Nystatin powder was on the overbed table. The resident stated the staff left it there because they had to use it again later. An observation was made on 09/20/22 at 8:23 a.m. of a bottle of Nystatin powder on the overbed table. Photographic evidence was obtained. An interview was conducted with the Director of Nursing (DON) on 09/21/22 at 8:36 a.m. She said the expectations were the medication should be stored locked in the medication room or on the medication cart. The bottle of Nystatin powder was brought from home due to the brand being different than the one used in the facility. She stated yesterday, 09/20/22, she went into Resident #95's room and talked to him about the importance of having his Nystatin powder kept on the medication cart. The DON said she spoke with the resident and told him that his wife did not need to bring in the bottle, due to the facility having it ordered and on the medication for him. A review of Resident #95's orders revealed an order for Nystatin powder, to be applied to the sacrum topically every shift. Start date of 03/29/22. No indication was found for self-administration of the medication. Review of the Admission/readmission Data Collection dated 03/02/22 revealed in Section O. entitled Medication Review, Resident #95 does not self-administer medication. 2. On 9/19/22 at 1:33 p.m., an observation was conducted of a treatment cart parked outside of room [ROOM NUMBER], on top of the treatment cart was a bottle of Ammonium Lactate 12% and a tube of Voltaren. The door to room [ROOM NUMBER] was closed. Staff K, Registered Nurse (RN) came out of room [ROOM NUMBER] at 1:36 p.m. and confirmed Ammonium Lactate and Voltaren were medications and should not be stored on top of the treatment cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 12 of 13 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 09/22/2022 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)

F 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, and interview, the facility failed to ensure residents, resident representatives, and visitors were notified of the facility's COVID-19 status following the admission of one (Resident #154) of one resident sampled for being admitted with COVID-19 virus. Residents Affected - Few Findings included: A review was completed of the facility's COVID-19 infection resident listing. The review identified Resident #154 tested positive on 9/8/22 and suffered no symptoms. The record review for Resident #154 identified the resident was admitted to the facility on [DATE] with a primary diagnosis of COVID-19. The transferring facility's History and Physical indicated that the resident had tested positive for COVID-19 and had started symptoms on 9/9/22. The Order Audit Report for Resident #154 included a completed physician order for Droplet isolation until 9/18/22. After review of the automated call list, the DON said she did not notify residents and/or families of the COVID status of the facility following the admission of Resident #154. The DON said since the resident had tested positive at the hospital she did not notify the residents and/or families there was a COVID+ person in the facility. The DON stated she did not know she had to (notify the families and residents), the Regional Director of Clinical Services (RDCS) nodded her head and said yes all COVID (cases) in the building. After the above mentioned call list was reviewed, the DON provided the last call log that notified residents and/or families of the COVID positivity status of the facility. The call log was dated 8/17/22 and indicated four cases of COVID-19 was being treated at the facility. This call log was dated 27 days prior to Resident #154's admission to the facility. The facility's COVID-19 Pandemic Plan, dated 3/2/20 and revised 3/11/22, identified that Residents and resident representatives will be notified: - By 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 OR three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. - Cumulative update weekly OR by 5 p.m. the next calendar day following the subsequent occurrence of each confirmed infection of COVID-19 or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 13 of 13

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0885GeneralS&S Dpotential for harm
Report COVID19 data to residents and families.

FAQ · About this visit

Common questions about this visit

What happened during the September 22, 2022 survey of AVIATA AT COUNTRYSIDE?

This was a inspection survey of AVIATA AT COUNTRYSIDE on September 22, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AVIATA AT COUNTRYSIDE on September 22, 2022?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 22, 2022