Health inspection·February 19, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's psychiatric assessments and progress notes revealed the following on date of service 11/30/23, Reason for Visit: Exposing himself to female residents. History of Present Illness: . Nursing staff reports pt. [patient] exposing his genitals to passing female residents, then puts it back under his shorts. Discussed options with [family member] via phone. She would like to utilize pharmacologic intervention and bring in some long sweat pants to hopefully prevent himself from exposing his genitals . next f/u [follow up]: prn [as needed]. Review of Resident #1's care conference record quarterly assessment, dated 11/30/23, revealed the following, .Comments: . [family member] concerned about recent touching behaviors and will be bringing long leg sweatpants for when he is up in wheelchair. Review of Resident #1's active physician orders revealed the following: Depakote Oral Tablet Delayed Release 250 Milligrams [MG] (Divalproex Sodium). Give 1 tablet by mouth twice daily for mood disorder. Start date 2/15/24. Donepezil Hydrochloride (HCI) Oral Tablet 10 MG (Donepezil Hydrochloride). Give 1 tablet by mouth one time a day related to unspecified dementia without behavioral disturbance. Start date 9/7/22. Fluoxetine HCI Oral Capsule 20 MG (Fluoxetine HCI). Give 1 capsule by mouth daily related to major depressive disorder, recurrent, unspecified. Start date 9/14/24. On 2/18/25 at 2:35 p.m., an interview with Staff C, Advanced Practice Registered Nurse (APRN) revealed she was not aware Resident #1 had a history of exposing himself or sexual behaviors prior to 10/1/24. She replied, Yes and no, when asked if the documented history of exposing himself could have been a precursor to the event that occurred on 10/1/24. Staff C, APRN stated she has follow-up encounters with the resident, Every four weeks or so. She confirmed she followed Resident #1 for his psychiatric diagnoses. Staff C, APRN stated she reviewed resident's behaviors and/or any issues with facility staff. She said nobody had communicated to her about sexual behaviors prior to 10/1/24. On 2/18/25 at 2:48 p.m., an interview with Staff B, Certified Nursing Assistant (CNA) revealed on the day the event occurred, she was walking down the hall looking in resident's rooms. She stated Staff A, PTA observed the contact between the two residents first. Staff B, CNA stated Resident #1, Is not supposed to be in females room. She stated, When he's in another person's room, he's up to no good. Staff B, CNA stated that's the only event she knew about regarding Resident #1. She said Resident #1 was not exposed during the event she observed on 10/1/24. Staff B, CNA stated Resident #1 liked to expose his genitals and, Play with himself. Staff B, CNA stated she doesn't think he does it towards someone or he intended to show people. She stated, That's just him. On 2/18/25 at 3:58 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the 10/1/24 reported incident between Resident #1 and another resident. The NHA stated as a result of the investigation, Resident #1's care plan was updated with a goal, To reduce number of exposures. He stated Resident #1's care plan in place correlates with the event on 10/1/24. The NHA confirmed there were no interventions in place prior to 10/1/24 even though the resident had known behaviors He confirmed through his interviews with the staff who witnessed the resident's contact, there were observations of Resident #1 exposing himself, and performing a sexual act on another resident. The NHA stated Staff B, CNA's feedback was the resident had a history of exposing himself. He stated there had been no incident of Resident #1 exposing himself since he became the NHA at this facility. The NHA stated he was not aware of a psychiatry note from 11/2023 about Resident #1 exposing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105587 If continuation sheet Page 2 of 3 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 02/19/2025 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 himself to female residents. He stated during the investigation he did not review previous records. The NHA stated the previous Director of Nursing (DON) would have reviewed the psychiatry note from 11/2023, brought it to the Interdisciplinary team (IDT) meeting, and discussed as a team/collaborated on interventions to update Resident #1's care plan. On 2/19/25 at 10:16 a.m., an interview with the NHA revealed Resident #1's [NAME] and care plan, Could be more meaningful. He stated the current care plan in place is for exposing himself and confirmed there were no interventions in place specific to the event that occurred on 10/1/24 when Resident #1 was observed in a sexual act with another resident. Review of the facility's policy titled Plans of Care, dated 11/30/24 and a revision date of 9/25/17 revealed the following, . Procedure: . Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident in response to current interventions after the completion of each OBRA (Omnibus Budget Reconciliation Act) MDS (Minimum Data Set) assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses 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 3 of 3