Health inspection·June 19, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to accurately complete one (#3) out of nine sampled residents' comprehensive assessment as evidence by the quarterly cognitive patterns, mood, and behaviors documented as not assessed. Residents Affected - Few Findings included: The admission Record for Resident #3 showed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified severity (of) vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and unspecified single episode (of) major depressive disorder. Resident #3 was observed on 6/19/23 at 9:44 a.m. lying on top of his bed with a blanket over his head, neither the resident or roommate acknowledged the knock on door or calling of the residents' name. On 6/19/23 at approximately 11:52 a.m., the resident was observed lying on top of the bed, uncovered by blanket, eyes closed, and without distress. The resident did not respond to calling of his name or knock on door. A review of Resident #3's quarterly comprehensive assessment Minimum Data Set (MDS)), dated 5/18/23, showed the resident was not assessed for Section C - Cognitive Patterns, Section D - Mood, and Section E - Behaviors. The MDS Coordinator (traveling) signed the sections on Friday June 2, 2023. The MDS indicated the resident had received 7 days of an antidepressant during the assessment period. The May and June 2023 Medication Administration Records (MAR) for Resident #3 showed the resident received 10 milligrams (mg) of Escitalopram Oxalate every night shift related to major depressive disorder single episode unspecified. The MAR indicated staff were monitoring the resident for behaviors, side effects, and outcome of the medication on each day and night shift and did not identify that the resident exhibited any behaviors. The review of Resident #3's previous quarterly comprehensive assessment, dated 2/15/23, indicated that sections C, D, and E had been completed with results of a Brief Interview of Mental Status score of 4 out of 15, which indicated severe cognitive impairment. The resident's mood symptoms included trouble falling or staying asleep, or sleeping too much and nearly every day, had a poor appetite or overeating, and that no behaviors had been exhibited. Resident #3's care plan included focuses that showed the following: - Uses antidepressant medication related to (r/t) depression. (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 4 Event ID: 105644 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612 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)