Health inspection·January 7, 2026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some allegation was substantiated because of calling names. The NHA stated Resident #3 was seen by psych on12/23/25. The NHA and the Nurse Consultant both stated there should have been documentation in the progress notes about the altercation with the resident. They stated the documentation needed was a progress note or a Situation, Background, Assessment, Recommendation (SBAR) which would include an assessment, and notification of needed parties. The NHA verified there was no documentation about the incident in the medical record.2. Resident #8 was admitted on [DATE] with diagnoses included but not limited to interstitial pulmonary diseases, Chronic Obstructive Pulmonary Disease, diabetes, asthma, cognitive communication deficit, depression, dialysis, Congestive Heart Failure, and hypertension. Review of the MDS dated [DATE] showed a BIMS score of 15, meaning the resident was cognitively intact.Review of a psych progress note for Resident #8 showed on 11/06/2025, the patient was seen at staff request following an episode of agitation during which he reportedly pushed another resident's walker. He is newly admitted for rehabilitation. Stated he has had a hard year but declines to elaborate and requested to stop the interview, stating he was becoming paranoid. Denies history of psychiatric treatment and declines medication for mood or anxiety at this time. Patient is not in need of additional referral or follow-up services.Review of Resident #8's medical record revealed there were no progress notes and no SBAR assessment was documented regarding the resident-to-resident incident on 11/06/2025.Review of the care plans showed there were no care plan updates related to the incident on 11/06/2025. 3. Resident #9 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to schizoaffective disorder, bipolar type, COPD, seizures, chronic pain, anxiety, depression, and hypertension. Review of the quarterly MDS dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired).Review of a psych services progress note for Resident #9 showed on 11/11/2025, Pt (patient) was seen today for follow-up after a resident-to-resident incident in which she was bumped by another resident while in her wheelchair. Upon evaluation, the patient was calm, cooperative and showed no adverse effects from the incident. She denied any abuse or neglect, and no psychosocial distress or injuries were noted.Review of Resident #9's medical record revealed there were no progress notes and no SBAR assessment was documented regarding the resident-to-resident incident on 11/06/2025.During an interview on 01/07/2026 at 3:21 p.m. the Nursing Home Administrator (NHA) and the Nurse Consultant stated on 11/06/25 at 2:00 p.m. Resident #9 alleged that Resident #8 was hitting her wheelchair with his wheelchair and when Resident #9 asked Resident #8 to stop, Resident #8 said, I will do worse to you. The NHA stated the residents were separated immediately and placed on frequent monitoring. The NHA stated they were placed on different smoke breaks. The NHA stated the Activities Director stated Resident #9 was trying to go out to smoke and Resident #8 was sitting next to her and bumped into her with his wheelchair, like bumper cars. The NHA stated the other residents on the patio were interviewed. All the other residents but one denied hearing the incident. A resident witness said that Resident #8 was in line to get out the door for smoking and he bumped into Resident #9. The resident witness stated he heard Resident #8 say to Resident #9, I will do worse. The NHA stated they both self-propel their wheelchairs. The NHA stated that Resident #9 stated Resident #8 hit her wheelchair but never hit her. The NHA verified Resident #8 was seen by psych services on 11/06/2025. The NHA stated Resident #9 was seen by the medical provider on 11/06/2025 and had no behaviors or issues. The Nurse Consultant stated the expectation would be for the nursing staff to document a progress note, an assessment and/ or an SBAR in the medical record for the incident on 11/06/2025. The NHA reviewed Resident #8's medical record and found no documentation related to the 11/06/2025 incident, no progress note, no SBAR, no assessment and no care plan update. The NHA stated she would expect to find both the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105644 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 105644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete documentation and a care plan update. The NHA reviewed Resident #9's medical record and found no documentation related to the 11/06/2025 incident, no progress note, no SBAR, and no assessment. The NHA stated she would expect to find documentation. The NHA stated there had not been any education provided to the nursing staff related to documentation post an incident, related to progress notes, SBAR, assessment, and updating the care plan. The NHA stated all incidents were discussed at morning meetings. The NHA stated all staff are made aware of incidents during the Abuse and Neglect education provided. The NHA stated that during the investigation, the medical record was reviewed for cognition, why the resident was admitted , diagnoses. The NHA stated they may not have looked at the progress notes for documentation of the incident. When asked the reportable showed the resident's progress notes were reviewed. The NHA verified she wrote that they were reviewed.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation, revised 11/06/2022 showed It is inherent in the nature and dignity of each resident at the center that he / she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and / or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse.Definitions:Mental and Verbal Abuse: Mental Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation for degradation. Verbal abuse may be considered a form of mental abuse.Verbal Abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age ability to comprehend our disability.Mental and verbal abuse include, but are not limited to:Harassing a residentMocking, insulting, ridiculingYelling or hovering over a resident, with the intent of intimidateMonitoring of residents who may be at risk is the responsibility of all facility staff2. Training: Employee Obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights.3. Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property and exploitation.Preliminary investigation: Immediately opened an allegation of abuse or neglect, the suspect (s) shall be segregated from residents pending the investigation of the resident allegation.The nurse or Director of Nursing / designee shall perform and document a thorough nursing evaluation and notify the attending physician.An incident report shall be filled by the individual in charge you received the report in conjunction with the person who reported the abuse. The report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion and submitted to the abuse coordinator.6. Protection: the resident will be evaluated for any signs of injury, including a physical exam and / or psychosocial assessment, as appropriate.Provide the resident with emotional support and counselling during and after the investigation, if needed.Review of the facility's policy, Plans of Care, revised 09/25/2017 showed Review, update and / or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completed of each OBRA MDS assessment, 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. Event ID: Facility ID: 105644 If continuation sheet Page 3 of 3