Health inspection·August 28, 2023

F 0624 Level of Harm - Minimal harm or potential for actual harm - A progress note, dated 07/22/23, showed, Level of consciousness noted as oriented to person oriented to place periods of confusion. - A progress note, dated 07/21/23, showed, Level of consciousness noted as oriented to person oriented to place periods of confusion. Residents Affected - Few - A progress note, dated 07/19/23, showed, Level of consciousness noted as oriented to person oriented to place periods of confusion. - A progress note, dated 07/17/23, showed, Level of consciousness noted as oriented to person oriented to place periods of confusion. - A progress note, dated 07/12/23, showed, Level of consciousness noted as oriented to person oriented to place periods of confusion. A review of the Discharge Plan and Instructions, dated 08/09/23, showed Resident #1 was discharged to an Assisted Living Facility. The mode of transportation for discharge was noted to be in a car. There was no recapitulation of stay noted in the discharge plan. The discharge summary stated Resident #1 was discharged to an Assisted Living Facility on 08/09/23 via insurance transport. The responsible party was not notified and the section of notification acknowledgements was left blank on the Discharge plan and instructions. During an interview on 08/28/23 at 2:05 p.m., the Social Service Director (SSD) stated the process for discharging a resident was to contact the family, doctor, and make sure everyone was on the same page for discharge. The SSD stated care plan meetings take place on Tuesdays and Thursdays and that is where social services talk about discharge planning and if there were any issues. The SSD stated she would expect to see that a family representative was notified the day of discharge and the notification of discharge be completed on the Discharge Planning and Instructions Form. The SSD confirmed the Discharge Planning and Instructions Form was incomplete in Resident #1's medical record. The SSD confirmed Resident #1's care plan did not show Resident #1's discharge plan to an Assisted Living Facility but rather plans for Resident #1 to remain in Long Term Care. The SSD confirmed there were no social service progress notes related to Resident #1's discharge planning only the incomplete Discharge Planning and Instructions Form. During an interview on 08/28/23 at 2:25 p.m., the Administrator stated Resident #1's family representative was contacted about possible future discharge to an Assisted Living Facility (ALF) as a plan for discharge. The Administrator stated the problem was There was a total misunderstanding. The Administrator stated the ALF representative was in the facility for marketing purposes when Resident #1 was up dancing to music. The ALF representative stated Resident #1 would be great to have as a resident at the ALF, at which time the facility's previous social worker understood it as the ALF accepted Resident #1 and initiated discharge. The Administrator stated Resident #1 was discharged from the facility to the ALF via insurance transport on 08/09/23. The Administrator stated Resident #1's Representative came to the facility but Resident #1 had discharged . The Administrator stated Resident #1's family representative was not happy Resident #1 was discharged without being informed and Resident #1 rode over the the ALF by himself without supervision. The Administrator stated Resident #1's Representative explained to the Administrator they would have preferred to have rode over to the ALF with Resident #1 and certainly did not agree with Resident #1 going alone due to the fact that Resident #1 was confused and had dementia. The Administrator stated she spoke with the ALF administrator the day of Resident #1's discharge who agreed and understood the discharge was a total (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 2 of 8 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few misunderstanding. The Administrator stated the ALF Administrator reported if the ALF formally accepted Resident #1 the ALF would have made plans to pick Resident #1 up at the facility and brought him to the ALF, not just have him sent by insurance transport alone. The Administrator stated ultimately the ALF chose to keep Resident #1 in the secure unit once discharged from the facility. The Administrator confirmed even though the previous social worker had talked to Resident # 1's family representative about future plans to discharge Resident #1 to an ALF, Resident #1's representative was not notified the day of Resident #1's discharge. During an interview on 08/28/23 at 3:10 p.m., the Assisted Living Facility (ALF) Administrator stated she was at the ALF when Resident #1 arrived in a taxi cab. The ALF Administrator stated the cab driver came to the ALF door and stated he was dispatched to drop Resident #1 off at this location but knew nothing else about Resident #1. The ALF Administrator stated the ALF was not expecting Resident #1 and at that time did not know Resident #1. The ALF Administrator stated Resident #1 was so confused that he didn't even know to get out of the cab. The ALF Administrator stated she had to physically go get Resident #1 out of the cab and escort him into the ALF. The ALF Administrator stated all Resident #1 carried was a see-through trash bag with a few things in it. The ALF Administrator stated Resident #1 told her he did not know why he was there and asked if he could just go home. The ALF Administrator stated she called the ALF Marketer the ALF Marketer stated Resident #1 was a potential admission, but the admission process was in the very beginning stages because Resident #1 hadn't even been evaluated to be admission candidate yet. The ALF Administrator stated the the Marketer said she had never even spoke to family yet about Resident #1 even being a resident yet. The ALF Administrator stated Resident #1 did not arrive at the ALF with any admission paperwork and Resident #1 had no identification. The ALF Administrator stated, If there wasn't a good Samaritan as a driver he could have disappeared easily. The ALF Administrator stated the ALF tried to call the facility but they kept hanging up on them. The ALF Administrator stated she finally called and demanded to talk to the Facility Administrator. The ALF Administrator stated when she reached the Facility Administrator Resident #1's Representative was in the Facility Administrators office and expressed being upset and worried about Resident #1's safety. The ALF Administrator stated when talking to the facility Administrator she expressed how horrified she was regarding Resident #1's discharge. The ALF Administrator stated she asked the Facility Administrator if the facility wanted ALF to send Resident #1 back to the facility until proper admission could take place however the ALF Administrator was told by the Facility Administrator she did not know if there was a room available for Resident #1 now. The ALF Administrator stated she notified Resident #1's family representative who came directly to the ALF. The ALF Administrator stated Resident #1's representative was furious for not being notified of Resident #1's discharge. The ALF Administrator stated Resident #1 was able to be admitted to the ALF. The ALF Administrator stated, This is the first time, I have ever seen a resident ever come in and dumped like a sack of potatoes. The ALF Administrator stated Resident #1 came to the ALF and was scared, confused and did not know why he was there. The ALF Administrator stated Resident #1 arrived in a cab alone which was also scary because the cab driver could have dropped Resident #1 off anywhere as confused as Resident #1 was but now being admitted in the ALF Resident #1 is now safe, doing well and happy. A review of the facility's policy Discharge to Resident to Home or Other Center revision date 08/03/18 stated, 1. Upon determination by the interdisciplinary team that resident is appropriate for discharge, the Nurse will obtain a physician's order for discharge to included: a) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 3 of 8 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0624 Place of discharge Level of Harm - Minimal harm or potential for actual harm b) Community resources or referrals required Residents Affected - Few c) Status of medications on discharge 2. Complete the Discharge Plans 3. The list of medications may be printed from the pharmacy for resident or legal representative review and signature. 5. Provide resident a copy of the Discharge Plan, and the pharmacy medication list. 6. Document final disposition in the resident's clinical record. A review of the facility's policy Notification of Change in Condition revision date 12/16/2020 stated, The nurse will notify the attending physician and resident representative when there is: Accidents Significant change in physical, mental and psychosocial changes Alter treatment in including new or discontinued. A transfer or discharge of the Patient/Resident from the Center Event of emergency situation when 911 is called Nurse will contact physician in the event the attending physician does not answer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 4 of 8 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0624 If Medical Director does not respond, call 911 and document in medical record. Level of Harm - Minimal harm or potential for actual harm Notify patient/resident and the representative of the change in condition. Residents Affected - Few Document on a 24-hour report Complete SBAR as indicated Resident #3 was admitted to the facility on [DATE] with a diagnosis of AMS (Altered Mental Status). Other diagnoses included Alzheimer's diseases, Parkinson's, encephalopathy and difficulty in walking, muscle wasting, Hyperlipidemia, Hypertensive, long term (current) use of insulin and benign prostatic hyperplasia without lower urinary tract system. The resident was discharged on 08/14/23. On 08/28/23 at 12:30 p.m. a telephone interview was conducted with Resident #3's family member. The family member stated the resident was admitted on a Thursday and on the following Monday she received a phone call to pick him up. The family member said, The facility stated he did not want to stay. I was upset because he was not stable to discharge. The nurse told me the family is there to take care of him. She said we could take him home because he could walk. The family member stated Resident #3 was not oriented to self. She said, He was confused and obviously was saying he wanted to go home because he was in an unfamiliar environment. He was not evaluated by any doctor that I know of. The family member stated she never spoke to any physician or any treating clinician during the 4-day stay. She stated she did not answer any questions related to care planning for his stay or even discharge. The family member stated the following morning, post-discharge she had reached out to the resident's Primary Care Physician's (PCP) office. He was seen from home by their Advanced Registered Nurse Practitioner (ARNP). Resident #3 continued with confusion while at home. The family member closely monitored the resident for fear he might get out of the home. The family member said, He was saying he wanted to go to Puerto Rico. He was obviously still in an altered mental state. I called the Director of Nursing (DON) to explain what was going on. Review of a document titled, Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 5000-3008), 08/10/23 showed Resident #3 was admitted to the facility with a primary diagnosis of dementia with confusion. An admission/readmission data collection form for Resident #3, dated 08/10/23 showed the resident was admitted from [name of hospital] for weakness/AMS (altered mental status). An elopement risk evaluation for Resident #3 dated 08/10/23 showed the resident was identified at risk. The resident was assessed as cognitively impaired, ambulates independently, has poor decision-making skills, has demonstrated exit-seeking behaviors, and wanders oblivious to safety needs. Review of progress notes for Resident #3 showed the following: 8/10/23 Resident new admit, independently ambulatory with walker, poor decision making, actively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 5 of 8 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0624 Level of Harm - Minimal harm or potential for actual harm exit seeking. Elopement evaluation done and wanderguard applied. Will monitor and continue to evaluate cognition. 8/13/23 Skilled note: Mood: fidgety. Other socially inappropriate behaviors: Wandering. Wander guard in place. Resident had bowel movement in a corner of the room despite knowing where the bathroom is. Residents Affected - Few A care plan initiated 8/11/23 showed a discharge focus indicating the resident wished to return home. The goals indicated the resident will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by review date. The resident will verbalize/communicate required assistance post discharge and the services required to meet needs before discharge. Interventions included to encourage the resident to discuss feelings and concerns with impeding discharge. Monitor for and address episodes of anxiety, fear of anxiety, distress. Evaluate and discuss with resident/representative prognosis for independent/ assisted living. Evaluate the resident's motivation to return to the community and make arrangements with required community resources to support independence post discharge. On 08/28/23 at 2.57 p.m., a telephone interview was conducted with Resident #3's ARNP. She stated she saw the resident the following day after he was discharged from the facility. She stated at the time he was not back to his baseline, he was cooperative even though confused. She said, We did not receive a schedule request to follow -up with him upon discharge. No one contacted us regarding his follow-up care. The family member called me because the resident was confused, agitated, and demanding to be let out. I scheduled a home visit because she could not transport him. At the time, she described sun-downing behaviors, he was increasingly upset. The ARNP stated they had to do a medication review after assessing his mood and behavior and adjusted his medications. The ARNP said, I advised [the family member] to follow -up with AHCA (Agency for Health Care Administration) because I did not feel he was ready to discharge. On 08/28/23 at 11:20 a.m. an interview was conducted with the Director of Nursing (DON). She stated the resident was admitted to the facility for a short-term stay. He was only with us for a 4 day stay. He came in for therapy, I think. He was discharged home with family. He was ambulatory with a walker. The DON said, He was an elopement risk, constantly exit seeking the whole time he was here. We had a Wanderguard on him. He was in the elopement book. He just did not want to be here. The DON stated Resident #3 was exit seeking and was hard to redirect. On 08/28/23 at 11:40 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She stated Resident #3 was sent home with a walker, and a family member accompanied him. She said, The resident was ambulating, he was wandering the facility, actively exit seeking. He had a Wander guard. He had a suitcase on top of walker. He stated he wanted leave. He wanted us to call the [family member]. He was admitted for altered mental status and the discharge plan was to go home with family. Staff A said, He discharged because he wanted to go, He was alert and confused. Staff A stated she thought the discharge was planned. She stated if the resident was seen by a physician or social services there would be a note. On 08/28/23 at 1:41 p.m. an interview was conducted with the facility's ARNP. She stated she saw the resident the day he was discharged . She stated the resident was admitted with altered mental status. She said, He did not display any behaviors when I saw him. He was ready to go home. I did not know that he was displaying any agitation during stay. I saw him at the nurses station. He had packed all his belongings. He was wandering the halls with his suitcase stating he wanted to go. He did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 6 of 8 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few display any other behaviors other than asking to leave. I don't know anything about his mental status other than he was confused. The facility's ARNP stated confusion was expected considering his Dementia diagnosis. She stated she did not know if that was out of his norm. She said, I could not hold him hostage. He had some capacity to make decisions. The nurse said he wanted to go home. I was not made aware of him exit seeking. He was alert and was asking to leave. The facility's ARNP stated the resident came from the hospital and his acute need was addressed. The ARNP stated she did not know if the resident was seen by any other physician. She stated she would normally document patient visits, but she had been busy. She stated there was no timeline on when the notes should be entered into the resident's record. On 08/28/23 at 1:55 p.m. an interview was conducted with the Social Services Director (SSD). She confirmed the discharge summary for Resident #3 was incomplete. She said, I was instructed by former SSD to initiate the discharge. I was undergoing training. I sent the home health request because the patient requested to go home. She stated the expectation would be for the SSD to see a patient within 5 days of admission. There should be a social services assessment if the resident was assessed. The SSD stated if the discharge was patient requested, they would ask the medical director to do an assessment and determine if the resident is ready to discharge. She stated after that they would then have the doctor sign off on the discharge order. The SSD said, We would notify the family and discuss the discharge location to ensure it was safe. This would all be documented in the resident's chart. The SSD confirmed she did not see any of the documentation. She said, I don't know why. The former SSD should have documented. Review of a facility policy titled, Discharge Planning, dated 11/30/14 showed an expectation to evaluate the resident's health status and formulate the best plan of discharge for each resident. Discharge planning begins the day of admission. The process involves the resident and family, care management/social services and the other members of the clinical team. 1.) An initial evaluation of a resident is completed upon admission. A discharge goal and length of stay will be established upon admission and reviewed/revised plan of care conferences. The goal is based upon clinical findings, availability of community and family resources and resident/family goals. 2.) Discharge planning record will be completed within 7 days after admission. Discharge planning is adjusted as appropriate. 3.) All discharge plans will be reviewed after 60 to 90 days according to the level of care. 4.) At the time of discharge, a discharge summary and home going instructions are provided to the resident or the residents caregiver . 5.) Residents discharged to home will be made aware of, understand, and agree with the proposed discharge plan, discharge date and other home care needs. 6.) Within 24 to 48 hours after discharge to home, another nursing facility or to another type of residential facility, a follow up phone call, or if necessary, home visit will be made to ascertain that community services/referrals are indeed being provided according to the discharge plan. 7.) Documentation of the after-discharge contact will be made on the social service progress note and labored, post discharge note. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 7 of 8 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 105718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Central Park 702 S Kings Ave Brandon, FL 33511 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 0624 8.) Should prescheduled services not be provided or arranged, the social worker will make every attempt to coordinate services and follow up again. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 8 of 8