Inspection·October 8, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 2 of 4 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 10/08/2025 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 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure nursing staff had the skills, knowledge and certification necessary to provide cardiopulmonary resuscitation (CPR) services for one resident (#1) of three residents sampled.Review of Resident #1's admission record revealed a readmission date of [DATE] with diagnoses to include but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, altered mental status, generalized muscle weakness, dysphagia, obstructive sleep apnea, stage III chronic kidney disease, hypertension, anemia, sepsis, pneumonia, metabolic encephalopathy, congestive heart failure (CHF), and dependence on supplemental oxygen. Review of Resident #1's physician order dated [DATE] showed the resident was a full code. Review of Resident #1's Care Plan revealed no care plan for a code status. Review of Resident #1's medical record revealed a note dated [DATE] at 8:25 a.m. authored by Staff A, Licensed Practical Nurse (LPN) titled: SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers: Unresponsiveness . Full Code; . At 2026 EST [eastern standard time] I was called to room [ROOM NUMBER]A. Upon arrival the pt [patient] was found unresponsive, pulse-less, and apneic. Code blue activated immediately. CPR [cardiopulmonary resuscitation] was initiated per ACLS [advanced cardiac life support] protocol. Code team arrived at bedside and resuscitation measures began. During code, pt achieved return of spontaneous circulation (ROSC) with thready pulse at 133 BPM [beats per minute] and blood pressure of 151/54 mmHg [millimeters of mercury] at 2033. At 2043 EMS [emergency medical service] arrived at bedside shortly thereafter. Repeat blood pressure 150/51 pulse 152. Pt stabilized for transport. During an interview on [DATE] at 2:03 p.m. Staff B, CNA stated during normal rounds finding Resident #1 unresponsive. Staff B, CNA stated immediately calling for Staff A, LPN. Staff A, LPN came into Resident #1's room. Staff A, LPN checked Resident #1's pulse and said it was low and told me to get another nurse. When returning Staff C, LPN, Staff F, CNA and Staff H, CNA were performing CPR. Staff A, LPN was standing between the dressers in the room. I was not needed in the room, so I went to open the door for EMS when they arrived. Staff B, CNA stated not being certified in CPR. During an interview on [DATE] at 9:31 a.m. Staff C, LPN stated hearing assistance was needed downstairs in Resident #1's room. Staff C, LPN explained being familiar with Resident #1 as having cared for the resident, the prior evening and knew resident was a full code. Staff C, LPN explained no other staff members were in the room upon entering. Staff F, CNA and Staff H, CNA entered at almost the same time as me. Staff C, LPN stated immediately checking Resident #1's pulse, resident did not have one. Resident #1 had oxygen on via nasal canal. Staff C said, Immediately, I dropped the head of the bed and started CPR. I became tired and requested to switch. Staff F, CNA took over compressions. I then placed Resident #1's CPAP (Continuous Positive Airway Pressure) on Resident #1. Staff E, RN (Registered Nurse) brought the backboard in, we checked resident #1's pulse and placed the backboard. Staff D, LPN entered, and I asked her to call 911. Staff F, CNA requested to switch at this time. Staff H, CNA jumped in and took over compressions. Staff H, CNA requested to switch and Staff F, CNA continued with the compressions. EMS arrived and took over. Staff C, LPN confirmed being certified in CPR. During an interview on [DATE] at 10:25 a.m. Staff F, CNA stated a code blue was called and headed to Resident #1's room. Staff H, CNA and I were just steps behind Staff C, LPN and entered the room. No other staff members were in the room when we all entered. Staff C, LPN immediately checked Resident #1's pulse and said there was not one. Staff C, LPN dropped the head of the bed, and decided resident was too heavy to move to the floor, then Staff C, LPN started CPR. Staff C, LPN got tired at about the same time the back board arrived, Staff H, CNA and I placed the board. Staff C, LPN Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105718 If continuation sheet Page 3 of 4 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 10/08/2025 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 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete checked for a pulse and then I jumped in and continued started compressions. Staff F said, I requested to switch. Staff C, LPN checked for a pulse, then Staff H, CNA started compressions. Another female was in the room and was going to switch with Staff H, CNA but just froze up (stood there). I therefore jumped back in and continued with compressions. Staff F, CNA stated not remembering who the female who froze up was as being new to the facility. EMS arrived and took over care of the resident. Staff F, CNA confirmed being certified in CPR. During an interview on [DATE] at 10:37 a.m. Staff A, LPN stated Staff B, CNA, yelled to come to Resident #1's room. Staff A said, I immediately went to the room, noted Resident #1 not responding. I ran out of the room to get the blood pressure machine, called a rapid response, and verified code status. Staff A, LPN stated taking the crash cart back to Resident #1's room. Staff H, CNA was providing compressions when I arrived back to Resident 1's room. Staff C, LPN was directing everyone and Staff F, CNA took over from Staff H, CNA. Staff A, LPN confirmed being certified in CPR. During an interview on [DATE] at 11:55 a.m. Staff D, LPN stated Staff A, LPN came to the nurse station and stated Resident #1 was unresponsive. Staff D said, I immediately checked Resident #1's code status. Resident #1 was a Full Code. Staff A, LPN and I grabbed the crash cart and headed to Resident #1's room. Staff C, LPN was already performing compressions on Resident #1 when we arrived at the room. Staff F, CNA and Staff H, CNA were standing next to the bed. I ran back to the nurse station and contacted 911 and began preparing the paperwork. Staff D, LPN confirmed being certified in CPR. During an interview on [DATE] at 2:18 p.m. Staff E, RN stated they called code blue over the speakers. Staff E, RN stated headed to Resident #1's room and upon arrival noted Staff C, LPN was working with Resident #1. The staff were not yet performing CPR; they determined Resident #1 was too heavy to move to the floor. Staff C, LPN asked me to get the crash cart and back board. Upon returning with the backboard and cart, Staff C, LPN was performing chest compressions. Staff C, LPN stopped and checked Resident #1 while Staff F, CNA and Staff H, CNA placed the backboard under Resident #1. Staff E, RN stated leaving the room since Staff C, LPN and Staff A, LPN were in the room. Staff E, RN confirmed being certified in CPR. Multiple attempts were made to reach Staff H, CNA via phone on [DATE] and [DATE] with no response. Staff H, CNA did not have a CPR certification located in the facility employee record. During an interview on [DATE] at 10:53 a.m. the Nursing Home Administrator stated during the review of Resident #1's code it was determined Staff H, CNA admitted to performing chest compressions on Resident #1 although not being certified in CPR. The NHA stated licensed nurses certified in CPR are the expected staff members to perform CPR in the facility. The NHA stated CPR is not in the CNA's job description and Staff H, CNA should not have performed chest compressions on Resident #1. Review of the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR) dated [DATE] revealed: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: * Resident identification * Fully executed Florida Do Not Resuscitate order (DHI 896), located in the advanced directive section of the medical record 3. Use the paging system and call Code Blue to Room Number or location of the event three times. 4. In the absence of a fully executed Florida Do Not Resuscitate order (DHI 896) the facility will immediately begin CPR. 5. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: The resident responds. 6. Notify the physician and resident representative/ legal representative 7. Document in the medical record. Event ID: Facility ID: 105718 If continuation sheet Page 4 of 4